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4.  Pneumonia in the immunocompetent patient 
The British Journal of Radiology  2010;83(996):998-1009.
Pneumonia is an acute inflammation of the lower respiratory tract. Lower respiratory tract infection is a major cause of mortality worldwide. Pneumonia is most common at the extremes of life. Predisposing factors in children include an under-developed immune system together with other factors, such as malnutrition and over-crowding. In adults, tobacco smoking is the single most important preventable risk factor. The commonest infecting organisms in children are respiratory viruses and Streptoccocus pneumoniae. In adults, pneumonia can be broadly classified, on the basis of chest radiographic appearance, into lobar pneumonia, bronchopneumonia and pneumonia producing an interstitial pattern. Lobar pneumonia is most commonly associated with community acquired pneumonia, bronchopneumonia with hospital acquired infection and an interstitial pattern with the so called atypical pneumonias, which can be caused by viruses or organisms such as Mycoplasma pneumoniae. Most cases of pneumonia can be managed with chest radiographs as the only form of imaging, but CT can detect pneumonia not visible on the chest radiograph and may be of value, particularly in the hospital setting. Complications of pneumonia include pleural effusion, empyema and lung abscess. The chest radiograph may initially indicate an effusion but ultrasound is more sensitive, allows characterisation in some cases and can guide catheter placement for drainage. CT can also be used to characterise and estimate the extent of pleural disease. Most lung abscesses respond to medical therapy, with surgery and image guided catheter drainage serving as options for those cases who do not respond.
PMCID: PMC3473604  PMID: 21088086
5.  Coverage of axillary lymph nodes with high tangential fields in breast radiotherapy 
The British Journal of Radiology  2010;83(996):1072-1076.
The aim of this study is to evaluate the coverage of axillary nodal volumes with high tangent fields (HTF) in breast radiotherapy and to determine the utility of customised blocking. The treatment plans of 30 consecutive patients with early breast cancer were evaluated. The prescription dose was 50 Gy to the whole breast. Axillary level I–II lymph node volumes were delineated and the cranial border of the tangential fields was set just below the humeral head to create HTF. Dose–volume histograms (DVH) were used to calculate the doses received by axillary nodal volumes. In a second planning set, HTF were modified with multileaf collimators (MLC-HTF) to obtain an adequate dose coverage of axillary nodes. The mean doses of the axillary nodes, the ipsilateral lung and heart were compared between the two plans (HTF vs MLC-HTF) using a paired sample t-test. The doses received by 95% of the breast volumes were not significantly different for the two plans. The doses received by 95% of the level I and II axillary volumes were 16.79 Gy and 11.59 Gy, respectively, for HTF, increasing to 47.2 Gy and 45.03 Gy, respectively, for MLC-HTF. Mean lung doses and per cent volume of the ipsilateral lung receiving 20 Gy (V20) were also increased from 6.47 Gy and 10.47%, respectively, for HTF, to 9.56 Gy and 16.77%, respectively, for MLC-HTF. Our results suggest that HTF do not adequately cover the level I and II axillary lymph node regions. Modification of HTF with MLC is necessary to obtain an adequate coverage of axillary levels without compromising healthy tissue in the majority of the patients.
PMCID: PMC3473605  PMID: 21088091
6.  Ureteric sarcoidosis — a rare entity 
The British Journal of Radiology  2010;83(996):e247-e248.
Primary ureteric involvement in sarcoidosis is very rare; to our knowledge, only a few cases have been reported in the literature. We present here a rare case of ureteric sarcoidosis presenting with obstructive uropathy.
PMCID: PMC3473606  PMID: 21088080
7.  CT evaluations of focal liver reactions following stereotactic body radiotherapy for small hepatocellular carcinoma with cirrhosis: relationship between imaging appearance and baseline liver function 
The British Journal of Radiology  2010;83(996):1063-1071.
This study aimed to assess the imaging appearances of focal liver reactions following stereotactic body radiotherapy (SBRT) for small hepatocellular carcinoma (HCC) and to examine relationships between imaging appearance and baseline liver function. We retrospectively studied 50 lesions in 47 patients treated with SBRT (30–40 Gy in 5 fractions) for HCC, who were followed up for more than 6 months. After SBRT, all patients underwent regular follow-ups with blood tests and dynamic CT scans. At a median follow-up of 18.1 months (range 6.2–43.7 months), all lesions but one were controlled. 3 density patterns describing focal normal liver reactions around HCC tumours were identified in pre-contrast, arterial and portal-venous phase scans: iso/iso/iso in 4 patients (Type A), low/iso/iso in 8 patients (Type B) and low/iso (or high)/high in 38 patients (Type C). Imaging changes in the normal liver surrounding the treated HCC began at a median of 3 months after SBRT, peaked at a median of 6 months and disappeared 9 months later. Liver function, as assessed by the Child–Pugh classification, was the only factor that differed significantly between reactions to treatment showing “non-enhanced” (Type A and B) and “enhanced” (Type C) appearances in CT. Hence, liver tissue with preserved function is more likely to be well enhanced in the delayed phase of a dynamic contrast-enhanced CT scan. The CT appearances of normal liver seen in reaction to the treatment of an HCC by SBRT were therefore related to background liver function and should not be misread as recurrence of HCC.
PMCID: PMC3473607  PMID: 21088090
8.  Molecular radiotherapy — the radionuclide raffle? 
The British Journal of Radiology  2010;83(996):995-997.
PMCID: PMC3473608  PMID: 21088085
9.  A case of pneumonitis and encephalitis associated with human herpesvirus 6 (HHV-6) infection after bone marrow transplantation 
The British Journal of Radiology  2010;83(996):e255-e258.
Human herpesvirus 6 (HHV-6)-associated encephalitis or pneumonitis has been reported in immunocompetent and immunosuppressed individuals. Several MRI studies in patients with HHV-6-associated encephalitis have been presented. However, to the best of our knowledge, no studies describing thin-section CT imaging in patients with HHV-6-associated pneumonitis have been reported. Here we describe a case of HHV-6-associated encephalitis and pneumonitis that developed after bone marrow transplantation. Thin-section CT images of the chest revealed ground-glass attenuation, consolidation and centrilobular nodules in both lungs.
PMCID: PMC3473609  PMID: 21088083
10.  Percentage of signal intensity loss for characterisation of focal liver lesions in patients with chronic liver disease using ferucarbotran-enhanced MRI 
The British Journal of Radiology  2010;83(996):1023-1028.
The purpose of this study was to determine the percentage of signal intensity loss (PSIL) threshold for the characterisation of focal liver lesions among patients with chronic liver disease. 55 nodules in 49 patients with chronic liver disease who underwent ferucarbotran-enhanced MR studies were included. Among the 49 patients, 40 had liver cirrhosis and 9 had chronic hepatitis. 8 haemangiomas, 3 focal nodular hyperplasia, 9 dysplastic nodules and 12 well, 19 moderately and 4 poorly differentiated hepatocellular carcinomas (HCCs) were revealed. The PSIL, signal-to-noise ratio and contrast-to-noise ratio of each lesion type were calculated. The diagnostic performance of PSIL on ferucarbotran-enhanced T2 weighted images (PSILT2WI) and T2 weighted fat-suppression images (PSILFS-T2WI) that characterised hepatic tumours was compared with receiver operating characteristic (ROC) analysis. Using ROC analysis, the diagnostic performance of PSILFS-T2WI was superior to that of PSILT2WI (p = 0.01). The mean PSILFS-T2WI of the benign lesions was significantly higher than that of HCC (p<0.001), and the mean PSILFS-T2WI of well-differentiated HCC was significantly higher than that of moderately/poorly differentiated HCCs (p = 0.001). With a PSILFS-T2WI threshold of 40% in lesions characterising ferucarbotran-enhanced FS-T2WI, the sensitivity, specificity, accuracy, positive predictive value and negative predictive value were 88.6%, 95%, 90.9%, 96.9% and 82.6%, respectively. In conclusion, with ferucarbotran-enhanced FS-T2WI, a PSILFS-T2WI threshold of 40% for characterising focal liver nodules among patients with chronic liver disease is recommended. It is useful for distinguishing HCC from benign nodules.
PMCID: PMC3473610  PMID: 20413445
11.  Population exposure to ionising radiation from CT examinations in Aosta Valley between 2001 and 2008 
The British Journal of Radiology  2010;83(996):1042-1051.
Recent and continuous advances in CT, such as the development of multislice CT, have promoted a rapid increase in its clinical application. Today, CT accounts for approximately 10% of the total number of medical radiographic procedures worldwide. However, the growing performance of the new CT generations have increased not only the diagnostic opportunities, but also the radiation dose to the patient. The relative contribution to the collective radiation dose is now estimated to be approximately 50%. Several papers have been published concerning the intensive use of CT and its contribution to the collective dose. However, most of the literature concerns the years 1997–2003 and the dosimetric evaluations are generally limited to the main standard protocols (chest, head and abdomen), deriving the effective dose by the simple application of the diagnostic reference levels. Only specific dosimetric analyses of single and innovative procedures have been published recently. Moreover, few data comes from Italian radiology departments. This paper aims to bridge these gaps. Firstly, it characterises in terms of measured CT dose index (CTDI) two last-generation scanners of the Radiological Department of Aosta Hospital. Secondly, it evaluates the effective dose from most of the CT examinations performed from 2001 to 2008 to compare protocols and technologies in line with the suggestions of the 2007 Recommendations of the International Commission on Radiological Protection, Publication 103. Finally, it estimates the collective dose to the population.
PMCID: PMC3473611  PMID: 21088089
12.  Development, implementation and evaluation of a dedicated metal artefact reduction method for interventional flat-detector CT 
The British Journal of Radiology  2010;83(996):1052-1062.
The purpose of this study was to develop, implement and evaluate a dedicated metal artefact reduction (MAR) method for flat-detector CT (FDCT). The algorithm uses the multidimensional raw data space to calculate surrogate attenuation values for the original metal traces in the raw data domain. The metal traces are detected automatically by a three-dimensional, threshold-based segmentation algorithm in an initial reconstructed image volume, based on twofold histogram information for calculating appropriate metal thresholds. These thresholds are combined with constrained morphological operations in the projection domain. A subsequent reconstruction of the modified raw data yields an artefact-reduced image volume that is further processed by a combining procedure that reinserts the missing metal information. For image quality assessment, measurements on semi-anthropomorphic phantoms containing metallic inserts were evaluated in terms of CT value accuracy, image noise and spatial resolution before and after correction. Measurements of the same phantoms without prostheses were used as ground truth for comparison. Cadaver measurements were performed on complex and realistic cases and to determine the influences of our correction method on the tissue surrounding the prostheses. The results showed a significant reduction of metal-induced streak artefacts (CT value differences were reduced to below 22 HU and image noise reduction of up to 200%). The cadaver measurements showed excellent results for imaging areas close to the implant and exceptional artefact suppression in these areas. Furthermore, measurements in the knee and spine regions confirmed the superiority of our method to standard one-dimensional, linear interpolation.
PMCID: PMC3473612  PMID: 20858662
13.  An atypical cause of trigeminal neuralgia and panhypopituitarism 
The British Journal of Radiology  2010;83(996):1087-1089.
PMCID: PMC3473613  PMID: 21088093
14.  CT-guided radiofrequency liver tumour ablation: use of a two-step coaxial system with a fine guide needle wire unit for high-risk cases 
The British Journal of Radiology  2010;83(996):1077-1079.
Accurate radiofrequency (RF) needle targeting to liver lesions under CT guidance is technically difficult and generally requires multiple needle manipulations, which carries potential risk. This approach is hardly applicable for precariously located lesions or for patients who have difficulty holding their breath. The aim of this study was to develop a novel two-step coaxial system to facilitate CT-guided RF ablation in difficult cases. The study group comprised 11 patients with 12 hepatic lesions. The coaxial system consisted of two parts: a 21-gauge pencil-tip guide needle wire (GNW) unit comprising a 150-mm-long needle segment and a 250-mm-long wire segment; and a 140-mm-long outer cannula with its stylet, which accepts a 17-gauge RF electrode needle. The GNW was inserted until the route of the GNW was confirmed to be positioned correctly. The cannula with the stylet was then advanced along the GNW. Lesions were successfully accessed using the GNW, even in patients who could not hold their breath, and manipulation was feasible within the limited space of the CT gantry. The light GNW also facilitated step-by-step CT-guided angular manipulations, unlike heavy RF electrodes, which are unstable during hands-free use unless deeply inserted. Therefore, this system enabled sequential ablations of large tumours by ensuring three different routes in advance by using the GNW. Insertion of the cannula along the GNW was simple. In conclusion, the two-step coaxial system enabled CT-guided RF tumour ablation to be performed in cases conventionally contraindicated owing to high risk of serious complications.
PMCID: PMC3473614  PMID: 21088092
16.  Diagnostic efficacy of gadoxetic acid-enhanced MRI in the detection of hepatocellular carcinomas: comparison with gadopentetate dimeglumine 
The British Journal of Radiology  2010;83(996):1010-1016.
This study compared the efficacy of gadoxetic acid-enhanced MRI and gadopentetate dimeglumine-enhanced MRI in the detection of small hepatocellular carcinoma (HCC). Both MRI techniques were performed on 43 patients with a total of 59 HCCs (size range, 0.5–2.0 cm), with a mean interval between the two MRI studies of 3 days (range, 2–7 days). Two observers reviewed both data sets in consensus. Diagnostic accuracy and sensitivity were evaluated using the alternative-free response receiver operator characteristic (ROC) method. The gadoxetic acid set showed a trend toward increased area under the ROC curve (Az value = 0.958) compared with the gadopentetate dimeglumine set (Az value = 0.927), but the difference was not significant (p = 0.362). The sensitivity of the gadoxetic acid set (n = 51, 86.4%) was significantly higher than that of the gadopentetate dimeglumine set (n = 38, 64.4%) (p = 0.0001). Gadoxetic acid-enhanced MRI is a more sensitive diagnostic tool for detection of HCC than gadopentetate dimeglumine-enhanced MRI.
PMCID: PMC3473616  PMID: 20682591
17.  Radiation dose evaluation in multidetector-row CT imaging for acute stroke with an anthropomorphic phantom 
The British Journal of Radiology  2010;83(996):1029-1041.
This study evaluated radiation dose and dose reduction in CT imaging for acute stroke. Radiation doses in three types of CT imaging (i.e. non-contrast-enhanced CT, CT perfusion (CTP) and CT angiography (CTA)) were measured with an in-phantom dosimetry system for 4-, 16- and 64-detector CT scanners in 5 hospitals. To examine the relationship between image quality and radiation dose in CTA, image contrast-to-noise ratio was evaluated. Doses to the brain, lens, salivary glands and local skin obtained with scan protocols in routine use were: 42–71 mGy, 30–88 mGy, 3.9–7.3 mGy and 40–97 mGy in non-contrast-enhanced CT; 41–75 mGy, 9.9–10 mGy, 1.5–2.1 mGy and 107–143 mGy in CTP; and 8.2–55 mGy, 26–69 mGy, 2.0–73 mGy and 32–72 mGy in CTA. For the combination of these CT examinations, on average a patient would receive 236 mGy for the maximum local skin dose and 4.2 mSv for the effective dose evaluated by the International Commission on Radiological Protection (ICRP) 103. Effective doses in CTP in this study were less than those obtained with representative protocols of Western countries. Average effective doses in each CT examination were not more than 1.5 mSv. The use of reduced kV and a narrow scan range would be effective in dose reduction of CTA and CTP, and intermittent scanning would be essential in CTP. Although lens and maximum local skin doses were far less than the thresholds for deterministic effects, since radiation risks would be increased in repeated CT examinations, efforts should be devoted to dose reduction in stroke CT examinations.
PMCID: PMC3473617  PMID: 21088088
18.  Metastatic meningioma: positron emission tomography CT imaging findings 
The British Journal of Radiology  2010;83(996):e259-e262.
The imaging findings of a case of metastasing meningioma are described. The case illustrates a number of rare and interesting features. The patient presented with haemoptysis 22 years after the initial resection of an intracranial meningioma. CT demonstrated heterogeneous masses with avid peripheral enhancement without central enhancement. Blood supply to the larger lesion was partially from small feeding vessels from the inferior pulmonary vein. These findings correlate with a previously published case in which there was avid uptake of fluoro-18-deoxyglucose peripherally with lesser uptake centrally. The diagnosis of metastasing meningioma was confirmed on percutaneous lung tissue biopsy.
PMCID: PMC3473618  PMID: 21088084
19.  Treatment of acute middle cerebral artery occlusion with a Solitaire AB stent: preliminary experience 
The British Journal of Radiology  2010;83(996):1017-1022.
We report our initial experience with a Solitaire AB neurovascular remodeling stent device in performing cerebral embolectomy in seven patients presenting to our institution with acute stroke who were resistant to iv thrombolytic drug treatment. The main inclusion criteria were: National Institutes of Health Stroke Scale (NIHSS) score ≥10; treatment performed within 8 h from the onset of symptoms and no large hypodensity on CT; and occlusion of a major cerebral artery on the CT angiogram. An admission and a post-interventional NIHSS score were calculated for all patients by two different neurologists. Efficacy was assessed radiologically by post-treatment thrombolysis in myocardial infarction (TIMI) scores and clinically by a 30-day Modified Rankin Scale (MRS) score. The mean duration of neurointerventional treatment was 84 min. All interventions were successful, with TIMI scores of 2 or 3 achieved in 100% of patients. There was one procedural complication in our series owing to a self-detached stent and one patient had a small asymptomatic basal ganglia haemorrhage. There was improvement of more than 4 points on the NIHSS score in 5 (72%) of the patients following treatment, of whom 4 (57%) had a 30-day MRS score of ≤2. The use of a Solitaire stent in acute stroke was safe, time-efficient and encouraging; however, a larger sample size will be required to further evaluate the use of this device, which could benefit a significant number of stroke patients.
PMCID: PMC3473619  PMID: 21088087
20.  Index to Authors 2010 
The British Journal of Radiology  2010;83(996):1091-1097.
PMCID: PMC3473620
21.  Cardiac magnetic resonance imaging illustrating Anderson–Fabry disease progression 
The British Journal of Radiology  2010;83(996):e249-e251.
Anderson–Fabry disease is an X-linked lysosomal storage disorder resulting from a deficiency of the enzyme α-galactosidase A (α-Gal A) and subsequent cellular storage of the enzyme's substrate globotriaosylceramide (Gb3) and related glycosphingolipids. We report a case of Anderson–Fabry disease with cardiac involvement evaluated with cardiovascular MRI. Disease progression was observed despite enzyme replacement therapy.
PMCID: PMC3473621  PMID: 21088081
22.  Hepatic artery pseudoaneurysms arising from within a hepatocellular carcinoma 
The British Journal of Radiology  2010;83(996):e252-e254.
We report a case of a 70-year-old man with a large hepatocellular carcinoma (HCC) containing two pseudoaneurysms measuring up to 2 cm in diameter. The pseudoaneurysms and part of the HCC were supplied by branches from the middle colic artery, which arises from the superior mesenteric artery. This complex arterial vasculature was visualised on CT and confirmed with conventional angiography.
PMCID: PMC3473622  PMID: 21088082
23.  MRI findings of uncommon non-hepatocyte origin primary liver tumours with pathological correlation 
The British Journal of Radiology  2010;83(996):1080-1086.
The objective of this article was to illustrate the MRI findings of uncommon non-hepatocyte origin primary liver tumours, correlate them with the pathological features and discuss differential diagnoses. In conclusion, the MRI findings of uncommon benign and malignant non-hepatocyte-origin primary liver tumours vary. Awareness of characteristic MRI features can aid differential diagnosis and prevent unnecessary surgery.
PMCID: PMC3473623  PMID: 20923912
24.  Diagnosis of colonic volvulus: findings on multidetector CT with three-dimensional reconstructions 
The British Journal of Radiology  2010;83(995):983-990.
Large bowel volvulus is a rare condition that can occur in patients who present with acute abdominal pain. Radiologists should be able to recognise its appearance on multidetector CT (MDCT) images so that the correct diagnosis can be made and catastrophic consequences can be avoided. In this article, we discuss and illustrate the MDCT and three-dimensional appearance of the various forms of large bowel volvulus. As MDCT allows the precise diagnosis of topography, mechanism and severity, this technique can provide an accurate assessment of large bowel volvulus.
PMCID: PMC3473716  PMID: 20965909
25.  MRI appearance of the pancreas in patients with cystic fibrosis: a comparison of pancreas volume in diabetic and non-diabetic patients 
The British Journal of Radiology  2010;83(995):921-926.
We investigated differences in the volume of the pancreas in cystic fibrosis (CF) patients with and without diabetes using MRI to study the natural history of CF-related diabetes (CFRD). We investigated 29 pancreas-insufficient adult CF patients, 13 with CFRD and 16 without diabetes. Patients with CFRD were receiving insulin therapy at the time of study. None of the non-diabetic CF patients had evidence of impaired glucose tolerance. Pancreas volume was estimated by MRI scans using T1 weighted fat-suppression sequences and assessed by an examiner who was unaware of the patients’ diabetes status. Pancreas volume of CF patients was measured and subsequently compared with that of non-CF age-matched Type 1 diabetes (T1DM) patients and healthy controls previously investigated. The two CF groups were matched for age and gender. There were no differences in spirometry values, body mass index or pancreatic exocrine function. The pancreas was visible by MRI in only 3 of 13 (23.1%) patients with CFRD and in 5 of 16 (31.3%) patients without diabetes (p-value = 0.7). In total, the pancreas was not detected by MRI as an anatomical entity in 21 of 29 (72.4%) CF patients, irrespective of their diabetes status. When comparing the four study groups, the pancreas was significantly smaller in CF patients than in T1DM patients and healthy controls.
PMCID: PMC3473715  PMID: 20965902

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