Comparison between MRI and CEUS in the follow-up of patients with blunt abdominal trauma managed conservatively

The Diagnosis and Management of Pediatric Blunt Abdominal Trauma-A Comprehensive Review

Blunt abdominal trauma in childhood has always been full of diagnostic and therapeutic challenges that have tested the clinical and radiological skills of pediatric surgeons and radiologists. Despite the guidelines and the studies carried out so far, to this day, there is no absolute consensus on certain points of view. Around the world, a paradigm shift towards non-operative treatment of hemodynamically stable children, with low complication rates, is noticeable. Children with blunt abdominal trauma require a standardized methodology to provide the best possible care with the best possible outcomes. This comprehensive review systematizes knowledge about all aspects of caring for children with blunt abdominal trauma, from pre-hospital to post-hospital care.

Management of Blunt Pancreatic Trauma in Children: A Persistent Controversy-Case Report and Comprehensive Literature Review

Blunt pancreatic injury (BPI) is relatively uncommon in children, and is associated with relatively high morbidity and mortality, especially if diagnosis is delayed. The aim of this report is to review the literature regarding controversial questions in the early diagnosis and management of pediatric BPI. A representative case of blunt pancreatic trauma in a six-year-old girl with delayed diagnosis and intraoperative and postoperative complications was described. A systematic search of databases and the grey literature in Scopus and Web of Science using relevant keywords was conducted. A total of 26 relevant articles published in last 5 years were found in PubMed. Although early CT performance is considered part of initial pancreatic trauma workup, the sensitivity of CT for detecting main pancreatic duct injuries in children is relatively low. MRCP and ERCP (if available) are useful for assessing ductal injury and should be performed when the status of the pancreatic duct is unclear on the CT. Most patients with low-grade pancreatic damage may be treated conservatively. Although surgery involving distal pancreatectomy remains the preferred approach for most children with high-grade pancreatic injury, there is growing evidence to suggest that non-operative management (NOM) is safe and effective. Most pancreatic pseudo cysts following NOM had relatively mild complications, and most resolved spontaneously. For those children who do require surgery, a conservative operative approach with the least risk is advocated. In conclusion, the optimal management for pediatric pancreatic trauma is controversial. Further clinical trials are required to generate clinical practice guidelines on pancreatic trauma in a child population.

Spread and feasibility of non-operative management (NOM) of traumatic splenic injuries in adults: a national survey

In hemodynamically stable adults sustaining a splenic trauma, non-operative management (NOM) represents the standard approach even in high-severity injuries. However, knowledge, structural, and logistic limitations still reduce its wider diffusion. This study aims to identify such issues to promote the safe and effective management of these injuries.A survey was developed using the SurveyMonkey® software and spread nationally in Italy. The survey was structured into: (1) Knowledge of classification systems; (2) Availability to refer patients; (3) Patients monitoring and follow-up; (4) Center-related.The survey was filled in by 327 surgeons, with a completeness rate of 63%. Three responders out of four are used to manage trauma patients. Despite most responders knowing the existing classifications, their use is still limited in daily practice. If a patient needs to be centralized, the concern about possible clinical deterioration represent the main obstacle to achieving a NOM. The lack of protocols does not allow standardization of patient surveillance according to the degree of injury. The imaging follow-up is not standardized as well, varying between computed tomography, ultrasound, and contrast-enhanced ultrasound.The classification systems need to be spread to all the trauma-dedicated physicians, to speak a common language. A more rational centralization of patients should be promoted, ideally through agreements between peripheral and reference centers, both at regional and local level. Standardized protocols need to be shared nationally, as well as the clinical and imaging follow-up criteria should be adapted to the local features.

Contrast-enhanced ultrasound (CEUS) in the follow-up of abdominal solid organ trauma: an international survey prior to the PseAn study

BACKGROUND

The blunt and penetrating abdominal trauma follow-up relies on contrast CT scan to detect solid organ injuries. CEUS is not widely used worldwide, despite its accuracy and feasibility in identifying parenchymal and vascular lesions. This survey aims to define the current use of CEUS in Trauma Centers and the expectations of Emergency Surgeons regarding its role.

METHODS

We sent an online questionnaire composed of 10 questions to trauma physicians worldwide during the period of September 2022 to March 2023.

RESULTS

59 participants from 53 different centers answered the questionnaire. 76.2% of the enrolled participants have CEUS available at their Institution, and 49.2% think that it can replace CT scan. Contrast-CT scan remains the preferred option in the follow-up of blunt liver (69.5%), spleen (72.9%) and kidney (76.3%) injuries, followed by CEUS which is used in 18.6% for liver, 20.3% for spleen and 15.3% for kidney injuries. The results are similar for penetrating abdominal trauma, with contrast CT scan being the first-line imaging technique (91.5% for liver, 91.5% for spleen and 88.1% for kidney injuries), followed by CEUS (5.1% for liver, 5.1% for spleen and 6.8% for kidney injuries).

CONCLUSIONS

Our survey shows that CEUS is still underutilized in the follow-up of abdominal trauma, even though many emergency surgeons consider it as a valid alternative to contrast CT scan.

[Blunt abdominal trauma in children and adolescents: treatment concepts in the acute phase]

Fatal accidents due to blunt force trauma are the leading cause of death in children and adolescents [1]. Abdominal trauma is the third most common cause of death after traumatic brain injury and thoracic injuries [2]. Abdominal injury is seen in approximately 2-5% of children involved in accidents [3]. Blunt abdominal injuries are common sequelae of traffic accidents (for example as seat belt injury), falls, and sports accidents. Penetrating abdominal injuries are rare in central Europe. Spleen, liver, and kidney lacerations are the most common injuries after blunt abdominal trauma [4]. In most situations, nonoperative management (NOM) has become the gold standard with the surgeon leading the multidisciplinary treatment [5].

A Nomogram Based on Contrast-Enhanced Ultrasound to Predict the Microvascular Invasion in Hepatocellular Carcinoma

OBJECTIVE

The aim of this study was to establish and validate a contrast-enhanced ultrasound (CEUS) nomogram for pre-operative microvascular invasion (MVI) prediction in hepatocellular carcinoma (HCC), and compare it with the nomogram based on gadopentetate dimeglumine-enhanced magnetic resonance imaging (Gd-MRI).

METHODS

A total of 251 patients with a single HCC were enrolled in this prospective study, including 176 patients in the training cohort and 75 patients in the validation cohort. Contrast-enhanced ultrasound (CEUS) with Sonazoid and Gd-MRI was performed pre-operatively. Post-operative histopathology was the gold standard for MVI. Univariate and multivariate logistic regression was performed to determine independent risk factors for MVI. Nomograms based on CEUS and Gd-MRI were established, and their discrimination, calibration and decision curve analysis were evaluated and compared.

RESULTS

Multivariate logistic regression revealed that arterial circular enhancement, non-enhancing area and thick ring-like enhancement in the post-vascular phase were independent risk factors for MVI. The areas under the receiver operating characteristic curve of the nomogram were 0.841 (0.779-0.892) and 0.914 (0.827-0.966) in the training and validation cohorts, with no significant difference compared with the Gd-MRI nomogram (p = 0.294, 0.321). The C-indexes were 0.821 and 0.870 in the training and validation cohorts. Decision curve analysis revealed that the CEUS nomogram had better clinical applicability than the Gd-MRI nomogram when the threshold probability was between 0.35 and 0.95.

CONCLUSION

The CEUS-based nomogram was available for predicting MVI in HCC, and its predictive performance was not inferior to that of Gd-MRI.

Non-Operative Management of Polytraumatized Patients: Body Imaging beyond CT

In the transition from the operative to the conservative approach for the polytraumatized patients who undergo blunt trauma, diagnostic imaging has assumed a pivotal role, currently offering various opportunities, particularly in the follow-up of these patients. The choice of the most suitable imaging method in this setting mainly depends on the injury complications we are looking for, the patient conditions (mobilization, cooperation, medications, allergies and age), the biological invasiveness, and the availability of each imaging method. Computed Tomography (CT) represents the “standard” imaging technique in the polytraumatized patient due to the high diagnostic performance when a correct imaging protocol is adopted, despite suffering from invasiveness due to radiation dose and intravenous contrast agent administration. Ultrasound (US) is a readily available technology, cheap, bedside performable and integrable with intravenous contrast agent (Contrast enhanced US—CEUS) to enhance the diagnostic performance, but it may suffer particularly from limited panoramicity and operator dependance. Magnetic Resonance (MR), until now, has been adopted in specific contexts, such as biliopancreatic injuries, but in recent experiences, it showed a great potential in the follow-up of polytraumatized patients; however, its availability may be limited in some context, and there are specific contraindications, such as as claustrophobia and the presence non-MR compatible devices. In this article, the role of each imaging method in the body-imaging follow-up of adult polytraumatized patients will be reviewed, enhancing the value of integrated imaging, as shown in several cases from our experience.

Management of pediatric blunt abdominal trauma with split liver or spleen injuries: a retrospective study

BACKGROUND

Blunt abdominal trauma is a prevailing cause of pediatric morbidity and mortality. It constitutes the most frequent type of pediatric injuries. Contrast-enhanced sonography (CEUS) and contrast-enhanced computed tomography (CECT) are considered pivotal diagnostic modalities in hemodynamically stable patients.

AIM

To report the experience in management of pediatric split liver and spleen injuries using CEUS and CECT.

PATIENTS AND METHODS

This study included 246 children who sustained blunt abdominal trauma, and admitted and treated at three tertiary hospitals in the period of 5 years. Primary resuscitation was offered to all children based on the advanced trauma and life support (ATLS) protocol. A special algorithm for decision-making was followed. It incorporated the FAST, baseline ultrasound (US), CEUS, and CECT. Patients were treated according to the imaging findings and hemodynamic stability.

RESULTS

All 246 children who sustained a blunt abdominal were studied. Patients' age was 10.5 ± 2.1. Road traffic accidents were the most common cause of trauma; 155 patients (63%). CECT showed the extent of injury in 153 patients' spleen (62%) and 78 patients' liver (32%), while the remaining 15 (6%) patients had both injuries. CEUS detected 142 (57.7%) spleen injury, and 67 (27.2%) liver injury.

CONCLUSIONS

CEUS may be a useful diagnostic tool among hemodynamically stable children who sustained low-to-moderate energy isolated blunt abdominal trauma. It may be also helpful for further evaluation of uncertain CECT findings and follow-up of conservatively managed traumatic injuries.

Detection of post-traumatic abdominal pseudoaneurysms by CEUS and CT: A prospective comparative global study (the PseAn study)-study protocol

The success of non-operative management in trauma increased with the availability of new-generation CT scan machines, endoscopy, and angiography, becoming the standard of care in hemodynamically stable trauma patients with abdominal solid organ injuries, with a success rate of 78% to 98%. Post-traumatic pseudoaneurysms (PAs) can develop at any region of an injured artery and they may cause delayed bleeding in splenic or hepatic trauma, with an incidence in patients treated with NOM of 2%-27% and 1.2%-6.1% respectively. Diagnosis is made by angiography, contrast-enhanced computer tomography (CT), or Doppler Ultrasound (US) while the use of contrast-enhanced ultrasound (CEUS), has increased in recent years although few data are available about CEUS feasibility in the follow-up setting. The PseaAn study has been designed to assess the role of CEUS in the follow-up of abdominal trauma by defining its sensitivity, specificity and predictive values compared with abdominal CT scan. The PseAn study is a multi-centric international diagnostic cross-sectional study initiated by the Level I Trauma Center of the Niguarda Ca' Granda Hospital in Milan, Italy. To study the role of CEUS in detecting post-traumatic splenic, hepatic, and renal PAs compared with the gold standard of CT with intravenous contrast at different follow-up time points, and whether it can replace CT scan in the follow-up of solid organ injuries, patients with OIS III and above will undergo a follow-up with both a CEUS and CT scan to detect post-traumatic parenchymal pseudoaneurysm within two to five days from injury. The use of CEUS in the follow-up of abdominal trauma follow-up (particularly blunt trauma) has increased, to minimise the use of ionizing radiation and contrast media and encouraging results have been published during the last decade showing that CEUS is an accurate technique for evaluating traumatic lesions of solid abdominal organs. Conclusions We think that CEUS, which is underused worldwide, is a useful and safe tool that may replace CT scan in follow-up with the major advantage of reduced radiation. Our current study may give stronger evidence to support this view.

The Technique and Advantages of Contrast-Enhanced Ultrasound in the Diagnosis and Follow-Up of Traumatic Abdomen Solid Organ Injuries

Trauma is one of the most common causes of death or permanent disability in young people, so a timely diagnostic approach is crucial. In polytrauma patients, CEUS (contrast enhanced ultrasound) has been shown to be more sensitive than US (ultrasound) for the detection of solid organ injuries, improving the identification and grading of traumatic abdominal lesions with levels of sensitivity and specificity similar to those seen with MDCT (multidetector tomography). CEUS is recommended for the diagnostic evaluation of hemodynamically stable patients with isolated blunt moderate-energy abdominal traumas and the diagnostic follow-up of conservatively managed abdominal traumas. In this pictorial review, we illustrate the advantages and disadvantages of CEUS and the procedure details with tips and tricks during the investigation of blunt moderate-energy abdominal trauma as well as during follow-up in non-operative management.

Contrast-enhanced ultrasound of blunt abdominal trauma in children

Trauma is the leading cause of morbidity and mortality in children, and rapid identification of organ injury is essential for successful treatment. Contrast-enhanced ultrasound (CEUS) is an appealing alternative to contrast-enhanced CT in the evaluation of children with blunt abdominal trauma, mainly with respect to the potential reduction of population-level exposure to ionizing radiation. This is particularly important in children, who are more vulnerable to the hazards of ionizing radiation than adults. CEUS is useful in hemodynamically stable children with isolated blunt low- to moderate-energy abdominal trauma to rule out solid organ injuries. It can also be used to further evaluate uncertain contrast-enhanced CT findings, as well as in the follow-up of conservatively managed traumatic injuries. CEUS can be used to detect abnormalities that are not apparent by conventional US, including infarcts, pseudoaneurysms and active bleeding. In this article we present the current experience from the use of CEUS for the evaluation of pediatric blunt abdominal trauma, emphasizing the examination technique and interpretation of major abnormalities associated with injuries in the liver, spleen, kidneys, adrenal glands, pancreas and testes. We also discuss the limitations of the technique and offer a review of the major literature on this topic in children, including an extrapolation of experience from adults.

Role of MRI in early follow-up of patients with solid organ injuries: How and why we do it?

Trauma represents one of the most common causes of death or permanent disability in the population below 50 years. At present, non-operative treatment is the commonly adopted strategy in hemodynamically stable patients with solid organ injuries, when there are not concomitant bowel and mesenteric injuries requiring a prompt surgical approach, but it may require multiple imaging follow-up examinations, especially in the case of major injuries. No data are available about magnetic resonance imaging utilization in the early follow-up of trauma patients with solid organ injuries, particularly in liver and spleen trauma. We report our preliminary experience in this field.

Application of Contrast-Enhanced Ultrasonography (CEUS) in the Assessment of Kidney Wound Recovery After Nephron-Sparing Surgery

Purpose

To investigate feasibility, repeatability and usefulness of contrast-enhanced ultrasonography (CEUS) in the assessment of kidney wound recovery after laparoscopic nephron-sparing surgery (LNSS) or robot-assisted nephron-sparing surgery (RANSS) and preliminarily research the clinical factors associated with the length of extravasation (LOE).

Patients and Methods

From April 2019 to January 2020, 130 patients that underwent LNSS or RANSS in our hospital were included, and 90 patients (90/130) received CEUS examinations each one day from the postoperative day 1. The discovery of the cessation of contrast medium extravasation from the renal wound was the primary endpoint named "ultrasonic healing", and LOE ranged from the day of surgery to "ultrasonic healing". Patient, tumor, perioperative factors and LOE were collected. Univariate analysis and multivariate linear regression analysis were applied for the determination of factors associated with LOE.

Results

The average postoperative LOE was 1.76 days (standard deviation, 1.115; 95% confidence interval: 1.52-1.99). Ultrasonic healing within three days was observed in 95.6% patients (86/90). Univariable and multivariable analyses showed that R and A components in R.E.N.A.L. nephrometry score were associated with LOE. Anterior location and R component score of 2 (tumor size>4cm) were related to longer LOE than posterior location and R score of 1 (tumor size<4cm). The incidence of complications in patients with LOE over one day was higher than those with LOE of one day.

Conclusion

CEUS was feasible, repeatable and useful in the assessment of kidney wound recovery. Tumor size and location were related to LOE after minimally invasive nephron-sparing surgery (MINSS). Length of stay after MINSS within three days might be relatively safe.

Magnetic Resonance Imaging, the Virtual Biopsy of Mesenteric Masses

ABSTRACT

The mesentery may be affected by multiple disease processes. Magnetic resonance imaging aids as a virtual pathological biopsy tool in the assessment of mesenteric masses because of superior soft tissue contrast and characterization. In this comprehensive review, we describe in detail the magnetic resonance imaging features of some solid and cystic mesenteric masses, with an emphasis on lesion-specific signal characteristics on T1- and T2-weighted images, diffusion-weighted imaging, and enhancement features on the dynamic postcontrast phase that aid in narrowing the differential diagnosis.

Contrast-Enhanced Ultrasound (CEUS) in Non-Traumatic Abdominal Emergencies

Conventional ultrasound imaging (US) is the first-line investigation in acute non-traumatic abdominal emergencies, but sometimes it needs further examinations, such as computed tomography (CT), to reach a certain diagnosis. Contrast-enhanced ultrasound (CEUS), through injection of contrast medium, may provide the radiologist with additional information that could not be investigated with baseline US. It could help reach a diagnosis and rapidly determine the proper therapy in an emergency setting. The purpose of this review is to explain and illustrate the various possibilities and limitations of CEUS in acute non-traumatic abdominal diseases, in particular acute inflammation, parenchymal infarcts, and hemorrhages.

Does contrast-enhanced ultrasound have a role in evaluation and management of pediatric renal trauma? A preliminary experience

BACKGROUND

To report our initial experience using intravenous contrast-enhanced ultrasound (CEUS) in pediatric renal trauma with the potential for substantial radiation reduction.

METHODS

A retrospective review of all patients who underwent intravenous CEUS at our institution between May 2015 and January 2018 for the suspicion of blunt renal trauma. CEUS was obtained either as an immediate or short-term comparison to contrast-enhanced computed tomography (CECT), or in outpatient follow-up.

RESULTS

CEUS was performed on 7 patients (9 kidneys) with age range 2 months to 16 years old. CEUS was utilized as a comparison to CECT in 4 of 7 patients for initial evaluation, clinical change, or short-term follow-up. CEUS alone was used in one patient with low suspicion for renal injury. In the remaining two patients, CEUS was obtained as a follow-up study weeks after the initial CECT, following conservative management. All patients with confirmed renal injury by CECT (n = 5) underwent a follow-up CEUS at 1-2 months.

CONCLUSIONS

In an era of conservative management for renal trauma in which operative intervention is dictated more often by the clinical course than radiographic findings, it is reasonable to consider alternative imaging methods such as CEUS in stable patients to decrease radiation exposure.

LEVEL OF EVIDENCE RATING

IV.

Contrast-enhanced ultrasonography (CEUS) in the follow-up of pediatric abdominal injuries: value and timing

AIMS

Primary aim was to investigate the value and safety of contrast-enhanced ultrasonography (CEUS) during follow-up (FU) of splenic, hepatic and renal post-traumatic injuries in a pediatric population. Secondary aim was to extrapolate appropriate timing of FU-CEUS.

METHODS

In a retrospective study, post-traumatic parenchymal injuries diagnosed with CT or CEUS, were subjected to non-operative management and followed with CEUS.

RESULTS

Forty-six patients were enrolled, with isolated or combined injuries, for a total of 30 splenic, 15 hepatic and 12 renal injuries. At admission 42/46 patients underwent CT and 4/46 underwent CEUS. During FU a total of 65 CEUS were performed: 16 within 72 h to check delayed active bleeding or parenchymal rupture; 24 between 5 and 10 days post admission, to pose indication to active mobilization or to discharge; 21 between 20 and 60 days post admission to document complete healing of the lesion or pose indication to discharge in most severe injuries. No complications related to CEUS were encountered.

CONCLUSIONS

CEUS is valuable and safe to follow patients with post-traumatic abdominal injuries, even if further data are needed for renal injuries. We propose a tailored approach based on injury grade and clinical course: in the first 3 days only in case of delayed bleeding or rupture suspect; between 5 and 10 days post trauma to ensure a safe active mobilization and/or pose indication to discharge, and over 20-30 days post trauma to pose indication to discharge in most severe injuries or document complete healing and permit return to sport activities.

Contrast-enhanced ultrasound (CEUS) in pediatric blunt abdominal trauma

Baseline ultrasound is the first-choice technique in traumatic hemodynamically stable children, and is essential in the early assessment of unstable patients to detect hemoperitoneum or other potentially fatal conditions. Despite the technological advancements in new ultrasound equipment and the experience of the operators, it is not always possible to rule out the presence of parenchymal traumatic lesions by means of baseline ultrasound nor to suspect them, especially in the absence of hemoperitoneum. For this reason, in the last decades, basic ultrasound has been associated with contrast-enhanced ultrasound (CEUS) to evaluate the stable little patient in cases such as low-energy blunt abdominal trauma. Because it relies on second-generation contrast agents, the CEUS technique allows for better detection of parenchymal injuries. CEUS has been demonstrated to be almost as sensitive as contrast-enhanced CT in the detection of traumatic injuries in patients affected by low-energy isolated abdominal trauma, with levels of sensitivity and specificity up to 95%. A very important point in favor of CEUS is its capacity to help distinguish the healthy patient, who can be discharged, from the one needing prolonged monitoring, operative management or hospitalization. Finally, we also have the ability to follow-up on low-grade traumatic lesions using CEUS, always keeping in mind patients' clinical conditions and their hemodynamics.

A rare case of accessory spleen torsion in a child diagnosed by ultrasound (US) and contrast-enhanced ultrasound (CEUS)

INTRODUCTION

Accessory spleen, also known as supernumerary spleen or splenunculum, is a congenital anomaly of the spleen due to a fusion defect during the embryogenesis. Usually it is detected casually during an ultrasound (US) examination of the abdomen and it is asymptomatic.

CASE REPORT

RESULTS: We present a case of a 12 years old male patient, with 2-days history of left abdominal pain, without fever, gastrointestinal or genitourinary symptoms. The day before our observation, the patient had gone to another hospital, from where he had been discharged with medical analgesic therapy, without any benefit. Blood tests were normal, the Ultrasound abdominal examination showed normal aspect of abdominal organs, but the presence in the left side of a small round parenchymal structure surrounded by hyperechogenic mesenteric fat. We interpreted this image as an accessory spleen, complicated by torsion. As the torsion of accessory spleen is a quite rare occurrence, we carried out a contrast enhanced ultrasound (CEUS) to get more information. CEUS showed the absence of enhancement of the nodular formation, suggestive for a complete lack of vascularization; the spleen was normally enhanced. While the management in case of accessory spleen torsion is non-operative, in this case the patient underwent surgical exploration, due to the persistence of abdominal pain despite the medical therapy, with clinical signs of peritoneal reaction, mimicking an acute abdomen. Surgery confirmed the diagnosis of accessory spleen torsion.

DISCUSSION AND CONCLUSIONS

In conclusion, US is the first diagnostic tool in pediatric abdominal pain and allows to direct the diagnosis; the use of CEUS helps to clarify the US reports, without leaving doubts about the parenchymal vascularization of the abdominal organ involved.

Role of contrast-enhanced ultrasound (CEUS) in the diagnosis and management of traumatic splenic injuries

Splenic injuries are common emergencies in the setting of abdominal trauma, as the spleen is the second most frequently injured abdominal organ after the liver. The treatment of splenic injuries underwent a severe shift from operative to non-operative due to an increased awareness of the double physiological function, both immunological and hematological, of the spleen. This, in turn, led to an increased application of splenic preservation techniques. The non-operative approach has been strengthened through radiological imaging and interventional radiology. While multidetector computed tomography is mandatory in the evaluation of hemodynamically stable patients after high-energy trauma, one ultrasound (US) can be used as a first-line technique to examine patients in cases of low-energy trauma. Unfortunately, baseline US has low sensitivity in the detection of traumatic injuries. With the introduction of contrast-enhanced ultrasound (CEUS) as a reliable alternative to baseline ultrasound for low-grade abdominal trauma, the sensitivity of the US technique in recognizing traumatic abdominal lesions has strongly increased, reaching levels of accuracy similar to those of the CT. It has also been strongly recommended for use with children, as it allows for the performance of imaging techniques with the lowest dose of radiation possible. In this review, the authors aim to present the typical appearance of traumatic splenic injuries, using enhanced CEUS capability to overcome baseline US limits, and to describe the different techniques applied according to the hemodynamic stability of the patient.

Dynamic MRI in the evaluation of the spine: state of the art

INTRODUCTION

Degenerative disease of the spine is a generic term encompassing a wide range of different disease processes, which leads to spinal instability; traumatic/neoplastic events can accelerate this aging process. Therefore, the dynamic nature of the spine and its mobility across multiple segments is difficult to depict with any single imaging modality.

METHODS

A review of PubMed databases for articles published about kMRI in patients with cervical and lumbar spinal desease was performed. We focused on the physiopathological changes in the transition from supine to upright position in spine instability.

DISCUSSION

Until a few years ago, X-ray was the only imaging modality for the spine in the upright position. Of the imaging techniques currently available, MRI provides the greatest range of information and the most accurate delineation of soft-tissue and osseous structures. Conventional MRI examinations of the spine usually are performed in supine position, in functional rest, but the lumbar spine instability is often shown only by upright standing. This can result in negative findings, even in the presence of symptoms. Regardless, the final result is distorted. To overcome this limitation, Kinetic MRI (kMRI) can image patients in a weight-bearing position and in flexed and extended positions, thus revealing abnormalities that are missed by traditional MRI studies.

CONCLUSION

Despite some limitations, the upright MRI can be a complementary investigation to the traditional methods when there are negative results in conventional MRI in symptomatic patients or when surgical therapy is scheduled.

Developments in the management of bone metastases with interventional radiology

Interventional radiology has known an exponential growth in the last years. Technological advances of the last decades, have made it possible to use new treatments on a larger scale, with safe and effective results. They could be considered as palliative treatments for painful lesions but also curative procedures, as single treatment or specially in combination with other techniques (surgery, radiation and oncology therapies, etc.).The main diffuse techniques are those of thermal ablation that destroy the target lesion through the heat; however there are also endovascular therapies that destroy the target tissue thanks to devascularization. Finally the is also the possibility to stabilize pathological fractures or impending fractures. In this paper all the most diffuse and effective techniques are reviewed and also a discussion of the main indications is done, with an analisys of the success and complications rates.

Diagnostic accuracy of contrast enhanced ultrasound in patients with blunt abdominal trauma presenting to the emergency department: a systematic review and meta-analysis

We aimed to investigate the diagnostic accuracy of contrast-enhanced ultrasound (CEUS) in evaluating blunt abdominal trauma for patients presenting to the emergency department. Electronic search of Scopus and Pubmed was performed from inception to September 2016. Human studies investigating the diagnostic accuracy of CEUS in identifying abdominal solid organ injuries were included. Risk of bias was assessed using the QUADAS tool. A total of 10 studies were included in the study and 9 of them were included for meta-analysis. The log(DOR) values ranged from 3.80 (95% CI: 2.81-4.79) to 8.52 (95% CI: 4.58-12.47) in component studies. The combined log(DOR) was 6.56 (95% CI: 5.66-7.45). The Cochran's Q was 11.265 (p = 0.793 with 16 degrees of freedom), and the Higgins' I² was 0%. The CEUS had a sensitivity of 0.981 (95% CI: 0.868-0.950) and a false positive rate of 0.018 (95% CI: 0.010-0.032) for identifying parenchymal injuries, with an AUC of 0.984. CEUS performed at emergency department had good diagnostic accuracy in identifying abdominal solid organ injuries. CEUS can be recommended in monitoring solid organ injuries, especially for patients managed with non-operative strategy.

MR imaging evaluation of the postoperative meniscus

MR imaging has been widely evaluated in the assessment of patients with recurrent or residual symptoms following meniscal surgery. Importantly, the causes of such symptoms may relate to failure or complication of the surgical procedure, a possible recurrent or residual meniscal tear, or may be related to other causes of joint symptoms, including tears of the contralateral meniscus, or local hyaline cartilage, or marrow abnormalities subjacent to or distant to the meniscal surgical site. The complex diagnostic issues involved in the MR imaging evaluation of the postoperative meniscus were identified in early MR imaging studies. The knowledge of the normal MR imaging appearance of the knee after the more common repair procedures will allow radiologists to recognize complications associated with such procedures. In this article, we discuss the MR imaging evaluation of the knee after meniscal surgery.

Follow-up of surgical and minimally invasive treatment of Achilles tendon pathology: a brief diagnostic imaging review

The follow-up of an operated tendon is primarily clinical, although clinical examination may not be sufficient in the presence of certain complications. The imaging techniques are of great value not only in the diagnosis of tendon pathologies, but also as an adjunct to clinical evaluation. This is particularly true in the follow-up of patients submitted to surgical tendon reconstruction, by monitoring morphological effects of different interventions and evaluating tendon healing processes. Interpretation of imaging findings requires knowledge of the imaging appearance of the operated tendon during the healing phase, to distinguish between normal postsurgical changes and real pathology, as well as knowledge of surgical technique, postoperative course (including type of prescribed therapy) and possible postoperative complications. The most important imaging modalities to examine the Achilles tendon are ultrasound and magnetic resonance imaging. This article gives a review of some of the most common treatment strategies for Achilles tendon pathology, expected postoperative imaging findings and postoperative complications.

Imaging of post-surgical treatment and of related complications in spinal trauma

Spinal trauma is a devastating event with a high morbidity and mortality. The rationale of imaging is to diagnose the traumatic abnormalities and characterize the type of injury, to estimate the severity of the lesions, to evaluate the potential spinal instability. In case of spinal instability, the goals of operative treatment are decompression of the spinal cord canal and stabilization of the disrupted vertebral column. Particularly, diagnostic imaging, mainly by CT and MR, has a main role in the post-treatment evaluation. The neuroradiological evaluation of the postoperative spine requires a general knowledge of the surgical approach to each spinal region and of the normal temporal evolution of expected postoperative changes. The neuroradiologist should evaluate the devices implanted, their related complications and promptly alert the surgeon of acute complications, mainly vascular and infective. During the follow-up, it is mandatory to know and search chronic complications as pseudomeningocele, accelerated degenerative disease, arachnoiditis, peridural fibrosis. Knowledge of specific complications relating to each surgical approach will assist the neuroradiologist in interpretation of postoperative images.

Imaging of postoperative shoulder instability

Postoperative imaging in shoulder instability is still a challenge for radiologists due to various postsurgical anatomical findings that could be considered pathologic in treated shoulder. For this reason is very important a deep knowledge about surgical procedures, anatomical changes after surgery and the appropriate diagnostic imaging modalities to work up the symptomatic postoperative shoulder. Postoperative imaging options include use conventional radiography, magnetic resonance imaging (MRI), MRI arthrography, computed tomography (CT) and CT arthrography. The purpose of our review is to explain the different surgical procedures and to describe postoperative changes detected with radiological imaging.

Pediatric musculoskeletal injuries: role of ultrasound and magnetic resonance imaging

Pediatric musculoskeletal system is particularly prone to traumatic and sports-related injuries, both acute and chronic, i.e., overuse injuries, because of inherent conditions of weakness, such as the open physis, representing the weakest aspect within the bone, the ligamentous supports and changing biomechanics. Being aware that a quick diagnosis is essential to preserve the good functionality of the limb involved, it is mandatory for the radiologist to recognize the most common patterns of these injuries, identifying those requiring a prompt surgery, as well as be confident with the technique performed, and be supported by an important background experience and knowledge skills.

Diagnostic imaging of blunt abdominal trauma in pediatric patients

Trauma is a leading cause of morbidity and mortality in childhood, and blunt trauma accounts for 80-90 % of abdominal injuries. The mechanism of trauma is quite similar to that of the adults, but there are important physiologic differences between children and adults in this field, such as the smaller blood vessels and the high vasoconstrictive response, leading to the spreading of a non-operative management. The early imaging of children undergoing a low-energy trauma can be performed by CEUS, a valuable diagnostic tool to demonstrate solid organ injuries with almost the same sensitivity of CT scans; nevertheless, as for as urinary tract injuries, MDCT remains still the technique of choice, because of its high sensitivity and accuracy, helping to discriminate between an intra-peritoneal form a retroperitoneal urinary leakage, requiring two different managements. The liver is the most common organ injured in blunt abdominal trauma followed by the spleen. Renal, pancreatic, and bowel injuries are quite rare. In this review we present various imaging findings of blunt abdominal trauma in children.

Contrast-enhanced ultrasound (CEUS) in blunt abdominal trauma

Baseline ultrasound is essential in the early assessment of patients with a huge haemoperitoneum undergoing an immediate abdominal surgery; nevertheless, even with a highly experienced operator, it is not sufficient to exclude parenchymal injuries. More recently, a new ultrasound technique using second generation contrast agents, named contrast-enhanced ultrasound (CEUS) has been developed. This technique allows all the vascular phase to be performed in real time, increasing ultrasound capability to detect parenchymal injuries, enhancing some qualitative findings, such as lesion extension, margins and its relationship with capsule and vessels. CEUS has been demonstrated to be almost as sensitive as contrast-enhanced CT in the detection of traumatic injuries in patients with low-energy isolated abdominal trauma, with levels of sensitivity and specificity up to 95%. Several studies demonstrated its ability to detect lesions occurring in the liver, spleen, pancreas and kidneys and also to recognize active bleeding as hyperechoic bands appearing as round or oval spots of variable size. Its role seems to be really relevant in paediatric patients, thus avoiding a routine exposure to ionizing radiation. Nevertheless, CEUS is strongly operator dependent, and it has some limitations, such as the cost of contrast media, lack of panoramicity, the difficulty to explore some deep regions and the poor ability to detect injuries to the urinary tract. On the other hand, it is timesaving, and it has several advantages, such as its portability, the safety of contrast agent, the lack to ionizing radiation exposure and therefore its repeatability, which allows follow-up of those traumas managed conservatively, especially in cases of fertile females and paediatric patients.