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1.  Usefulness of Ultrasound Examinations in the Diagnostics of Necrotizing Enterocolitis 
Summary
Background
Necrotizing enterocolitis (NEC) is one of the most serious disorders of gastrointestinal tract during neonatal period. Early diagnosis and adequate treatment are essential in the presence of clinical suspicion of NEC. Plain abdominal radiography is currently the modality of choice for initial evaluation of gastrointestinal tract in neonates. However, when the diagnosis is uncertain, abdominal ultrasound with bowel assessment might be an important complementary examination. The aim of the study was to evaluate usefulness of ultrasound in the diagnosis of NEC and its value for implementation of proper treatment.
Material/Methods
The data of nine neonates diagnosed with NEC, hospitalized at the Provincial Hospital No. 2 in Rzeszow in the period from September 2009 to April 2013 was retrospectively analyzed. Apart from abdominal radiography, abdominal ultrasound with bowel assessment was performed in all nine cases. Imaging findings, epidemiological data, coexisting risk factors and disease course were assessed.
Results
Most children in the group were preterm neonates. Findings in plain abdominal radiography were normal or nonspecific. A wider spectrum of findings was demonstrated in all ultrasound examinations and intestinal pneumatosis, a pathognomonic sign for NEC, was more frequently noted than in plain abdominal x-ray. Most children were treated by surgical intervention with resection of necrotic bowel loops and in more than half of the cases location of changes identified during surgery was concordant with ultrasonographic findings.
Conclusions
Abdominal ultrasound examination might be helpful in the diagnosis of NEC, especially when plain abdominal radiography findings do not correlate with clinical symptoms. However, abdominal radiography is still considered the modality of choice. The range of morphological changes detectable on ultrasound examination is much wider than in plain abdominal radiography. Ultrasound examination allows for more accurate assessment of changes within intestines and adjacent tissues, which aids clinicians in making more accurate therapeutic decisions and implementing proper treatment.
doi:10.12659/PJR.890539
PMCID: PMC4283822  PMID: 25574248
Diagnostic Imaging; Emergency Treatment; Neonatology
2.  Endovascular Treatment of an Adolescent Patient with a Ruptured Intracranial Aneurysm – Case Report and Review of Literature 
Summary
Background
The occurence of aneurysms in young patients, under 18 years of age, is estimated at 0.5–2% of all diagnosed aneurysms.
Case Report
We reported on a case of a 16-year-old patient with subarachnoid hemorrhage diagnosed due to a ruptured cerebral vessel aneurysm. The angio-CT revealed an aneurysm of the middle cerebral artery, in its distal branch. An ad hoc coil embolization was performed with angiographic success.
After 6 months following the ictus, the patient underwent a control angiography which confirmed total occlusion of the aneurysm with no residual inflow. Clinical examination revealed no neurological deficits and the patient was rated 0 in mRS (modified Rankin Scale).
Conclusions
In experienced departments of interventional neuroradiology the endovascular treatment should be the treatment of choice.
doi:10.12659/PJR.891344
PMCID: PMC4284941  PMID: 25574249
Embolization, Therapeutic; Intracranial Aneurysm; Pediatrics; Subarachnoid Hemorrhage
3.  Computed Tomography Features of Pulmonary Nocardiosis in Immunocompromised and Immunocompetent Patients 
Summary
Background
Nocardiosis primarily occurs in the setting of immunocompromising conditions. However, it may also occur in immunocompetent patients. We described computed tomography features of pulmonary nocardiosis and compared immunocompetent and immunocompromised patients.
Material/Methods
CT images of 25 patients (Mean age of 39.5 years; 76% male) with pulmonary nocardiosis proved by bronchoalveolar lavage or biopsy were reviewed by two experienced pulmonary radiologists and detailed findings were reported on. Fourteen patients (56%) were immunocompetent, while 44% had an underlying immunocompromising condition, including chronic granulomatous disease (CGD) (n=4), diabetes mellitus (DM) (n=2), malignancy (n=2), HIV (n=1), concomitant CGD and DM (n=1), and steroid therapy for nephrotic syndrome (n=1).
Results
Most patients had bilateral involvement with no zonal predominance. Multiple pulmonary nodules (96%) were the most common CT findings, followed by consolidation (76%) and cavity (52%). Other findings included bronchiectasis (48%), pleural thickening (40%), ground glass opacity (32%), mass-like consolidation (20%), intrathoracic lymphadenopathy (16%), pleural effusion (12%), reticular infiltration (4%), and pericardial effusion (4%). There was no statistically significant difference in the CT findings of immunocompromised and immunocompetent groups.
Conclusions
Pulmonary nocardiosis presents mainly as multiple pulmonary nodules, consolidations, and cavity in both immunocompromised and immunocompetent patients. However, these features are more suggestive of nocardiosis in the setting of an underling immunocompromised condition.
doi:10.12659/PJR.892042
PMCID: PMC4288394  PMID: 25584096
Immunocompetence; Immunocompromised Host; Lung Diseases, Fungal; Multidetector Computed Tomography; Nocardia Infections
4.  Calyceal Diverticulum of the Kidney – Diagnostic Imaging Dilemma in Pediatric Patients – Case Report 
Summary
Background
Calyceal diverticula are rarely diagnosed in children. They can mimic other renal cystic lesions and correct diagnosis can be difficult to establish. Connection between fluid collection and collecting system confirmed by imaging studies is the key diagnostic finding.
Case Report
In this report we present a case of pediatric patient with calyceal diverticulum, with initial ultrasonographic diagnosis of simple renal cyst. Final diagnosis was established after extended diagnostics following infection of a fluid collection.
Conclusions
1. Differential diagnosis of well-circumscribed solitary renal fluid collections in children should include particularly: simple cyst, calyceal diverticulum and the first demonstration of ADPKD. 2. Diagnosis of calyceal diverticulum should be confirmed by contrast studies. 3. Standard management of calyceal diverticula in children includes ultrasonographic follow-up and conservative treatment and rarely requires surgical intervention.
doi:10.12659/PJR.892053
PMCID: PMC4298278  PMID: 25610511
Child; Nephrology; Pediatrics; Radiology; Urology
5.  Central Nervous System Lymphoma in a 3-Year-Old Male Suffering from a Severe Juvenile Xanthogranuloma – the Usefulness of Perfusion Weighted Imaging and Diffusion Weighted Imaging in the Diagnostics of Pediatric Brain Tumors 
Summary
Background
Primary Central Nervous System Lymphomas (PCNSLs) are rare, malignant brain tumors derived from lymphocytes B. Juvenile xanthogranuloma (JXG) is a non-Langerhans histiocytic cell disorder in children which mostly affects the skin. Rare fatalities have been reported in extracutaneous manifestation. Brain magnetic resonance imaging (MRI) is a method of choice in the diagnostics of all neoplastic CNS lesions. Perfusion weighted imaging (PWI) and diffusion weighted imaging (DWI) allow for more detailed analysis of brain tumors including the rate of neoangiogenesis and cellularity. We presented a pediatric patient suffering from JXG with CNS involvement and the role of brain MRI including DWI and PWI in the evaluation of brain focal lesions.
Case Report
A 3-year-old male with severe JXG underwent two stem cell transplantations with a development of neurological complications. The patient underwent emergency CT and MRI which revealed a non-specific enhancing focal brain lesion. In DWI it showed restricted diffusion while PWI revealed low values of rCBV and the signal intensity curve returning above the baseline level. Advanced MRI techniques such as DWI and PWI suggested PCNSL. Stereotactic biopsy confirmed PCNSL due to Ebstein-Barr virus reactivation.
Conclusions
The use of advanced MRI sequences is important to differentiate brain lesions in pediatric patients. The use of PWI and DWI facilitated the diagnosis of PCNSL. It is important to remember that PCNSLs show a very typical pattern of changes visualized with MRI such as: usually strong homogenous enhancement, restricted diffusion and low perfusion.
doi:10.12659/PJR.892106
PMCID: PMC4306264  PMID: 25624957
Central Nervous System Neoplasms; Diffusion Magnetic Resonance Imaging; Lymphoma, B-Cell; Magnetic Resonance Angiography; Magnetic Resonance Imaging; Xanthogranuloma, Juvenile
6.  Typical MDCT Angiography Findings of an Unusual Cutaneous Neoplasia; Masson Tumor 
Summary
Background
Intravascular papillary endothelial hyperplasia (IPEH), also known as masson tumour, is a lesion composed of proliferating endothelial cells.
Case Report
In this article we explained clinical, histological and radiological features of IPEH involving the scalp, localized on the left side of the skull and in the periauricular region.
Conclusions
Radiologically, intravascular papillary endothelial hyperplasia could be misdiagnosed as malignant or benign vascular tumour. On cross-sectional imaging it is useful demonstrating the extremely vascular component of IPEH. But IPEH has no specific radiologic features that we can use to differentiate from the aforementioned lesions. Due to that, histopathological examinations are needed to diagnose IPEH.
doi:10.12659/PJR.892043
PMCID: PMC4306265  PMID: 25624958
Angiography; Hyperplasia; Multidetector Computed Tomography
7.  Intracranial Lesions with Low Signal Intensity on T2-weighted MR Images – Review of Pathologies 
Summary
In this article we presented intracranial pathological substances and lesions with low signal intensity on T2-weighted images. Eight groups of substances were discussed i.e. 1. Gadolinium-based contrast materials, 2. hemoglobin degradation products 3. melanin, 4. mucous- or protein-containing lesions, 5. highly cellular lesions, 6. lesions containing mineral substances such as: calcium, copper and iron, 7. turbulent and rapid blood or CSF flow 8. air-containing spaces. Appropriate interpretation of signal intensity as well as analysis of lesion location and clinical symptoms enable a correct choice of a further diagnostic algorithm or, in many cases, final diagnosis based exclusively on an MRI examination.
doi:10.12659/PJR.892146
PMCID: PMC4307690  PMID: 25628772
Magnetic Resonance Imaging; Diagnosis; Differential, Brain — radiography
8.  Vertebroplasty of Cervical Vertebra 
Summary
Background
The first vertebroplasty was performed by Harve Deramond in France in 1984 due to a hemangioma of cervical vertebral body. Procedure technique consisted of inserting a needle through the bony palate of the oral cavity. Bone cement injected under pressure not only fills the areas of bone loss. The heat released in the process of crystallization causes denaturation of pathological tissue proteins (metastasis) and disrupts blood supply (hemangiomas). The aim of this study was to evaluate the method of treatment from anterolateral access.
Material/Methods
In the years 2007–2012 the procedure was performed in 6 men and 9 women aged from 42 to 71 years (mean age: 56.3 years). In 10 cases the reason for vertebroplasty was the vertebral hemangioma, in another 4 – pathological vertebral fractures due to metastases, and in one case – multiple myeloma. Procedures were performed from anterolateral access, under local anesthesia, under x-ray guidance (fluoroscopy). Bone needle was inserted into the vertebral body, followed by injection of PMMA cement.
Results
In 100% cases pain relief was observed immediately after the procedure and beneficial therapeutic effect was obtained. No life-threatening complications and clinical symptoms were observed. Average length hospital stay amounted to 2.9 days.
Conclusions
Cervical spine vertebroplasty from anterolateral access seems to be a safe, effective and beneficial method of treatment. It reduces the risk of infection in comparison to the transoral method.
doi:10.12659/PJR.892165
PMCID: PMC4311945
Bone Cement; Hemangioma, Cavernous, Central Nervous System; Magnetic Resonance Imaging; Spinal Interventional Radiology; Vertebroplasty
9.  Radiation Safety Awareness Among Medical Staff 
Summary
Background
The common access to imaging methods based on ionizing radiation requires also radiation protection. The knowledge of ionizing radiation exposure risks among the medical staff is essential for planning diagnostic procedures and therapy.
Evaluation of the knowledge of radiation safety during diagnostic procedures among the medical staff.
Material/Methods
The study consisted of a questionnaire survey. The questionnaire consisted of seven closed-ended questions concerning the knowledge of the effects of exposure to ionizing radiation as well as questions related to responder’s profession and work experience. The study group included a total of 150 individuals from four professional groups: nurses, doctors, medical technicians, support staff. The study was carried out in the three largest hospitals in Gdańsk between July and October 2013.
Results
The highest rates of correct answers to questions related to the issue of radiation protection were provided by the staff of radiology facilities and emergency departments with 1–5 years of professional experience. The most vulnerable group in terms of the knowledge of these issues consisted of individuals working at surgical wards with 11–15 years of professional experience.
Conclusions
Education in the field of radiological protection should be a subject of periodic training of medical personnel regardless of position and length of service.
doi:10.12659/PJR.892758
PMCID: PMC4315635
Medical Staff; Radiation Dosage; Radiation Protection
10.  Toxic Lung Injury in a Patient Addicted to “Legal Highs” – Case Study 
Summary
Background
Toxic lung injury may manifest itself in many different ways, ranging from respiratory tract irritation and pulmonary edema in severe cases to constrictive bronchiolitis, being a more distant consequence.
It is most often the result of accidental exposure to harmful substances at work, at home, or a consequence of industrial disaster.
Case Report
This article presents a case of toxic lung injury which occurred after inhalation of legal highs, the so-called “artificial hashish” and at first presented itself radiologically as interstitial pneumonia with pleural effusion and clinically as hypoxemic respiratory insufficiency. After treatment with high doses of steroids, it was histopathologically diagnosed as organizing pneumonia with lipid bodies.
Conclusions
Due to the lack of pathognomonic radiological images for toxic lung injury, information on possible etiology of irritants is very important. As novel psychoactive substances appeared in Europe, they should be considered as the cause of toxic lung injury.
doi:10.12659/PJR.892334
PMCID: PMC4319657
Drugs; Lung Diseases, Interstitial; Lung Injury; Radiography; Respiratory Insufficiency
11.  Triaxial System in Re-Embolization for Recanalization of Pulmonary Arteriovenous Malformations 
Summary
Background
Recanalization occurs occasionally, following coil embolization of pulmonary arteriovenous malformations (PAVM), and can lead to ischemic stroke; therefore re-embolization is important. A 1.9-Fr. no-taper microcatheter that can be inserted into a 2.7-Fr. microcatheter (named the triaxial system) has recently become available, and contributes to super-selective catheterization for small or tortuous vessels. The aim of this study was to evaluate the usefulness of re-embolization for recanalization of PAVM using the triaxial system.
Material/Methods
Recanalization was diagnosed in 8 patients with 13 PAVMs between June 2011 and November 2012, and re-embolization was attempted with a conventional microcatheter at first in all 13 PAVMs. However, in three of them it failed with the conventional microcatheter, and then the system was exchanged to the triaxial system. Thus, re-embolization using the triaxial system was performed in 3 PAVMs of 3 female patients, with a median age of 63 years (range, 46–73 years). We assessed technical success, complications, and outcome.
Results
The disappearance of recanalization was confirmed by angiography in all re-embolization procedures (technical success rate was 100%). Re-embolization was then successfully achieved inside the original coils, and no branch artery of normal lung tissue was embolized. There were no complications related with this procedure. The blood flow of recanalization was decreased in all cases in a follow-up of 27–33 months (median, 31).
Conclusions
Triaxial system appears to be useful for recanalization of PAVM, especially in difficult cases with a conventional system.
doi:10.12659/PJR.892378
PMCID: PMC4322549
Catheterization; Embolization, Therapeutic; Pulmonary Artery
12.  CT-assisted transfemoral intrahepatic portosystemic shunt in a long duration follow-up: A case report 
Summary
Background
Transjugular intrahepatic portosystemic shunt (TIPS) in patients with portal hypertension may be considered as a rescue therapy in case of recurrent variceal bleeding or failure of endoscopic management.
Case Reports
We present a case of a patient with massive gastroesophageal variceal bleeding refractory to numerous endoscopic treatments in which TIPS was considered in an attempt to decrease the risk of potentially fatal rebleeding. Standard TIPS procedure was not feasible due to altered anatomy of the liver resulting from right hemidiaphragmatic paresis. Computed Tomography (CT) fluoroscopic guidance was utilized for direct percutaneous puncture of the left hepatic and left portal vein with subsequent guidewire snaring to perform portosystemic shunting via femoral access. Since the procedure, no recurrent variceal bleeding was reported and the shunt remained patent at a 3-year follow-up. Although stent fracture with fragment migration was observed.
Conclusions
Significant variation in liver anatomy does not preclude the creation of nonsurgical portosystemic shunt. In these cases, combined percutaneous and endovascular technique may be utilized.
doi:10.12659/PJR.889841
PMCID: PMC3940701  PMID: 24596585
Liver Cirrhosis; Hemidiaphragmatic Paresis; Portasystemic Shunt; Transjugular Intrahepatic; CT guidance
13.  Evaluation of transient osteoporosis of the hip in magnetic resonance imaging 
Summary
Transient osteoporosis is a relatively rare condition of unknown etiology that causes temporary bone loss. The syndrome is characterized by self-limited course and spontaneous resolution after 6 to 12 months. The pathogenesis of transient osteoporosis is not fully understood but several hypotheses that have been proposed include trauma, neurovascular dysfunction and transient hyperemia. Clinical manifestations include sudden onset of pain in the hip that usually worsens with weight bearing and leads to functional disability involving the affected extremity. Radiographs are frequently unremarkable, but may reveal periarticular osteopenia 3–6 weeks after the onset of clinical symptoms. There is no radiographic evidence of demineralization during the early phase of syndrome, as a result advanced imaging is required. Magnetic resonance imaging is the most sensitive and predictable test for an early diagnosis and monitoring of disease progression.
doi:10.12659/PJR.889827
PMCID: PMC3937050  PMID: 24587837
transient osteoporosis; hip joint; MRI; bone marrow edema
14.  MRI findings of a remote and isolated vaginal metastasis revealing an adenocarcinoma of the mid-sigmoid colon 
Summary
A remote vaginal metastasis from a colo-rectal carcinoma is extremely rare. Only few cases have been described in the literature. The radiological appearances of a vaginal metastasis from colon-rectal cancer have not been extensively investigated. We report the MRI findings with clinical and pathological correlations of a remote and isolated vaginal metastasis revealing a mid-sigmoid adenocarcinoma in a 67 years old woman.
doi:10.12659/PJR.890032
PMCID: PMC3930582  PMID: 24567770
Sigmoid Neoplasms; Magnetic Resonance Imaging; Neoplasm Metastasis; Adenocarcinoma
15.  Congenital vascular malformations in scintigraphic evaluation 
Summary
Background
Congenital vascular malformations are tumour-like, non-neoplastic lesions caused by disorders of vascular tissue morphogenesis. They are characterised by a normal cell replacement cycle throughout all growth phases and do not undergo spontaneous involution.
Here we present a scintigraphic image of familial congenital vascular malformations in two sisters.
Material/Methods
A 17-years-old young woman with a history of multiple hospitalisations for foci of vascular anomalies appearing progressively in the upper and lower right limbs, chest wall and spleen. A Parkes Weber syndrome was diagnosed based on the clinical picture. Due to the occurrence of new foci of malformations, a whole-body scintigraphic examination was performed.
A 12-years-old girl reported a lump in the right lower limb present for approximately 2 years, which was clinically identified as a vascular lesion in the area of calcaneus and talus. Phleboscintigraphy visualized normal radiomarker outflow from the feet via the deep venous system, also observed in the superficial venous system once the tourniquets were released. In static and whole-body examinations vascular malformations were visualised in the area of the medial cuneiform, navicular and talus bones of the left foot, as well as in the projection of right calcaneus and above the right talocrural joint.
Conclusions
People with undiagnosed disorders related to the presence of vascular malformations should undergo periodic follow-up to identify lesions that may be the cause of potentially serious complications and to assess the results of treatment. Presented scintigraphic methods may be used for both diagnosing and monitoring of disease progression.
doi:10.12659/PJR.889874
PMCID: PMC3927420  PMID: 24567769
congenital vascular malformations; scintigraphy; 99mTc-RBC
16.  Avascular necrosis of the lunate bone (Kienböck’s disease) secondary to scapholunate ligament tear as a consequence of trauma – a case study 
Summary
Background
Avascular necrosis of the lunate bone (Kienböck’s disease), is a condition in which lunate bone, loses its blood supply, leading to necrosis of the bone.
There is probably no single cause of Kienbock’s disease. Its origin may involve multiple factors, such as the blood supply (arteries), blood drainage (veins), and skeletal variations. Trauma, either isolated or repeated, may possibly be a factor in some cases. This case presented with multifactorial etiology.
Case Report
In the presented case, a patient with negative ulnar variant had injured her right wrist and presented at an orthopedic clinic due to nonspecific pain 6 months later. An arthro-MRI examination revealed necrosis of the lunate bone, scapholunate ligament tear and coexisting TFCC (triangular fibrocartilage complex) tear.
Conclusions
Early diagnosis and treatment can prevent progression of necrotic lesions and bone collapse. MRI examination seems to be the key diagnostic method in the early stage of the Kienböck’s disease with negative x-ray and CT images. Arthro-MRI examination also allows us to identify the underlying ligamentous injury. In cases of traumatic etiology, an additional CT test enables stating the final diagnosis.
doi:10.12659/PJR.890027
PMCID: PMC3921098  PMID: 24523832
Kienböck’s disease; scapholunate ligament; MR/CT arthrography
17.  Imaging of patients treated with bariatric surgery 
Summary
Over the past few years, obesity has become a major clinical and population concern in the majority of developed countries. Obesity leads to significant systemic disorders, such as hypertension, hypercholesterolemia, hypertriglyceridemia and insulin resistance, and also increases the risk of developing cardiovascular diseases (ischemic heart disease, ischemic stroke), metabolic diseases (type 2 diabetes), certain types of cancer, and degenerative bone disorders (osteoarthritis). Health hazards associated with epidemic of obesity and potential benefits of weight loss have spurred interest in new treatment methods. Bariatric surgical procedures constitute a recognized alternative in cases where conservative management of obesity fails. Several bariatric operations can be distinguished: restrictive procedures, such as adjustable gastric band (AGB) and vertical banded gastroplasty (VBG); predominantly malabsorptive procedures, such as biliopancreatic diversion (BPD), and a combination of both methods, such as Roux-en-Y gastric bypass. The adverse consequences of surgical treatment of obesity include i.a.: intestinal anastomotic leakage, impaired intestinal permeability and internal hernia, dilatation of the stomach, gastrointestinal anastomotic stenosis, marginal ulceration, incisional hernia. Basic knowledge of procedures in the surgical treatment of obesity is of vital importance for the radiologist during evaluation of upper gastrointestinal tract in the early and late postoperative period, allowing correct interpretation of acquired images as well as recognition of typical complications.
doi:10.12659/PJR.889978
PMCID: PMC3913212  PMID: 24497896
obesity; bariatric surgery; radiography
18.  Transmigration of mandibular canine – case report 
Summary
Background
Transmigration is a phenomenon of movement of an unerupted tooth in the bone across the midline. This anomaly is not often found. Transmigration is more prevalent in females than in males, and more often encountered in the mandible than maxilla, it affects mostly canines.
Case Report
The aim of this study was to present a case report of a mandibular canine transmigration in a patient aged 12. Intraoral examination determined hypodontia of right second premolar and delayed eruption of left second premolar in maxilla, as well as persistent deciduous teeth: right second molar, left canine and second molar. The patient was referred for a Cone-Beam CT examination, which allowed precise visualization of the transmigrating canine as well as ruled out resorption of roots of mandibular incisors.
Results
The treatment with a maxillary fixed orthodontic appliance was finished after obtaining a satisfactory result. Proper alignment of the incisors in the anterior-posterior plane and correct midline position were accepted by the patient. Transmigrating canine after consultation with the surgeon was designed to further radiological observation.
doi:10.12659/PJR.890090
PMCID: PMC3919958  PMID: 24520309
transmigration; dental anomalie; CBCT
19.  A 128-slice CT scanner helpful in localising coronary sinus ostium during CRT-D implantation – case report 
Summary
Background
Cardiac resynchronization therapy (CRT) has become a successful treatment option for symptomatic heart failure in patients with poor left ventricular (LV) systolic function and broad QRS complex in the surface electrocardiogram (ECG).
Case Report
In this report we present a case of a 70-year-old woman with advanced heart failure due to ischaemic heart disease who underwent an upgrade from VVIR stimulator (pacemaker, PM) to cardiac resynchronization therapy defibrillator (CRT-D). The first attempt was unsuccessful due to problems with inefficient cannulation of the orifice of the coronary sinus (CS). After performing a 3D reconstruction with a 128-slice CT scanner, it was possible to carry out the up-grade to CRT-D resulting in enormous clinical improvement.
Conclusions
The case represents an example of the usefulness of 3D reconstruction with the 128-slice CT scanner used after failed CRT-D implantation due to difficulties with efficient cannulation of the coronary sinus orifice in a rare anatomical variant.
doi:10.12659/PJR.889859
PMCID: PMC3913256  PMID: 24497895
cardiac resynchronization therapy; cardioverter-defibrilator (CRT-D); 128-slice CT scanner; coronary sinus
20.  Pyelolymphatic backflow demonstrated by an abdominal CT: A case report 
Summary
Background
Pyelolymphatic backflow phenomenon, which is a subtype of pyelorenal backflow, is a rare condition that occurs during the acute phase of urinary obstruction. Pyelorenal backflow has already been described in humans with retrograde pyelography. Our report presents a rare case of pyelolyphatic backflow demonstrated by a computed tomography.
Case Report
A 67-year-old man with a history of bladder carcinoma was admitted to the emergency department due to right-sided flank pain and hematuria. Hematuria resolved after insertion of a 3-way urinary catheter, but flank pain persisted. As a result, an abdominopelvic CT was performed. CT revealed numerous tiny, serpiginous tubular structures connected with each other and filled with urine. They began intrarenally and extended caudally surrounding the ureter in the retroperitoneum. Subsequently, the patient underwent an ultrasound-guided nephrostomy to decompress the collecting system of the right kidney. Antegrade pyelography revealed minimal hydroneprosis. However, no leakage from the ureter to the retroperitoneum was observed, proving that the changes demonstrated by a CT were due to pyelolymphatic reflux caused by increased pressure in the collecting tubules filling the lymphatics with opaque urine.
Conclusions
This report presents a very rare case of pyelolymphatic reflux demonstrated by a CT. We present this case report as a reminder that although rare, pyelolymphatic reflux can occur as a result of obstruction without manifestations of hydronephrosis and it can be confused with leakage from the ureter.
doi:10.12659/PJR.889930
PMCID: PMC3905711  PMID: 24478814
computed tomography; pyelolymphatic backflow; urinary obstruction
21.  Evaluation of radiation doses delivered in different chest CT protocols 
Summary
Background
There are differences in the reference diagnostic levels for the computed tomography (CT) of the chest as cited in different literature sources. The doses are expressed either in weighted CT dose index (CTDIVOL) used to express the dose per slice, dose-length product (DLP), and effective dose (E). The purpose of this study was to assess the radiation dose used in Low Dose Computer Tomography (LDCT) of the chest in comparison with routine chest CT examinations as well as to compare doses delivered in low dose chest CT with chest X-ray doses.
Material/Methods
CTDIVOL and DLP doses were taken to analysis from routine CT chest examinations (64 MDCT TK LIGHT SPEED GE Medical System) performed in 202 adult patients with FBP reconstruction: 51 low dose, 106 helical, 20 angio CT, and 25 high resolution CT protocols, as well as 19 helical protocols with iterative ASIR reconstruction. The analysis of chest X-ray doses was made on the basis of reports from 44 examinations.
Results
Mean values of CTDIVOL and DLP were, respectively: 2.1 mGy and 85.1 mGy·cm, for low dose, 9.7 mGy and 392.3 mGy·cm for helical, 18.2 mGy and 813.9 mGy·cm for angio CT, 2.3 mGy and 64.4 mGy·cm for high resolution CT, 8.9 mGy. and 317.6 mGy·cm for helical ASIR protocols. Significantly lower CTDIVOL and DLP values were observed for low dose and high resolution CT versus the remaining CT protocols; doses delivered in CT ASIR protocols were also lower (80–81%). The ratio between medial doses in low dose CT and chest X-ray was 11.56.
Conclusions
Radiation dose in extended chest LDCT with parameters allowing for identification of mediastinal structures and adrenal glands is still much lower than that in standard CT protocols. Effective doses predicted for LDCT may exceed those used in chest X-ray examinations by a factor of 4 to 12, depending on LDCT scan parameters. Our results, as well as results from other authors, suggest a possibility of reducing the dose by means of iterative reconstruction. Efforts towards further dose reduction which would permit replacing chest X-ray with low dose CT in certain research screening projects should be encouraged.
doi:10.12659/PJR.889952
PMCID: PMC3894921  PMID: 24454417
radiation safety; radiation protection; computed tomography (CT); chest CT; lung CT; low dose CT
22.  Predictors of residual flow in embolized intracranial ruptured aneurysms at early follow-up 
Summary
Background
The possibility of recanalization and the need for retreatment are the most important drawbacks of intracranial aneurysm embolization. The purpose of the study was to prospectively analyze the results of early follow-up angiography of embolized ruptured aneurysms in an attempt to determine factors predicting the presence of residual flow.
Material/Methods
Evaluation included 72 patients with 72 aneurysms, which were followed-up 3 months after the treatment. Analysis of residual flow predictors included: age and gender, clinical state in Hunt-Hess scale, aneurysm localization, aneurysm three dimensions and volume, neck width, sac-to-neck ratio, initial result of embolization, number of coils used and the use of hydrogel coils and stents.
Results
Mean sac diameter was 6.5±3.9 mm, and mean neck width was 2.9±1.4 mm. Follow-up angiography presented residual flow in 26 aneurysms (36.1%): class 2 in 8 aneurysms (11.1%), and class 3 in 18 cases (25.0%). Stable aneurysm filling was observed in 45 cases (62.5%), progression of residual flow in 25 cases (34.7%), and regression in 2 cases (2.8%). According to ROC analysis independent predictors of residual flow were aneurysm neck diameter (AUC 0.857, 95% CI: 0.755–0.928, p<0.0001) and sac-to-neck ratio (AUC 0.817, 95% CI: 0.708–0.898, p<0.0001). Cut-off point of the ROC curve was established at 2.8 mm for neck diameter, and 1.73 for sac-to-neck ratio.
Conclusions
Aneurysm neck diameter and sac-to-neck ratio are independently related to the residual flow in embolized ruptured aneurysms at early follow-up.
doi:10.12659/PJR.889919
PMCID: PMC3945010  PMID: 24611084
Follow-up Imaging; Embolization; Therapeutic; Intracranial Aneurysm
23.  Occult left atrial ball-like thrombus in a patient referred for surgical removal of suspected cerebellum tumor 
Summary
Background
Atrial fibrillation and related cardio-embolic cerebrovascular accidents are two well-defined major healthcare problems worldwide. It has been approximated that 2.2 million people in America and 4.5 million in European Union have paroxysmal or persistent atrial fibrillation. And atrial fibrillation itself is an independent long-term risk factor of stroke. We present a case of patient referred to our center for surgical removal of suspected cerebellum tumor, a case that had a rather unexpected ending.
Case Report
A 58-year-old male patient with a history of atrial fibrillation, congestive heart failure (NYHA II/III), stable coronary artery disease, diabetes type 2 and hyperlipidemia presented with vertigo, headaches, mainly during physical activity and increased tiredness. Performed computer tomography revealed two lesions in the cerebellum and in the left lateral chamber. The diagnosis of a proliferative disease of the cerebellum was established and patient was referred to the Neurosurgical Department. Fortunately, before the operation the echocardiography was performed, which revealed two lesions in left atrium. The decision of the Heart Team was to refer the patient for an open-heart surgery, in which two thrombi were removed. Neurosurgeons decided to withdraw from further surgery and proceed with head MRI and conservative treatment, deciding that the lesion in the cerebellum was most likely an ischemic area.
Conclusions
Looking at the brain lesion should always be done from the whole patient’s perspective. And using mutlimodality imaging may lead to appropriate diagnosis, correct course of therapeutic action and unexpected ending of a rather non-extraordinary case.
doi:10.12659/PJR.889863
PMCID: PMC3959890  PMID: 24653787
multimodality imaging; cerebellum; thrombus; atrail fibrillation
24.  Radiological imaging in pediatric rheumatic diseases 
Summary
Radiological imaging plays a fundamental role in the diagnosis and monitoring of rheumatic diseases. The basic method of imaging is a classic X-ray picture, which for many years has been used as a single method for the recognition and evaluation of the effects of disease management. In today’s modern day treatment of rheumatic diseases, ultrasonography and magnetic resonance are more commonly performed for early detection of inflammatory changes in the region of soft tissue, subchondral bone and bone marrow. In spite of their usefulness and fundamental role in the diagnosis, X-ray still remains an essential tool in the diagnosis of rheumatoid arthritis in children and is complementary to today’s methods of imaging diagnostics. In clinical practice, X-ray imaging is still an important examination performed not only to recognize the disorders, but also to provide a differential diagnosis. It helps estimate disease progression and is used to monitor the effects of treatment and the development of possible complications. Differential diagnosis of rheumatic diseases is performed on the basis of localization and type of radiographic changes. The surrounding periarticular soft tissues, bone structures, joint space, with special attention to articular bone surfaces and epiphyses, are analyzed. The aim of this work is to describe characteristic inflammatory changes present on X-ray imaging typical for the most commonly diagnosed rheumatic diseases in children, such as juvenile idiopathic arthritis, systemic lupus erythematosus, systemic scleroderma, mixed connective tissue disease, juvenile dermatomyositis, juvenile spondyloarthropathy and systemic vascular disease.
doi:10.12659/PJR.889816
PMCID: PMC3965289  PMID: 24669280
radiograms; arthritis in children; imaging; juvenile idiopathic arthritis; juvenile spondyloarthropathies
25.  The role of ultrasonography in the diagnosis of rheumatoid arthritis and peripheral spondyloarthropathies 
Summary
In recent years a dynamic development of ultrasound technology has been observed. Consequently, ultrasound is increasingly being utilized in rheumatology. With the introduction of high-frequency (up to 18 MHz) linear probes, sensitive Doppler techniques, harmonic imaging options and cross beams, ultrasound is used in the initial diagnosis of rheumatic diseases, monitoring of the effectiveness of treatment and confirmation of remission.
Ultrasound cannot identify specific rheumatic diseases, but it does allow for an evaluation of the type of pathology, including an assessment of disease progression and its location. These irregularities include: synovial pathologies, effusion, tendon, cartilage and bone lesions, tendon and ligament pathology at the site of their insertion (enthesopathies). This publication discusses the wide spectrum of changes in peripheral joints and entheses observed on ultrasound. Special consideration is given to the ultrasound, which besides an MRI is a leading diagnostic tool in the diagnosis of early stages of the disease and monitoring of disease progression.
doi:10.12659/PJR.889864
PMCID: PMC3969051  PMID: 24688619
Ultrasonography; Spondylarthropathies; Ultrasonography; Arthritis; Juvenile

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