Vascular tree-in-bud sign in Pulmonary Tumour Thrombotic Microangiopathy (PTTM): CT findings for a difficult radiological early antemortem diagnosis

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Prognostic value of CT pulmonary angiography parameters in acute pulmonary embolism

OBJECTIVES

Computed tomographic pulmonary angiography (CTPA) is the first-line test in acute pulmonary embolism (APE) diagnostic algorithm, but its correlation with short-term outcome remains not clear at all. The aim is to determine whether CTPA findings can predict 30-day mortality of patients with APE in Emergency Department.

METHODS

This retrospective monocentric study involved 780 patients with APE diagnosed at the Emergency Department of our institution (period 2010-2019). These CTPA findings were evaluated: embolic obstruction burden score (Qanadli score), common pulmonary artery trunk diameter, right-to-left ventricular ratio, azygos vein and coronary sinus diameters. Comorbidities and fatal/nonfatal adverse outcomes within 30 days were recorded. Troponin I values were correlated with angiographic parameters with multiple logistic regression analysis.

RESULTS

The all-cause and APE-related 30-day mortality rates were 5.9% and 3.6%, respectively. Patients who died within 30 days were older with higher prevalence rates of malignancy. Qanadli score and all CTPA parameters correlate with Troponin I level and the presence of RVD at echocardiography (p values < 0.0001). Instead, RV/LV ratio and coronary sinus diameter correlate with 30-day mortality (p values < 0.05). At the multivariate logistic regression analysis, only coronary sinus and RVD remained significant with an HR = 2.5 (95% CI 1.1-5.6) and HR = 1.9 (95% CI 0.95-3.7), respectively.

CONCLUSION

CTPA quantification of right ventricular strain is an accurate predictor of 30-day mortality. In particular, it seems that a dilated coronary sinus (>9 mm) has an additional prognostic value in association with echocardiographic signs of right-heart disfunction and high Troponin I levels.

Chest X-ray in the emergency department during COVID-19 pandemic descending phase in Italy: correlation with patients' outcome

PURPOSE

The aims of our study are: (1) to estimate admission chest X-ray (CXR) accuracy during the descending phase of pandemic; (2) to identify specific CXR findings strictly associated with COVID-19 infection; and (3) to correlate lung involvement of admission CXR with patients' outcome.

MATERIALS AND METHODS

We prospectively evaluated the admission CXR of 327 patients accessed to our institute during the Italian pandemic descending phase (April 2020). For each CXR were searched ground glass opacification (GGO), consolidation (CO), reticular-nodular opacities (RNO), nodules, excavations, pneumothorax, pleural effusion, vascular congestion and cardiac enlargement. For lung alterations was defined the predominance (upper or basal, focal or diffuse, central or peripheric, etc.). Then radiologists assessed whether CXRs were suggestive or not for COVID-19 infection. For COVID-19 patients, a prognostic score was applied and correlated with the patients' outcome.

RESULTS

CXR showed 83% of specificity and 60% of sensitivity. GGO, CO, RNO and a peripheric, diffuse and basal prevalence showed good correlation with COVID-19 diagnosis. A logistic regression analysis pointed out GGO and a basal or diffuse distribution as independent predictors of COVID-19 diagnosis. The prognostic score showed good correlation with the patients' outcome.

CONCLUSION

In our study, admission CXR showed a fair specificity and a good correlation with patients' outcome. GGO and others CXR findings showed a good correlation with COVID-19 diagnosis; besides GGO a diffuse or bibasal distribution resulted in independent variables highly suggestive for COVID-19 infection thus enabling radiologists to signal to clinicians radiologically suspect patients during the pandemic descending phase.

Behçet disease in Emergency Department: a rare case presenting with haemoptysis and massive pulmonary arterial aneurysms

Behçet disease (BD) is a systemic disorder caused by underlying vasculitis of unknown origin. In this paper we present a case of a 26-year-old male patient who was admitted at our Emergency Department with massive haemoptysis due to pulmonary arterial involvement in BD. The discussion of this case helps to remember that BD is the main cause of aneurysm of the pulmonary arteries and a cause of haemoptysis in young patients. Therefore, the radiologist plays a key role in the identification of intrathoracic alterations with chest computed tomography. The knowledge of clinical manifestations and distinctive elements of BD allow an accurate diagnosis and let the patient to be directed towards an appropriate treatment, in order to avoid the onset of life-threatening complications.

Chest X-ray in new Coronavirus Disease 2019 (COVID-19) infection: findings and correlation with clinical outcome

Aim

The purpose of this study is to describe the main chest radiological features (CXR) of COVID-19 and correlate them with clinical outcome.

Materials and methods

This is a retrospective study involving patients with clinical-epidemiological suspect of COVID-19 infection, who performed CXRs at the emergency department (ED) of our University Hospital from March 1 to March 31, 2020. All patients performed RT-PCR nasopharyngeal and throat swab, CXR at the ED and clinical-epidemiological data. RT-PCR results were considered the reference standard. The final outcome was expressed as discharged or hospitalized patients into a medicine department or intensive care unit (ICU).

Results

Patients that had a RT-PCR positive for COVID-19 infection were 234 in total: 153 males (65.4%) and 81 females (34.6%), with a mean age of 66.04 years (range 18–97 years). Thirteen CXRs were negative for radiological thoracic involvement (5.6%). The following alterations were more commonly observed: 135 patients with lung consolidations (57.7%), 147 (62.8%) with GGO, 55 (23.5%) with nodules and 156 (66.6%) with reticular–nodular opacities. Patients with consolidations and GGO coexistent in the same radiography were 35.5% of total. Peripheral (57.7%) and lower zone distribution (58.5%) were the most common predominance. Moreover, bilateral involvement (69.2%) was most frequent than unilateral one. Baseline CXR sensitivity in our experience is about 67.1%. The most affected patients were especially males in the age group 60–79 years old (45.95%, of which 71.57% males). RALE score was slightly higher in male than in female patients. ANOVA with Games-Howell post hoc showed significant differences of RALE scores for group 1 vs 3 (p < 0.001) and 2 vs 3 (p = 0.001). Inter-reader agreement in assigning RALE score was very good (ICC: 0.92—with 95% confidence interval 0.88–0.95).

Conclusion

In COVID-19, CXR shows patchy or diffuse reticular–nodular opacities and consolidation, with basal, peripheral and bilateral predominance. In our experience, baseline CXR had a sensitivity of 68.1%. The RALE score can be used in the emergency setting as a quantitative method of the extent of SARS-CoV-2 pneumonia, correlating with an increased risk of ICU admission.

Exogenous lipoid pneumonia: when radiologist makes the difference

PURPOSE

To report high-resolution CT (HRCT) findings in our group of patients with exogenous lipoid pneumonia (ELP), confirmed with histopathological findings and clinical-anamnestic data, in order to describe the most common radiological patterns of this rare disorder.

MATERIALS AND METHODS

In this retrospective study, HRCT of 10 patients with ELP were evaluated by three radiologists. Diagnosis of ELP was made through CT, bronchiolo-alveolar lavage (BAL) and a pneumological examination associated with an accurate medical anamnesis. Five patients had a histologically proven ELP, through lung biopsy. All patients had a chronic exposition to substances made of animal fat or mineral/vegetable oils.

RESULTS

In our cohort of patients with ELP, the following parenchymal patterns were observed: 8/10 patients had lung consolidation with adipose density (attenuation values < - 40 HU); 10/10 patients had multiple areas of ground glass opacity; 6/10 patients had smooth thickening of interlobular septa and ground glass opacities ("crazy-paving" pattern); 2/10 patients presented nodules > 2.5 cm with spiculated margins (tumor-like); 5/10 patients showed reactive lymph nodes enlargement. The oldest lesions were characterized by bronchiectasis and fibrosis around the lipidic consolidations.

CONCLUSION

Pulmonary alterations found in HRCT exams can be confused with other lung diseases (especially lung tumors) and they are always a challenge even for the most experienced radiologist. In our experience, although non-specific, consolidation areas with low HU values and crazy-paving pattern are frequently associated in ELP. These characteristics should alert the radiologist to consider ELP among the possible differential diagnoses, always correlating the results of CT examination with appropriate clinical-laboratory evaluations and an accurate anamnesis.

Fibrotic lung toxicity induced by cytotoxic drugs, radiation and immunotherapy in patients treated for lung cancer

Patients treated for lung cancer may develop lung toxicity induced by chemotherapy (DILD), radiation or combined radiation recall pneumonitis. In the literature, some cases of immune-mediated pneumonitis have been reported associated with immunotherapy. The clinical and radiologic features of interstitial lung toxicity are unspecific, dyspnoea and dry cough are the most common symptoms while the most frequent radiological pattern is the cryptogenic organizing pneumonia (COP). Why only some individuals treated with these drugs develop interstitial lung toxicity is unclear.In the last few years some studies have reported the utility of KL 6 for the evaluation of DILD. The treatment is based on high doses of systemic steroids or immune suppressor. In this study we report severe interstitial lung damage in patients treated with different anti-blastic, immune and radiation therapies. Treated with surgery, chemotherapy, immuno and radiotherapy for lung cancer, they unfortunately died of severe DILD.

Lung Cancer in Patients with Severe Idiopathic Pulmonary Fibrosis: Critical Aspects

Idiopathic pulmonary fibrosis (IPF) is a rare interstitial lung disease limited to the lung with an undefined etiopathogenesis and a very short life expectancy (less than 5 years). IPF susceptibility has been associated with several genetic and environmental risk factors and the prognosis is conditioned by comorbidities such as gastro-esophageal reflux, depression, venous thromboembolism, pulmonary hypertension and lung cancer. At 5 years follow-up, 15% of IPF patients develop lung cancer, which can significantly reduce their survival. Because diagnostic or therapeutic procedures such as surgical, radiation or pharmacological treatments may induce acute exacerbations and increase mortality, the management of lung cancer in IPF patients is a very difficult task. This study discusses advantages and disadvantages of lung cancer treatments in patients with severe IPF, highlighting several controversial aspects on this topic, including potential nintedanib treatment.

Fibrotic Lung Toxicity Induced by Hydroxycarbamide

A patient treated for 4 months with hydroxycarbamide (hydroxyurea) for chronic myelomonocytic leukemia was admitted to hospital for recently developed severe dyspnea and acute respiratory failure. The computed tomographic scan of the chest showed diffuse ground glass opacities, some centrilobular low-density nodules (resembling hypersensitivity pneumonitis-like pattern), and minimal interstitial reticulation of the subpleural region. The analysis of bronchoalveolar lavage fluid excluded infection, as did serological examinations. The patient was started on oxygen therapy and with relief of thrombocytopenia and suspected hemolytic anemia, hydroxyurea treatment was discontinued. The patient underwent steroid therapy, with a rapid progressive improvement of clinical and radiological features. As hydroxyurea is increasingly used for a number of systemic disorders, physicians must be aware of its potential lung toxicity, requiring immediate cessation of the treatment and empiric corticosteroid therapy.

Traumatic lesions of corpus callosum: early multidetector CT findings

Corpus callosum is one of the common sites of brain lesion, whose involvement is an indicator of a more severe prognosis, produced by traumatic shearing stresses resulting in diffuse axonal injury (DAI). Computed tomography (CT) in acute phase is considered to have a limited role for the detection of non-hemorrhagic or petechial hemorrhagic DAI lesions. New generation multidetector CT scanners allow faster acquisition of thinner-slice images and post-processing reformations. Three patients with severe closed head trauma underwent CT examinations using a multidetector scanner, a few hours and the day after injury. The review of original images with narrow window width and integration with reconstruction of thinner slices from raw-data and post-processing multiplanar reformations (MPR) helped to detect the onset of hypodense or predominantly hypodense areas of corpus callosum, not present at admission and afterwards confirmed by MRI.

Value of hepatic arterial phase CT versus lipiodol ultrafluid CT in the detection of hepatocellular carcinoma

OBJECTIVE

To evaluate the role of hepatic arterial phase (HAP) spiral computed tomography (CT), as compared with iodized oil (Lipiodol ultrafluid [LUF]) CT for revealing nodular hepatocellular carcinomas (HCC).

METHODS

Twenty-four cirrhotic patients underwent two-phase HCT examination: HAP 25 seconds and portal phase 70 seconds after injection of 1.5 mL/Kg contrast medium. All patients also underwent hepatic angiography and intraarterial infusion of iodized oil; LUF CT was performed 3-4 weeks after infusion. HCT images were compared with LUF CT images for detection of hepatic nodules.

RESULTS

We found no significant difference between the sensitivity of HAP CT and LUF CT for nodules >10 mm, while HAP CT was more sensitive than LUF CT in revealing nodules <10 mm (47 vs. 27, p < 0.001).

CONCLUSIONS

HCT should be considered as the first method for the detection of HCC, whereas LUF CT should be used only for therapy.

[Neural network based detection of pulmonary nodules on chest radiographs]

PURPOSE

We investigated the capabilities of an artificial neural network-based Computer-Aided Diagnosis (CAD) system in improving early detection of pulmonary nodules on chest radiographs.

MATERIAL AND METHODS

We used a data-set of 145 digitized chest films. Two different radiologists read the radiographs to detect the sites of possible nodules. The system uses two neural networks trained on a training-set of 100 radiographs selected from the data-set. The first network is used to focus attention on the sites of potential nodules while the second calculates the likeliness of nodule presence in ROIs. The clinical test was performed on 45 more radiographs from the training-set, but different from those in the data-set, which were positive for both benign and malignant nodules. These latter plain films showed 65 nodular lesions which differed by shape and acquisition technique.

RESULTS

Sensitivity was 89% in all radiographs while specificity, evaluated by ROI, and accuracy, were 98%.

CONCLUSIONS

There are potential limitations in nodule detection on plain radiographs. Some of them are operator-dependent, such as nonsystematic investigation, lesion underestimation, and poor reading, and some are technique-dependent, such as X-ray beam/tube, low voltage, patient positioning, focus-film distance and development process. CADs may contribute to improving detection of pulmonary nodules because the false-negative rate is decreased and sensitivity consequently increased. The high sensitivity and specificity rates of neural networks encourage further trials on wider data-sets to help the radiologist in the early detection of pulmonary nodules.

Morphometric analysis of the acromioclavicular joint

The width of the articular space of the acromioclavicular (AC) joint was investigated to evaluate normal range values and any possible variations in relation to age and sex. Radiographs of the AC joints of 72 males and 28 female (age range: 38-83 yrs) were studied. The articular space width of the AC joint was measured using a semiautomatic computerized system. The measurements were performed bilaterally at the level of smallest distance between the articular surfaces in all the radiograms. The mean value of the articular space width was calculated for all the subjects as a single group, for that of the males and for that of the females. The films were then divided into four groups according to age (< 50; 50-59; 60-69; > 70 yrs) and the mean value per group was calculated. The values obtained were studied using variance analysis. No significant difference were found in the mean values of the articular space width when males and females were compared as regards to age. However, even if the articular space width diminished, in both sexes, with an increase in age, the differences between age classes were not statistically significant.

Auditory evoked potentials (AEPs), early (BAEPs) and long latency components (LLCs) in Parkinson's disease: a 12 month follow-up study

In 14 untreated informed patients (5 M, 9 F, mean age 62 yrs) with initial idiopathic Parkinson's disease AEPs, early (BAEPs) and long latency components (LLCs) were studied. In 10 subjects experimental session were carried out before treatment (L-Dopa plus Carbidopa, 0.25-0.50 g/die) and at 2, 6 and 12 months intervals. At the same time all patients underwent clinical assessment by Webster Rating Scale evaluation. BAEPs. The IPLs prolonged (greater than 2.5 SD) in 6 patients: in 3 the III-V, in 2 the I-V and in 1 the I-III. The absolute latencies were abnormally prolonged in 11 subjects: V wave in 4, III wave in 3, II wave in 2 and I wave in 3. The absence of one or more components were observed in 12 out of 14 patients, the most frequently absent was the II wave (12 patients). LLCs. The absolute latencies of P1 and N1 waves were prolonged respectively in 4 and in 3 subjects. The P1-N1 IPL was prolonged only in one patient. A follow-up study demonstrated transitory improvement of the AEPs previously observed abnormalities. The improvement was partially in agreement with clinical assessment.

Auditory and somatosensory evoked potentials (AEPs and SEPs) and ballistic movements in Parkinson disease

In five patients with initial idiopathic Parkinson disease AEPs (early and late components of auditory evoked potentials), SEPs (somatosensory evoked potentials) and arm ballistic movements (abduction of the humerus) were studied. Experimental sessions were conducted before starting treatment (L-Dopa plus Carbidopa) and at two and six month intervals. Before treatment evoked potential abnormalities were found in four out of five patients; EMG patterns underlying ballistic arm abduction movements were altered in all patients; corresponding prolonged duration of initial movements and low mean velocities were found. After treatment AEP and SEP showed a reduction of previously observed abnormalities and both EMG patterns and kinematic variables consistently improved. It is suggested that the electrophysiological investigations employed in this preliminary study may be a useful tool in clinical and pharmacological researches on Parkinson disease.

Pseudoperiodic paroxysmal discharge in a case of hemorrhagic shock

We report a case of hemorrhagic shock associated with an EEG pattern resembling pseudoperiodic lateralized paroxysmal discharges, repeated focal motor seizures on the opposite side of the prevalent EEG abnormalities and consciousness disturbances in the absence of a demonstrable cerebral lesion occurring in a 45 year-old woman without a personal or familial history of epilepsy. This unusual electroclinical picture appeared inexplicably several days after the hemorrhagic shock when the laboratory data had already normalized. The only cause of this picture seemed to be brain hypoxia and the metabolic disorders consequent upon hemorrhagic shock.

[Electrophysiologic studies (auditory and somatosensory evoked potentials) in Friedreich's ataxia]

Auditory and somatosensory evoked potentials were recorded from 10 patients suffering from Friedreich's ataxia. All patients were subjected to audiological tests and EMG-ENG study. Acoustic evoked potentials recordings included brainstem acoustic evoked potentials and long latency components. Peripheral and central components of somatosensory evoked potentials were obtained by stimulating the median nerve at the wrist and elbow. Various abnormalities of the cortical components were observed in all patients for both acoustic and somatosensory evoked potentials. Analysis of brainstem acoustic evoked potentials and of the early components of somatosensory evoked potentials showed a different incidence of abnormalities. The main feature of brainstem acoustic evoked potential changes was the frequent absence of one or more waves; the greatest abnormalities occurred in patients whose disease was of long duration. Long latency components (N85) were significantly prolonged in all but one patient. There was often an absence or reduction of early somatosensory evoked potentials with normal or near normal latencies, even though cortical responses were markedly prolonged. The sensory conduction velocity between stimulation sites at wrist and elbow was normal in all patients. Clinically brainstem acoustic evoked potentials may prove to be a reliable means of monitoring the progression of the disease, while long latency components and somatosensory evoked potentials could be used as complementary procedures in early diagnosis.

Auditory evoked potentials (early, middle, late components) and audiological tests in Friedreich's ataxia

A functional assessment of the acoustic pathways in a group of 9 patients with Friedreich's ataxia was performed. In none of them was symptomatic auditory impairment noticeable. All patients were submitted to audiological tests and AEP recording. AEPs included early (BAEPs), middle (MLCs) and long (LLCs) latency components. The absence of one or more BAEP waves was observed in 5 out of 9 patients. N85 latency was significantly increased in all but one patient. MLCs, particularly P12, N15, P25 were often normal in amplitude and latency, scarcely showing a positive relationship with abnormalities of preceding and following waves. Pure tone audiometry revealed cochlear or neural impairment only in 2 patients. Speech audiometry showed deficits in all patients. These investigations, taken as a whole, showed a prevalent involvement of the brain-stem acoustic pathways, presumably at different levels, seldom associated with eighth nerve impairment. In some cases LLC (N85) abnormalities could not be interpreted as a consequence of impaired function in peripheral and brain-stem acoustic sites and might suggest a cortical dysfunction. Major BAEP abnormalities were observed in patients with longer disease duration, while N85 changes were unrelated to the duration and the severity of the illness. The former may prove to be a reliable means of monitoring the progression of the disease, the latter could be employed as a complementary procedure in its early diagnosis.

[Neurophysiological (evoked auditory and somatosensory potentials) and neuroradiological (cranial CT) study in patients with olivopontocerebellar atrophy]

Thirteen patients affected by either dominant or recessive and/or sporadic olivopontocerebellar atrophy were studied. All patients were subjected to auditory evoked potential recordings including early and long latency components, CT scans, vestibular and EMG-ENG examinations. In nine patients somatosensory evoked potentials were also recorded. Clear-cut abnormalities in brainstem auditory evoked potentials were observed in only two patients while a slight reduction of the IV-V/I amplitude ratio was found in seven cases. N85 was increased in two patients. The main feature of somatosensory evoked potentials abnormalities was a delayed N20 in association with prolonged N13-N20 central conduction time (five patients). For all patients the CT scan varying degrees of cerebellar and brainstem atrophy. There was no clear correlation between the abnormalities revealed by neurophysiological and neuroradiological investigations and the severity and duration of the illness. It is noteworthy that auditory and/or somatosensory evoked potential changes were found in all dominant olivopontocerebellar atrophy patients.

Gynecomastia in epileptics treated with phenobarbital, phenytoin and fluoresone: two case reports

Gynecomastia developed in two epileptic patients some months after the addition of oral fluoresone 750 mg daily to the phenobarbital and phenytoin already being administered. The common systemic diseases that may give rise to gynecomastia were excluded. One of the patients presented hyperprolactinemia and a raised estrogen/androgen ratio but the hormone levels were not raised in the other. The onset of symptoms after fluorescence in both cases is highly suggestive, although the pathogenetic mechanism is not clear.

Electrophysiological investigations of the brainstem in the vertebrobasilar reversible attacks

A total of 70 selected patients affected by reversible ischemic attacks in the vertebrobasilar system were studied. 50 patients presented transient ischemic attacks (TIA), while the other 20 patients suffered from 1-2 protracted transient ischemic attacks (PTIA). All patients underwent brainstem acoustic evoked potentials (BAEP) and electrooculography (EOG) 7-20 days from the last reversible ischemic attack, when all signs and symptoms completely disappeared. The combination of BAEP and EOG gave objective evidence of brainstem dysfunction in 61 out of 70 patients. BAEP resulted abnormal in 26 patients (16 TIA, 10 PTIA), EOG in 49 (36 TIA, 13 PTIA). Serial controls at 3, 6, and 12 months were conducted in 27 patients. 5 patients showed a normalization for BAEP and 7 for EOG 12 months after the first examination.

[Continuous partial epilepsy in a case of cerebral abscess of long duration]

A patient affected by continuous clonus of the right half of his tongue and face with dysphasia and right hemiparesis is described. Partial continuous epilepsy of Kojewnikow was diagnosed. The CT scan showed a spreading lesion surrounded by intense oedema in the left central region, as well as a longstanding subdural hematoma complicated by osteitis. This finding lead to a diagnosis of cerebral abscess which was confirmed by surgery. In this paper it is also analyzed the cortical and/or subcortical origin of this peculiar type of epilepsia.