New packaging methods of body packers: Role of advanced imaging in their detection. A case study

Body packing is one of the common ways to traffic illicit drugs. Drug mules usually swallow or insert drugs within the gastrointestinal tract or other orifices. Detection of such drug packets has become difficult because of the constantly improving packaging techniques and the sophistication used by traffickers. Suspected obstruction or perforated hollow viscus requires employment of appropriate radiological procedures and techniques for accurate detection and precise diagnosis. A delay diagnosis and inappropriate action may carry disastrous physical consequences for the body packers. It is crucial for radiologists to acquire enough experience to deduce different types of drug packets from their imaging characteristics and to accurately guide emergency physicians and security officials. The packets are not always radiodense, therefore they can be difficult to detect on conventional abdominal radiographs. In this report, the authors illustrate 5 cases with different packaging methods and materials that give rise to radiological challenges.

Ruptured Berry Aneurysm as the initial presentation of Polycystic Kidney Disease: A case report and review of literature

Intra-cranial saccular aneurysms, also known as Berry aneurysms, have a well-known association with autosomal dominant polycystic kidney disease (ADPKD). Aneurysmal rupture can be the initial presentation of the disease. ADPKD has two types of gene mutations: PKD1 and PKD2. The latter one is of a milder form presenting later in life. Imaging plays a crucial role in the diagnosis and assessment in order to provide adequate management of these patients however, there are no official standardized guidelines established for screening of these intracranial aneurysms.

Pulmonary venous varix associated with mitral regurgitation mimicking a mediastinal mass: A case report and review of the literature

Pulmonary vein varix is an unusual cause of a mediastinal mass on a chest radiograph. It may be found as an isolated malformation or as a sequela of pulmonary venous hypertension. We encountered a case presenting with left hemiparesis and a past medical history of rheumatic heart disease. The chest radiograph revealed a well-defined mediastinal mass that turned out to be a hugely dilated pulmonary vein on contrast enhanced computed tomography of the chest. The computed tomography of the brain and upper abdomen revealed bilateral cerebral infarction and splenic infarction. In the literature, one-third of the reported cases of pulmonary vein varix are acquired secondary to mitral valve disease.

Bilateral symmetrical comparison of the proximal femur using 3D-CT models

PURPOSE

Superimposed three-dimensional (3D)-models obtained from CT-images have been used to evaluate displacement of femoral neck fractures, but this method assumes symmetrical anatomy of normal femurs. The present study aimed to compare the spatial orientation of the left and right proximal femur, thus establishing if 3D models can be used as a reference standard for the evaluation of fracture displacement.

METHODS

We generated 3D-CT-models of 20 patients with no skeletal pathology of the proximal femurs. Three observers independently determined the positions of the fovea and the femoral head, and a vector intersecting the centre points of the fovea and the femoral head defined the rotation. Differences in positions and rotations were determined by superimposing the 3D-CT-models of both femurs.

RESULTS

The mean distance (95% CI) between positions of the left and right fovea was 3.1 mm (2.7-3.4) and between the left and right femoral head 2.8 mm (2.6-3.0). The minimal detectable change was 2.8 for the fovea and 2.3 for the femoral head, and the repeatability coefficients between 2.1-2.7 and 1.0-2.9, respectively. Mean difference in rotation of the femoral head was 6° (5.3-6.6) with a minimal detectable change of 8.8 and repeatability coefficients ranging from 5.8 to 10.0.

CONCLUSIONS

Distances between the left and right femoral heads were larger than what could be explained by measurement error alone, suggesting that there may be minor side-to-side differences. However, these differences are small, and 3D-CT-models can be used as a reference standard to evaluate displacement of femoral neck fractures.

Intracranial Teratoma: Imaging, Intraoperative, and Pathologic Features: AIRP Best Cases in Radiologic-Pathologic Correlation

Editor's Note.-RadioGraphics continues to publish radiologic-pathologic case material selected from the American Institute for Radiologic Pathology (AIRP) "best case" presentations. The AIRP conducts a 4-week Radiologic Pathology Correlation Course, which is offered five times per year. On the penultimate day of the course, the best case presentation is held at the American Film Institute Silver Theater and Cultural Center in Silver Spring, Md. The AIRP faculty identifies the best cases, from each organ system, brought by the resident attendees. One or more of the best cases from each of the five courses are then solicited for publication in RadioGraphics. These cases emphasize the importance of radiologic-pathologic correlation in the imaging evaluation and diagnosis of diseases encountered at the institute and its predecessor, the Armed Forces Institute of Pathology (AFIP). Online supplemental material is available for this article.

Tuberculous Spondylitis Presenting as Severe Chest Pain

This case report describes a 32-year-old male who presented to an emergency department with severe chest pain and a history of cough, fever, night sweats, loss of appetite and weight. Chest radiography revealed a left upper lobe consolidation and multiple compression deformities in the thoracic spine. Magnetic resonance imaging demonstrated significant kyphosis and vertebral plana at two thoracic levels. Anterior compression of the spinal cord and adjacent soft tissue masses were also noted.

MRI spectrum of bone changes in the diabetic foot

PURPOSES

(1) To assess the prevalence of bone marrow changes in the diabetic foot and (2) to discuss the clinical significance of these changes.

METHODS

85 patients with radiographic and magnetic resonance imaging (MRI) foot examinations were selected. Inclusion criteria were clinical diagnosis of diabetes and bone changes on radiographs and MRI. The material was selected from the image storage (PACS) system. We searched for vascular (infarct and necrosis), traumatic (bruise and occult fractures), destruction and debris, dislocation, osteochondritis, osteomyelitis. Five patients had bilateral examinations. A total of 90 feet were evaluated.

RESULTS

From 90 feet, 17 (18.9%) presented with vascular changes, from them, 11 feet had infarct and 6 feet had necrosis. Twenty (22.2%) feet had traumatic changes; of them, 10 (50%) had edema on MRI. Five (25%) cases had occult fracture on MRI; and 5 (25%) had visible fracture on both X-ray and MRI. Bone destruction was detected in 8 (8.9%) feet. Bony debris was visualized in three of them. Bone dislocation was visualized in 11 (12.2%) feet. There was evidence of osteochondritis in twenty-four (26.7%) feet. Osteomyelitis was diagnosed in ten (11.1%) feet.

CONCLUSION

Diabetic foot is a challenge for both clinicians and radiologists due to its complexity. The bone derangements inherent to the diabetic foot can be evaluated with high accuracy with MRI.

MRI of the Achilles tendon: a comprehensive review of the anatomy, biomechanics, and imaging of overuse tendinopathies

The Achilles tendon is the largest tendon in the body; it plays an important role in the biomechanics of the lower extremity. It can withstand great forces, especially during sporting exercises and pivoting. The pathologies related to the Achilles tendon are diverse and many carry undesirable consequences. We retrospectively analyzed the images of patients who underwent examinations of the ankle/foot region to review the anatomy of the Achilles tendon and its surroundings and to search for pathologies consistent with overuse injuries. The anatomy of the tendon is described from origin to insertion. The imaging characteristics of the Achilles tendon including pitfalls are reviewed. We also describe the Achilles overuse injuries: paratenonitis, tendinosis, tendon tear, atypical tear, tendon re-tear, retrocalcaneal bursitis, retro-Achilles bursitis, Haglund's deformity, and tendon calcification. We present other entities like tendon ossification and failed transplanted Achilles tendon, with emphasis on MRI.

Recombinant human bone morphogenetic protein 2-induced heterotopic ossification of the retroperitoneum, psoas muscle, pelvis and abdominal wall following lumbar spinal fusion

A 45-year-old man presented with vertebral collapse at L5 as an initial manifestation of multiple myeloma and underwent spinal fusion surgery using recombinant human bone morphogenetic protein-2 (rhBMP-2). Subsequent computed tomography (CT) scans and X-rays revealed heterotopic ossification of the left psoas muscle, pelvis, and anterior abdominal wall. While the occurrence of heterotopic ossification has previously been reported when rhBMP-2 has been used for spinal fusion surgery, this case demonstrates that it can occur to a much greater degree than previously seen.

MRI of the median nerve and median artery in the carpal tunnel: prevalence of their anatomical variations and clinical significance

OBJECTIVE

Anatomical variations of the median nerve and the persistent median artery (PMA) in the carpal tunnel (CT) are important to understand for their clinical and surgical significance. The aim of this cohort retrospective study was to investigate the prevalence of aberrant median nerve branches and persistent median artery in the CT in a selected population using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

MR wrist images of 194 patients, 77 males and 117 females, aged 12-80 years were randomly selected and retrieved from our clinical and radiology data base. The MR examinations were performed using either 1.5-T or 3.0-T magnet using a cylindrical receive-transmit wrist coil for all cases. The course of the bifurcation of the median nerve was followed on axial T2-weighted and axial proton density fat saturated images and classified as either proximal, within, or distal to the CT. The flexor retinaculum proximally and the metacarpal bases were used as anatomic landmarks to subdivide these three categories. In addition, the median artery was searched in order to assess the prevalence of its presence inside the CT. A total of 194 wrists were analyzed by two musculoskeletal-trained radiologists. They were blinded on the population age, gender, and the sides of the wrists. Agreement was reached by consensus.

RESULTS

Among the 194 wrists, there was bifurcation of the nerve proximal to the CT in 12 (6.1%) wrists. There was nerve bifurcation within the CT in 36 (18%) wrists. Nerve bifurcation distal to the CT was more frequently observed, occurring in 147 (75%) wrists. Only one nerve trifurcation was seen within the CT. There was no gender predominance for the nerve bifurcation within the tunnel. There were 107 right wrists and 87 left wrists. On the right side, bifurcation of the nerve within the CT was seen in 21 (19.6%) wrists; and on the left side bifurcation of the nerve was present in 15 (17.2%) wrists. Statistically, we found no significant difference in the prevalence of the bifid nerve within the tunnel in the subgroups based on age, gender, or side of the wrists. A persistent median artery (PMA) within the tunnel was observed in 21 (11%) wrists--10 males and 11 females. Of these, four (19%) cases were presented with coexistent PMA and bifid median nerve within the tunnel. Statistically, we found that the two variations are not independent traits, and their covariance is not null.

CONCLUSION

There was a high prevalence of bifid median nerve (19%) and PMA (11%) within the tunnel regardless of gender or age. The PMA was more frequent on the left side.

Bone marrow edema: pathophysiology, differential diagnosis, and imaging

Bone marrow edema (BME) has been a topic of increasing interest in the literature in recent years. BME is associated with numerous pathologies and is becoming recognized not only as a considerable pain generator, but also as an entity which is, in some cases, significantly linked to the worsening of patient prognosis. To date, no thorough imaging review of BME has been published. An electronic literature search was conducted through PubMed with a time parameter of January 1975 through December 2007. The primary search parameter was "bone marrow edema." Over 800 papers were listed as written in English and involving humans. Other refining parameters included "AND syndrome," "AND transient," "AND arthritis," "AND infection," "AND tumor," "AND neoplasm," "AND iatrogenic," "AND radiation therapy," and "AND inflammation." More current articles were favored over dated articles on the same topic. A total of 106 journal articles were collected concerning BME and multiple pathologic processes. The data contained therein was compiled and organized into a comprehensive format. BME can be caused by, and found concurrent with, a broad spectrum of pathologies which exhibit a variety of imaging findings. BME is also associated with the deterioration of certain pathologies. This presentation is a comprehensive discussion of different pathological conditions inducing or associated with BME. Differential diagnosis through appropriate imaging is vital to case management and could contribute to the prevention or decreased progression of certain pathologies. Continued investigation into the imaging of BME and its associated diseases, as well as the effect of BME on prognosis, is warranted.

Magnetic Resonance Imaging of the Triangular Fibrocartilage Complex Lesions: A Comprehensive Clinicoradiologic Approach and Review of the Literature

OBJECTIVE

This article illustrates the frequent lesions of the triangular fibrocartilage complex (TFCC) by means of magnetic resonance imaging.

METHODS

We performed a retrospective chart review of the magnetic resonance images of 109 patients from our database. All subjects had history of trauma, and all underwent both radiographic and magnetic resonance imaging examination of the wrist. The changes (degeneration, tears) of the TFCC were assessed.

RESULTS

Ten patients were excluded because of incomplete imaging protocol (4 patients) and low-quality images (6 patients). From the 99 wrists remaining, the TFCC was normal in 30 (30.3%). Degenerative changes were found in 40 (40.4%) wrists. Partial and complete tears were present in 17 (17.1%) and 12 (12.1%) wrists, respectively.

CONCLUSION

The TFCC lesions in acute traumatic wrists should not be overlooked; they may contribute to wrist pain and disability after treatment of existing bone injuries.

Osmolarity: a decisive parameter of bowel agents in intestinal magnetic resonance imaging

The aim was to evaluate the importance of the osmolarity of different oral agents for bowel distension and the level of related adverse events. The longitudinal design included the exposition of different oral MR agents on two separate occasions. Four groups of volunteers were randomly given 350 ml gastrografin of three different concentrations and water. On the second occasion they received mannitol, iohexol or iodixanol with equivalent osmolarities, but the control group (water) received mannitol. We recorded the outcomes as the degree of bowel distension determined as the mean bowel section area and the total level of discomfort recorded from a visual analogue scale (VAS). The statistical analysis included scatter plots with the best-fitted line with linear regression to study the association between osmolarity and section area and the association between osmolarity and adverse events. A dose-response association was found between increasing osmolarity levels and bowel area in square centimeters (P = 0.00001). A similar dose-response association existed between increasing levels of osmolarity and adverse events (P = 0.001). Osmolarity appears to be more important for bowel distension than the physico-chemical characteristics of the nonabsorbable oral agents. The optimum osmolarity level is determined by the patient's tolerance of the adverse events.

Postlymphoproliferative disorder affecting bone after a renal transplantation

OBJECTIVE

To illustrate a posttransplant lymphoproliferative lymphoma presenting as a solitary osseous lesion situated in the rib.

CLINICAL FEATURES

A 53-year-old man was referred to a surgical department because of persistent local pain over the lower part of his left posterior hemithorax. Due to a previous history of chronic glomerulonephritis, a renal transplant was performed 7 years previously, followed by immunosuppressive therapy with azathioprine cyclophosphamide.

INTERVENTION AND OUTCOME

Surgical removal of the rib lesion was performed because of the patient's history of the organ transplant. The histological study of the surgically removed tissue revealed diffuse infiltration of the marrow by lymphoid-like cells. There was evidence of interstitial fibrosis, and further immunohistochemical examination showed the presence of B cells in the specimen confirming the diagnosis of B-cell lymphoma.

CONCLUSION

This case report discusses an unusual presentation of a lymphoma induced by immunosuppressive therapy in a patient who had received an organ transplant. Such lesions may appear in any organ or system, although this is distinctively unusual to involve the skeletal system.

Deforming lipoblastomatosis of the lower extremity

OBJECTIVE

Lipoblastomatosis is a rare disorder in infants and children and nonexistent in adults. We discuss a case of a newborn child with lipoblastomatosis extensively involving the pelvis and lower extremities. The clinical and radiological characteristics of the disorder are discussed.

CLINICAL FEATURES

A 2-month-old male had an enlarging deformity of the pelvis and lower extremities with progression of the condition from birth. There was no family history related to the disease. No other clinical abnormalities were present.

INTERVENTION AND OUTCOME

Lipoblastomatosis is initially treated with surgical excision of the lipomatous neoplastic tissue. The postsurgical outcome is satisfactory; however, the likelihood of recurrence has been reported.

CONCLUSION

We present the features of lipoblastomatosis, an uncommon disorder affecting infants and children. The clinical and radiologic manifestations of the disease are assessed with emphasis on magnetic resonance imaging.

Pediatric excretory MR urography: comparative study of enhanced and non-enhanced techniques

Our purpose was to compare the quality of ureteral imaging in pediatric patients using two different MR sequences: the non-enhanced heavily T2-weighted (W) turbo spin-echo sequence (TSE) and the gadolinium-enhanced T1W fast-field-echo sequence (T1 FFE). An experimental study on three pigs was first performed. The TSE, before and after furosemide injection, was followed by the T1 FFE sequence. The clinical study included 11 infants and 10 children. With some modifications the same MR parameters and techniques were used as in the animal study. The TSE with TR 8000 ms and TE 650 ms implied 6 radial stacks each of 40 mm thickness. The T1 FFE included TR 18 ms, TE 2.9 ms, flip angle 60, and 50 slices with thickness 0.7 mm. After post-processing, image reconstructions qualitative and quantitative analysis were performed. Complete visualization of the ureters was achieved in 35 of 42 (83%) cases. Seventy-four percent of the ureters were completely visualized with T1 FFE compared with only 19% with TSE. Sixty-nine percent of the ureters were better imaged with T1 FFE than TSE and 21% equally well imaged. Four ureters (10%), either obstructed or due to poor renal function, were better imaged with TSE. The two sequences are complementary. Visualization of non-obstructed ureters is excellent with T1 FFE and the sequence is superior to TSE. The TSE, however, may be equal to or even better than T1 FFE in visualizing obstructed ureters or ureters draining malfunctioning kidneys.

Clinical and radiological manifestations of the rheumatoid wrist. A comprehensive review

OBJECTIVE

The intent of this review article is to present the common clinical and radiological features of the rheumatoid wrist as seen in everyday practice. Imaging of the rheumatoid wrist is discussed with emphasis on magnetic resonance imaging (MRI) and its current and future role in the diagnosis and treatment follow-up of the disease.

DATA SOURCE

A search of the current medical literature from 1990 to present through PubMed was performed without constraints. Search terms used included: MRI, rheumatoid arthritis, wrist, treatment, diagnosis, radiology, clinical manifestations, and incidence.

STUDY SELECTION

The articles included in this review were selected by historical significance, date of publication, pertinent review information, and, most specifically, those articles studying the current uses for imaging the rheumatoid wrist.

DATA SYNTHESIS

This review demonstrated an overall agreement between numerous studies that the usefulness of MRI evaluation of the rheumatoid wrist is in its early stages of development. Many of the features of this examination of the wrist are discussed and contrasted with plain film radiographic examination.

RESULTS

The role of the clinician in the diagnosis and treatment, including complementary care, as well as the follow-up of rheumatoid arthritis in the wrist is unquestionable. The role of plain film examination as a diagnostic tool is excellent. The current and future role of MRI of rheumatoid arthritis is becoming obvious and will likely become the diagnostic imaging tool of choice in the near future.

CONCLUSION

MRI provides more specific information on rheumatoid lesions in the wrist than plain film imaging. This is especially true when intravenous contrast is utilized. The clinician's use of physical examination, laboratory examination, radiography, and MRI will provide for early diagnosis, treatment, and follow-up of RA in the wrist.

Magnetic resonance assessment of the double-crush phenomenon in patients with carpal tunnel syndrome: a bilateral quantitative study

Our main goal was to assess the coexistence of narrowed cervical foramens and cervical canal stenosis in patients with carpal tunnel syndrome (CTS). We took magnetic resonance (MR) images of 120 wrists and 480 foramens in 60 age and sex matched subjects (30 patients with CTS and 30 controls). All patients had nerve conduction velocity tests before MR examination. We measured the volume of the carpal canal in all participants bilaterally. We also quantified the cross-sectional areas of the cervical foramens on both sides from C4 to T1 and measured the diameter of the cervical canal in all participants. We searched for the prevalence and location of cervical spondylosis and disc prolapse on the side of the symptomatic wrist(s). All patients had CTS-related neurophysiological findings. There was no correlation between the symptoms and the reduced carpal canal volume. The mean (SD) area of the foramens was 109.5 (12.8) mm2 in the patients compared with the controls 126.4 (28.7) mm2 (p = 0.007). Cervical spondylosis and disc prolapse were more common in the patients than the controls at the C5-C6 and C6-C7 levels, and their locations were on the same side as the symptoms in the wrist(s) in 50% of cases. There was no difference in the size of the cervical canal between the two groups. The higher incidence of narrowed cervical foramens in the patients and its concordance with affected nerve roots on the same side as the CTS symptoms support the hypothesis of a double-crush phenomenon.

Does carpal canal stenosis predict outcome in women with carpal tunnel syndrome?

OBJECTIVE

We investigated the role of carpal canal stenosis as a predictor of outcome in patients who underwent surgical treatment for carpal tunnel syndrome (CTS).

METHODS

We performed magnetic resonance imaging (MRI) of the wrist in 31 female patients with clinically and neurophysiologically confirmed CTS. With a computerized analyser we quantitatively calculated the focal narrowest point of the tunnel. Patient's assessment of CTS-related symptoms were obtained by using a visual analogue scale before, and 6 months after treatment.

RESULTS

Seventeen (56%) patients improved in all symptoms after treatment. The focal narrowest point of the tunnel was identified at its distal third in all patients, at 8 mm from the outlet. The median area of the narrowest point in those who improved clinically (n=17) was 238.9 mm2 compared with 269.8 mm2 in others (n=14), P=0.046.

CONCLUSION

Identification of carpal canal stenosis may be important in selecting candidates for treatment in symptomatic CTS.

[Carpal tunnel syndrome]

BACKGROUND

Carpal tunnel syndrome is the most common mononeuropathy. Typical symptoms include pain or discomfort in the hand, paresthesia, weakness and altered temperature or dryness of the skin along with neurophysiological findings. The presence of these symptoms in the area of the median nerve distribution supports the diagnosis.

MATERIAL AND METHODS

This review article is based on current knowledge about carpal tunnel syndrome as obtained from the Medline and the Cochrane database systems.

RESULTS

The prevalence of carpal tunnel syndrome in the population is around 3%. A higher incidence is reported in women and in manual workers in general. The higher incidence in women may be less evident than previously expected. The size of the carpal canal do not predict the disease, but narrowing of the canal in its distal third has been reported in both patients and non-symptomatic controls.

INTERPRETATION

Differences in job exposure between men and women may explain the increased incidence in women. Although the relationship between symptom production and structural changes in the carpal tunnel affecting the median nerve is still debated, narrowing of the canal in its distal third may predict the syndrome.

Impact of occupational variables in carpal tunnel syndrome

OBJECTIVE

We studied the impact of work-related factors on the outcome in patients operated for carpal tunnel syndrome.

METHODS

The population consisted of 106 CTS patients who worked at the time of operation. We registered social and occupational data from the patients.

RESULTS

Median time of sick leave was 7 weeks for the total group. Sixty-four percent reported a relationship between their work and the disease. Eighty-nine percent of the operated patients returned to their previous work after operation.

CONCLUSIONS

A majority of the patients attributed the CTS-related symptoms to their occupation. Work-related factors may therefore be one possible explanation for the socioeconomical consequences of CTS. A permanent drop-out from work in more than 1 out of 10 patients after CTS treatment indicate that CTS form a substantial socioeconomical burden in the society.

Necrotizing fasciitis: unreliable MRI findings in the preoperative diagnosis

The authors present two cases of necrotizing fasciitis (NF), one case of dermatomyositis and one case of posttraumatic muscle injury, which have similar magnetic resonance imaging findings in terms of skin, subcutaneous fat, superficial and deep fasciae and muscle involvement. These cases highlight the need for cautious interpretation of magnetic resonance imaging (MRI) findings, for they are nonspecific and the preoperative decision should be based mostly on the evolution of the clinical status.

MRI of the spine and spinal cord: imaging techniques, normal anatomy, artifacts, and pitfalls

BACKGROUND

Magnetic resonance imaging (MRI) is widely used to evaluate the spine and spinal cord.

OBJECTIVE

In this article, MRI of the spine is discussed in terms of normal anatomy, standard and advanced imaging techniques, general indications, limitations, and potential for the future.

DISCUSSION

Although MRI does not provide the high bony detail possible with computed tomography, the appropriate combination of the sequences takes advantage of the different tissue characteristics to discriminate the various bony-and soft-tissue structures of the spine.

CONCLUSION

MRI enables the imaging specialist to evaluate a large anatomic region in multiple planes and can better examine the spinal cord.

MR urography in children: current status and future development

The normal anatomy and many pathologies of the pediatric genitourinary system can be assessed with different imaging modalities. Most of them are based on the use of ionizing radiation and/or invasive techniques. The contribution of magnetic resonance imaging in this regard has opened new ways of approaching pathological conditions in this patient group. The addition of the newly developed rapid techniques has enhanced the superiority of MRI, and both morphological and functional evaluation of the genitourinary system can be achieved. There are different factors on which rely the optimization and the efficiency of magnetic resonance urography (MRU). Of importance is adequate patient immobilization and the use of optimal imaging sequences. The rapid technical development, including the advent of the post-processing respiratory navigator, allows acquisition of high-quality images independent of the patient's respiratory rate. In the future, it is expected that MRU, due to its non-use of ionizing radiation, will become the most important tool in the diagnostic work-up of genitourinary pathologies in infants and small children.

Relationship between brain structure sizes and performing rapid limb movements. A quantitative magnetic resonance study

In this study, we aimed to determine the relationship between the size of cerebral structures evaluated by quantitative magnetic resonance technique and the ability of performing rapid-velocity limb movements. Forty-seven healthy women with a mean age of 43.4 years (range 22-68) were included. Exclusion criteria were systemic diseases including alcoholism. Finger and ankle tapping were quantitatively recorded for both right and left extremities. A mean value for the right and left side was calculated. To determine atrophy, we measured the area of the corpus callosum, the cerebrum and the cerebellum on midline sagittal sections. On transverse images, the ventricle-to-brain ratio, the bifrontal ratio and the bicaudate ratio were selected as atrophy parameters. Also, the prevalence of white matter hyperintensities was assessed. Fifteen (32%) had hyperintense white matter lesions. Using simple regression analysis, the frequencies of both finger (r = 0.37, beta = -0.002, p = 0.022) and ankle (r = 0.35, beta = -0.001, p = 0.032) tapping were associated with reduced cerebellar size. No association was found for other atrophy parameters or the number of hyperintense white matter lesions. This study indicates that impaired ability to perform fast limb movements may be related to a relative cerebellar atrophy.

Virus reduction in the preparation of intravenous immune globulin: in vitro experiments

BACKGROUND

While immune globulins for intravenous administration (IGIV) have an excellent record with respect to virus safety, concern regarding these preparations has been raised by reports of transmission of hepatitis C virus (HCV) to patients treated with IGIV and the presence of genetic material for HCV in IGIV preparations.

STUDY DESIGN AND METHODS

This in vitro study evaluated the effectiveness of several manufacturing steps, including ethanol precipitation and pasteurization, in reducing HIV and model viruses including encephalomyocarditis (EMC) virus, pseudorabies virus (PRV), bovine viral diarrhea virus (BVDV), Sindbis virus, vaccinia virus, and vesicular stomatitis virus (VSV), as well as HCV RNA, in IGIV.

RESULTS

Ethanol precipitation carried out after pasteurization resulted in virus reductions (log10) of >3.97 for HIV, 1.95 for EMC virus, >5.39 for PRV, and 3.52 for BVDV. Pasteurization inactivated EMC virus by 4.52 log10 and resulted in a log10 reduction of >6.54 for HIV, >5.39 for PRV, >6.64 for BVDV, >7.78 for Sindbis virus, >5.84 for vaccinia virus, and >6.99 for VSV. All viruses except EMC virus were reduced below the limit of detection within 6 hours of the beginning of pasteurization. Cohn processing of Fraction II + III paste and the 4.5-percent alcohol precipitation step prior to pasteurization provided additional virus removal. Studies using the polymerase chain reaction technique found that HCV RNA was detectable in the starting fraction of Cohn Fraction II paste, but not in the final IGIV preparation.

CONCLUSION

These findings strongly support the viral safety of IGIV prepared by this method and show a significant added measure of virus safety associated with pasteurization of this preparation.

MRI of bilateral bipartite hamulus: a case report

Normal skeletal variants are a common occurrence in clinical practice and may lead to misinterpretation. As part of a case control study investigating the carpal tunnel, our asymptomatic and voluntary participant underwent magnetic resonance (MR) imaging of both wrists from the metacarpal bases to the distal radiocarpal joint. The imaging techniques included spin echo (SE), turbo spin echo (TSE) and fast field echo (FFE) sequences using 4 mm-slice thickness. As an incidental finding bipartite hamulus was detected bilaterally. The anomaly was evident in both hamuli with similar MRI characteristics. The congenital origin was further supported by the absence of trauma or surgery to the wrists. In this case report the authors discuss the anatomical variant, bilateral bipartite hook of the hamate, and demonstrate the reliability of contiguous slices of MR axial slices in displaying an anatomical variant of the carpus. This normal variant of the hamate is not commonly encountered in MR imaging of the wrist and can be misinterpreted as fracture or post-traumatic sequelae. Images of the normal hamulus are presented for comparison.

[Thyroid-associated ophthalmopathy]

Thyroid-associated ophthalmopathy is a local autoimmune reaction in the orbit. Typical signs are retraction of the eyelid, periorbital oedema, proptosis and impaired eye motility. Exposure keratopathy or compression of the optic nerve may be a complication. Patients with severe proptosis or progressive loss of vision need an efficient and safe treatment modality. Immunosuppression may be the first choice, followed by surgical decompression of the orbit. We describe a combined external and endoscopic approach with resection of the lateral, inferior and medial orbital walls. In this way, the increased intraorbital pressure is relieved. Retraction of the upper eyelid is corrected by transconjunctival approach and the release of muscles from the tarsus.

Magnetic resonance imaging of the thorax in the evaluation of asbestosis

The purpose of the study was to evaluate the accuracy of magnetic resonance imaging (MRI) in detecting subclinical morphological changes caused by asbestos exposure. Conventional chest radiographs according to the International Labour Organisation (ILO) categories 0-11 and spirometric data were compared with MRI in 17 men with mean (+/-2SD) asbestos exposure time of 24.6+/-13.0 yrs. Mean age was 62.0+/-9.4 yrs. The inclusion criterion was an ILO score of 2 or more. Electrocardiographic registrations and antirespiratory movement artefact techniques were used in all MRI examinations to avoid movement artefacts. Mean ILO grading was found to be 7.7+/-3.8 on chest radiography and 9.8+/-2.0 with MRI (p=0.01). Five patients had a higher ILO stage as evaluated by MRI, but in nine patients the staging remained unchanged. MRI revealed mediastinal adenopathy in four patients. Forced expiratory volume in one second (expressed as a percentage of the predicted value) was negatively correlated with ILO score as assessed by MRI (r=-0.4, p=0.032). Magnetic resonance imaging seems to be more sensitive than conventional radiographs in detecting subclinical fibrosis as well as the extent of pleural asbestosis.

Quantitative MRI and electrophysiology of preoperative carpal tunnel syndrome in a female population

The tunnel size is reported to play a role in median neuropathy. The aim of the study was to quantify the volume of the carpal tunnel in a selected population with idiopathic carpal tunnel syndrome (CTS), as the narrowest point of the canal was noted. Twenty-seven patients with CTS and 28 asymptomatic controls were examined. All participants were women. Both groups underwent nerve conduction studies and magnetic resonance (MR) of the wrists. On the MR axial images, the volume of carpal tunnels, the wrists and the thenar muscles were calculated bilaterally in all subjects. The values for the signal intensity of the median nerve from all wrists were also quantified and correlated with the neurophysiological findings. The carpal tunnel volume (CTV) and the wrist volume (WV)/CTV ratio were almost identical in both groups (p = 0.36 and p = 0.45, respectively). The focal narrowest point of the tunnel was similarly located in both populations, and detected at its distal third, about 8 mm from the outlet. The median nerve in the patients emitted a higher signal compared with the controls, p = 0.037. Between the two groups, there were differences in the amplitude and the distal latency of the median sensory branch (p = 0.0001 and p = 0.0001, respectively), as well as in the amplitude and the F-wave latencies of the median motor branch (p = 0.045 and p = 0.017, respectively). There was no difference in the size of the carpal tunnel in women with idiopathic CTS compared with healthy controls, as the focal narrowest point was equally located in both groups near the canal outlet.

Bilateral fast magnetic resonance imaging of the operated carpal tunnel

Our aim was to quantify the structural changes of the carpal tunnel including area and volume after surgical release. We studied 28 patients who underwent 31 operations for carpal tunnel syndrome (CTS), mean age 54.7 years (range 32-78). All had abnormal nerve conduction studies. Magnetic resonance imaging (MRI) of both wrists was done before and after operation using two fast imaging sequences, turbo spin echo (TSE) and fast field echo (FFE). The same surface coils and parameters were used in both instances. With a computerised analyser we calculated the volume of the whole tunnel from inlet to outlet before and after operation and the wrist volume:carpal tunnel volume ratio. The intensity of the magnetic resonance signal emitted by the median nerve was assessed in all wrists before and after operation. The mean (SD) volume of the tunnel in 31 wrists with CTS was 11511.7 (2857) mm3 before and 13803.4 (3034.9) mm3 after operation (p = 0.0001). The mean (SD) relative signal intensity of the median nerve was 1.7 (1.8) preoperatively and 1.3 (1.1) postoperatively (p = 0.19). Other postoperative changes included persistent nerve enlargement (n = 21), misalignment of the tendons (n = 20), fibrous tissue deposits (n = 20), fat tissue deposits (n = 21), and muscle oedema (n = 6). The modifications of the carpal canal as a consequence of open surgical release (including increased volume and displacement of the flexor tendons) argue for the use of an endoscopic procedure in the treatment of CTS.

Magnetic resonance spin echo and fast field echo imaging of aneurysmal bone cyst: comparison with X-ray and computed tomography

OBJECTIVE

To discuss the case of an 8-yr-old boy with an aneurysmal bone cyst of the right proximal humerus, including the features imaged on plain film radiography, computed tomography (CT), magnetic resonance imaging (MRI), including spin echo and fast field echo imaging.

CLINICAL FEATURES

The patient suffered for 1 yr from intermittent but progressive pain in his right upper arm and shoulder area. There was no history of trauma or known systemic disease. There was decreased range of motion in abduction of the glenohumeral joint and pain on focal pressure along the deltoid muscle. A complete imaging evaluation consisting of plain film radiography, CT and MRI was performed, which revealed the classical imaging features of an aneurysmal bone cyst. An additional cystic lesion was detected by the MRI that was not appreciated on the plain films or CT.

INTERVENTION AND OUTCOME

The patient was referred for biopsy to confirm the preliminary diagnosis of aneurysmal bone cyst. No treatment was instituted.

CONCLUSION

Evaluation of aneurysmal bone cyst may be completed with CT scanning and more specifically with MRI MRI coronal T2, weighted images are advantageous for visualization of the main cystic lesion and any additional cysts. Fast field echo images show a better contrast between the cyst and bone marrow with extension of the cyst into the epiphysis as evident in this case. Follow-up studies revealed complete healing of the cyst with only residual densities in the humeral metaphyseal area.

Quantitative MRI analysis of anatomic dimensions of the carpal tunnel in women

114 wrists from two groups of asymptomatic women of 25-45 years of age (group I, no = 30) and over 45 years (group II, no = 27) were examined: a) to quantify the anatomic features of the carpal tunnel, and b) to search for age-related changes in the anatomy of the tunnel. Bilateral MRI axial wrist images were obtained by means of turbo spin echo (TSE) and fast field echo (FFE) sequences. We measured the length, the cross-sectional areas, the volume of the carpal tunnels-from inlet to outlet- and the volume of the wrists, bilaterally. A carpal tunnel volume/wrist volume (CTV/WV) ratio was obtained in both groups. We also searched for the location of the narrowest point of the canal. The mean (SD) length of the tunnel, from inlet to outlet, was 36.3 mm (SD = 3.4), in both groups. The tunnel had a cone shape, with the inlet constantly larger than the outlet in all subjects. The mean (SD) cross-sectional area of the tunnel inlet was found to be larger in group II, compared to group I (p = 0.029). The calculated mean (SD) volume of the tunnel also appeared significantly larger in the older group (p = 0.023). The narrowest point of the canal was identified at its distal third, at 8 mm from the outlet, in both groups. We conclude that: a) quantitative MRI is a valuable method for assessing the anatomic characteristics of the carpal tunnel, and b) the anatomy of the tunnel is affected by age.

The rheumatoid wrist: bilateral MR analysis of the distribution of rheumatoid lesions in axial plan in a female population

In this case-control study, we analyzed 146 wrists: a) to search for the distribution pattern of the rheumatoid lesions and, b) to correlate the distribution pattern of these lesions with the clinical parameters. Thirty-one patients with rheumatoid arthritis (RA) and 42 controls-all women-were examined by means of a bilateral MR fast field echo (FFE) sequence, in axial plan. The wrist was divided into three regions: metacarpal (level I), carpal (level II) and radioulnar (level III). Erosions were present in thirty (97%) patients and in six (14%) controls. They were asymmetrically distributed at all levels, mainly at level II. Marrow infiltration and bone destruction were seen in 35% of the patients in an asymmetrical pattern at level I and II, respectively. These lesions were absent in the control group. Subchondral cysts were asymmetrically present in both groups-in 48% of the patients at levels II and III, and in 11% of the controls at level II. In the patient group, this asymmetrical pattern of the lesions correlated with the disease duration at levels I and II (p = 0.011 and p = 0.013, respectively). Most lesions were found at the radial force-bearing column of the wrist, more in the right side. Synovial hypertrophy and hyperintense median nerve were evident in 96% and 70% of the patients, respectively. We concluded that contrary to common belief rheumatoid damages to the carpal bones become rather asymmetrical as the disease progresses. The line of force along the radial side of the wrist possibly influences the distribution pattern of the rheumatoid lesions.

Quantitative cerebral MRI in epileptic patients

OBJECTIVES

To determine cerebral atrophy parameters on MRI images of epileptic patients.

MATERIAL AND METHODS

Examination of the brain was performed in a 0.5 Tesla magnet in 32 women with epilepsy and 36 female healthy controls. Fifteen patients were classified to have generalised epilepsy and 17 had partial seizure onset. Epileptic patients with structural brain changes were excluded. At midsagittal level the area of corpus callosum, cerebrum and cerebellum were selected as atrophy parameters. At transverse level the ventricle-brain ratio (VBR) as a measure of overall cerebral atrophy, bifrontal ratio (BFR) reflecting atrophy in the area of the frontal horns, bicaudate ratio (BCR) and bioccipital ratio (BOR) were calculated to evaluate atrophy in the region of nucleus caudatus as well as in the occipital area.

RESULTS

The mean values of VBR were significantly larger in the two epileptic groups than in controls, p = 0.0003. No significant difference in mean VBR were found between focal and generalised seizure onset epilepsy. Also significant decreased cerebellar area on midsagittal section was detected in epileptic patients with partial onset epilepsy compared with controls, p = 0.037. Atrophy was not associated with type and duration of epilepsy, but VBR and age were positively associated in patients with generalised onset seizures.

CONCLUSION

These findings suggest general brain atrophy to be present in epileptic patients including those with partial epilepsy. Whether atrophy in epileptic patients occurs as a consequence of disease-related factors like hypoxia or treatment with antiepileptic drugs has to be investigated in a prospectively designed study.

Quantitative magnetic resonance imaging and the electrophysiology of the carpal tunnel region in floor cleaners

OBJECTIVES

The purpose of this study was to evaluate possible structural changes of the wrist and subclinical damage in the median nerves of healthy floor cleaners.

METHODS

Twenty-four cleaners and 19 referents (noncleaners), all women, underwent bilateral magnetic resonance (MR) wrist examination and nerve conduction studies. They were all randomly selected from an occupational health service. From MR images the volumes of the wrist, carpal tunnel, and thenar and hypothenar muscles were calculated, as well as the signal intensity of the median nerve, bilaterally.

RESULTS

No significant difference in the volume of the carpal tunnel was found in the two groups. The relative signal intensity of the median nerve was 0.55 for the cleaners and 0.48 for the referents (P = 0.05). The mean nerve conduction velocity values were 55.2 m.s-1 for the right median nerve of the cleaners and 57.4 m.s-1 for the right median nerve of the referents (P = 0.03). The median nerve of the cleaners had a mean sensory amplitude of 128.2 microV compared with 162.8 microV for the referents (P = 0.01). There was a tendency towards a longer distal latency of the median nerve in the cleaner group.

CONCLUSIONS

This study revealed subclinical intrinsic damage to the median nerve, as demonstrated by MR, and poorer electrophysiological nerve function among workers at high risk (cleaners) compared with workers at lower risk (noncleaners).

MRI of anatomical variants of the wrist in women

In the analysis of magnetic resonance (MR) images of the wrist joint, some structural variations may lead to misinterpretation. Our aim was to search for different anatomical variants and their MR characteristics on axial images. Two groups of patients with rheumatoid arthritis (thirty one) and carpal tunnel syndrome (sixty two), and a group of asymptomatic controls (fifty four) underwent bilateral MR axial wrist imaging from the metacarpal bases to the distal radiocarpal joint. The imaging techniques included spin echo (SE), turbo spin echo (TSE) and fast field echo (FFE) sequences, using 3 mm-slice thickness. Different anatomical variants including hypoplasia of the hamulus or hook of the hamate bone (4 cases), anomalous muscles (lumbricals) inside the carpal tunnel (2 cases), unusual location (5 cases) and double branching of the median nerve (14 cases), and aberrant median artery (one case) were detected. These variants, if unfamiliar to MR readers, may be misinterpreted as pathological features.

Bilateral fast MR imaging of the rheumatoid wrist

To evaluate the structural changes in the carpal tunnel and possible intrinsic median nerve damages in RA patients, quantitative bilateral magnetic resonance imaging (MRI) of the wrists was performed by means of a fast imaging sequence. Thirty-three women with RA and 42 controls were examined. The length of the carpal tunnel, the carpal tunnel volume/wrist volume (CTV/WV) ratio and the signal intensity of the nerve were calculated in both groups, bilaterally. The CTV/WV ratio was 0.12 in the patients and 0.11 in the control group (p = 0.007). A negative association was found between disease duration and carpal tunnel volume/wrist volume ratio (p = 0.049). Mean distal latency in the right motor median nerve was 3.0 +/- 0.4 msec (patients) and 3.4 +/- 0.6 msec (controls) (p = 0.002). Mean values in the right sensory branch were 1.2 +/- 0.1 msec (patients) and 1.4 +/- 0.3 (controls) (p = 0.01). The lack of association between the size of the carpal canal and neurophysiological parameters found in this study may suggest a possible protection of the median nerve by the increased canal size in patients with RA.

Quantitative cerebral MR in rheumatoid arthritis

PURPOSE

To determine the presence of hyperintense white matter lesions and atrophy reflecting cerebral vasculitis in rheumatoid arthritis.

METHODS

Thirty-three patients with rheumatoid arthritis and 48 control subjects were examined with MR. Mean age was 45.1 years (range, 26 to 55 years) for the patients and 42.2 years (range, 25 to 55 years) in the control group. To determine atrophy we measured the area of corpus callosum, the cerebrum, and the cerebellum on midline sagittal sections. On transverse images, the ventricle-to-brain ratio, the bifrontal ratio, and the bicaudate ratio were selected as atrophy parameters. Area and signal intensity were measured for the biggest and the smallest lesions in both groups.

RESULTS

Nine patients (27%) had hyperintense lesions compared with 15 (31%) of the control subjects. Mean numbers of hyperintense lesions were 1.3 in patients and 2.1 in control subjects. Mean area of the largest lesion in each patient was 27.4 mm2 for the patients and 29.8 mm2 in the control group. In patients with long disease duration (> 15 years) the mean ventricle-to-brain ratio was 0.09 compared with 0.08 in the control subjects. The midsagittal area of the cerebellum was 1349.8 mm2 in the patients with long disease duration and 1573.3 mm2 in the control group. No difference in number of hyperintense white matter lesions was detected between patients with long disease duration and the control subjects. Comparing the total group of patients with the control subjects, no significant differences in atrophy parameters or hyperintense white matter lesions were found. Also, there were no significant differences in relative signal intensity of the hyperintense lesions and corpus callosum between the two groups. We were not able to detect differences between treated versus untreated patients.

CONCLUSION

This study indicates a tendency of more cerebral and cerebellar atrophy in patients with severe rheumatoid arthritis. The number and size of the white matter lesions were not significantly different in the two groups and do not support a higher frequency of even clinically silent infarcts caused by vasculitis in the patients with rheumatoid arthritis compared with control subjects.

Magnetic resonance imaging of the wrist: occult osseous lesions

This article illustrates the magnetic resonance imaging (MRI) features of occult osseous lesions in three different patients. All three patients suffered from a history of wrist trauma, but had negative plain film radiographs. The three types of occult lesions (bone bruise, microfracture and chronic osseous damage) are described, and their MRI characteristics are demonstrated by proton density and T2 weighted images. MRI proved to be the diagnostic modality of choice for the detection of posttraumatic intrinsic marrow changes.