Urolithiasis in pregnancy: Advances in imaging modalities and evaluation of current trends in endourological approaches

OBJECTIVE

Given the challenges involved in diagnosis and treatment of pregnant women with urolithiasis, we aim to review the imaging modalities and current endourological management of these patients.

MATERIALS AND METHODS

We performed a review of the available literature on urolithiasis in pregnancy. This included evaluation, diagnostic imaging, and therapeutic options. The databases we searched from included Google Scholar and PubMed. A total of 346 abstracts were screened. After our inclusion/exclusion criteria were met, we were left with 42 sources: 18 retrospective studies, 10 reviews/meta-analyses, 8 sets of guidelines, 5 randomized control trials, and 1 prospective cohort.

RESULTS

We begin our review with the literature available on the safety and efficacy of imaging modalities in the surgical planning for urolithiasis in pregnant patients. This includes renal ultrasound, abdominal x-ray, computed tomography scan, and magnetic resonance imaging. While computed tomography may result in an added radiation exposure, with possible safety concerns, magnetic resonance imaging seems to be safer, however a less sensitive test. We next describe safety, efficacy, and outcomes of various surgical interventions for urolithiasis in pregnant patients. This encompasses ureteral stenting, percutaneous nephrostomy, ureteroscopy, extracorporeal shock wave lithotripsy, and percutaneous nephrolithotomy. Ureteroscopy is a safer approach, but percutaneous nephrolithotomy offers higher stone-free rates. Using an evidence-based approach, we propose an algorithm for management of the pregnant women with renal colic.

CONCLUSION

Management of the pregnant women with suspected urolithiasis is a unique challenge for healthcare providers. A multi-disciplinary approach should be taken to optimize outcomes through an evidence-based approach.

Imaging acute pancreatitis

OBJECTIVES

Acute pancreatitis is common; the clinical course of this potentially severe condition varies widely. This paper aims to review the role of different imaging techniques in the management of acute pancreatitis, describe the main imaging findings for this entity, and explain the terms and criteria used to classify them.

CONCLUSIONS

Imaging techniques play a key role in the management of acute pancreatitis, from diagnosis and staging to identifying and treating complications, as well as in determining the underlying causes of the condition. For these reasons, radiologists should know the advantages and limitations of each imaging technique in the evaluation of acute pancreatitis, be familiar with the wide spectrum of imaging findings associated with it, and how to use the specific terminology derived from the Atlanta classification to ensure the standardization and quality of reports.

[Urinary stone imaging tests.]

Imaging in urolithiasis has a wide group of techniques, with different characteristics, limitations, and indications, which together allow the management of this prevalent pathology. Plain abdominal radiography and ultrasound are very accessible and in expensive techniques that combined present an acceptable sensitivity and specificity. They are widely used for monitoring the evolution of stone disease and for evaluation after treatments (surgery or SWL). Ultrasound is the primary radiological diagnostic tool in the pediatric population and in pregnant women. CT has prevailed over IVP in the anatomical assessment of the urinary tract and the description of the characteristics of the lithiasis, although it shows a greater exposure to ionizing radiation, so the use of low and ultra-low dose CT is spreading. In this article we also discuss other imaging techniques suchas Digital to mosynthesis, Fluoroscopy and DMSA Scintigraphy.

Additional value of hybrid PET/MR imaging versus MR or PET performed separately to assess cardiovascular disease

INTRODUCTION AND OBJECTIVES

Hybrid positron emission tomography (PET) and magnetic resonance (MR) imaging is an emerging technology in the diagnosis of cardiovascular disease; however, there have been no reports of its use in the national clinical setting. Our objective was to evaluate the additional value of integrated PET/MR systems compared with MR and PET performed separately in this setting.

METHODS

We prospectively included 49 patients, 30 to assess myocardial viability (coronary group) and 19 to assess inflammatory, infectious, and tumoral diseases (noncoronary heart disease group). All patients underwent cardiac ¹⁸F-fluorodeoxyglucose PET/MR. PET/MR studies included attenuation correction sequences, followed by simultaneous cardiac PET and cardiac MR acquisition, with protocols adapted to the clinical indication (cine, tissue characterization and/or late enhancement imaging).

RESULTS

Most (87.8%) PET/MR studies were initially interpretable. Use of PET/MR improved diagnosis vs PET or MR performed separately in 42.1% of coronary cases and 88.9% of noncoronary cases. PET/MR enabled reclassification of 87.5% of coronary cases initially classified as showing inconclusive results on MR or PET and 70% of noncoronary cases.

CONCLUSIONS

In our series, multimodality PET/MR technology provided additional diagnostic value in some patients with cardiovascular disease compared with MR and PET performed separately, especially in cases of noncoronary heart disease and in those with inconclusive results on MR or PET. In our experience, the main benefits of PET/MR include the possibility of simultaneous acquisition, the in vivo integration of anatomical/functional/metabolic aspects, and the interaction of different experts in imaging modalities.

Importance of cardiac magnetic resonance findings in the diagnosis of left dominant arrythmogenic cardiomyopathy

INTRODUCTION AND OBJECTIVES

Left dominant arrhythmogenic cardiomyopathy (LDAC) has recently been recognized as falling on the spectrum of arrhythmogenic cardiomyopathy. It is characterized by fibroadipose replacement of the left ventricle. The aim of this study was to describe the most frequent forms of clinical presentation of LDAC, imaging findings, and events at follow-up, highlighting the importance of cardiac magnetic resonance (CMR).

METHODS

Prospective registry of patients with findings compatible with LDAC. CMR image analysis and clinical follow-up was performed. The primary endpoint was the appearance of major adverse cardiovascular events (MACE) during follow-up, defined as sudden cardiac death, sustained ventricular arrhythmias, and heart transplant.

RESULTS

We included 74 consecutive patients (mean age, 48.6 years; 50 men [67.6%]). The most frequent CMR indications were chest pain with normal coronary angiography, ventricular arrhythmias, and suspicion of cardiomyopathies. The main CMR findings were midwall and/or subepicardial pattern of late gadolinium enhancement (91.9%), fatty epicardial infiltration (83.8%), and left ventricle segmental contractility abnormalities (47.9%). At a mean follow-up of 3.74 years, 24 patients (32.4%) had a MACE (sudden cardiac death 8.1%, sustained ventricular arrhythmias 21.6%, and heart transplant 4.1%). Independent predictors for the appearance for MACE were a CMR study showing severe late gadolinium enhancement, male sex, and practicing sports.

CONCLUSIONS

CMR is a key tool for diagnosing LDAC. Characteristic findings are subepicardial fatty infiltration and midwall-subepicardial late gadolinium enhancement. The prognosis of this population is poor with a high incidence of sudden cardiac death and ventricular arrhythmias.

Partial segmental thrombosis of the corpus cavernosum: imaging findings

Partial segmental thrombosis of the corpus cavernosum is an unusual clinical condition of unknown origin that mainly affects young males, whose characteristic presentation is the appearance of unexplained perineal pain associated with a palpable perineal mass. This entity consists of thrombosis in the perineal portion of the corpus cavernosum, usually unilateral and it is associated with underlying malignant pathologies and predisposing factors such as microtrauma. After the adequate adherence to conservative treatment, the appearance of complications such as erectile dysfunction is very uncommon.

Value of dual-energy CT enterography in the analysis of pathological bowel segments in patients with Crohn's disease

OBJECTIVE

To analyze whether there are significant differences in the objective quantitative parameters obtained in the postprocessing of dual-energy CT enterography studies between bowel segments with radiologic signs of Crohn's disease and radiologically normal segments.

MATERIAL AND METHODS

This retrospective study analyzed 33 patients (16 men and 17 women; mean age 54 years) with known Crohn's disease who underwent CT enterography on a dual-energy scanner with oral sorbitol and intravenous contrast material in the portal phase. Images obtained with dual energy were postprocessed to obtain color maps (iodine maps). For each patient, regions of interest were traced on these color maps and the density of iodine (mg/ml) and the fat fraction (%) were calculated for the wall of a pathologic bowel segment with radiologic signs of Crohn's disease and for the wall of a healthy bowel segment; the differences in these parameters between the two segments were analyzed.

RESULTS

The density of iodine was lower in the radiologically normal segments than in the pathologic segments [1.8 ± 0.4mg/ml vs. 3.7 ± 0.9mg/ml; p<0.05]. The fat fraction was higher in the radiologically normal segments than in the pathologic segments [32.42% ± 6.5 vs. 22.23% ± 9.4; p<0.05].

CONCLUSION

There are significant differences in the iodine density and fat fraction between bowel segments with radiologic signs of Crohn's disease and radiologically normal segments.

Stroke and temporal arteritis: A study of 6 cases

INTRODUCTION

Though uncommon, ischaemic stroke due to temporal arteritis carries serious difficulties for diagnosis and subsequent management and requires a high level of suspicion.

METHODS

We analysed a series of 6 patients with biopsy-proven temporal arteritis presenting with ischaemic stroke. We discuss clinical characteristics, difficulties of assessment, short- and long-term progression, treatment, and the usefulness of new diagnostic techniques.

RESULTS

Our sample of 6 patients had a mean age of 68.3 years; 50% were women. The majority of patients showed systemic symptoms. Anterior and posterior circulation were affected similarly. MRI angiography, Doppler sonography, and PET-CT proved to be very useful for diagnosis and treatment. Mean follow-up time was 26 months. Clinical outcomes were far from good: 33% scored≥3 on the modified Rankin scale, including one death. Two patients had recurrent stroke despite treatment with full doses of corticosteroids, and 2 underwent angioplasty.

CONCLUSIONS

Stroke caused by giant cell arteritis is a serious and potentially severe condition which requires a high level of suspicion and early treatment with corticosteroids. New diagnostic techniques contribute to refining patient assessment and identifying the optimal treatment. Endovascular treatment may be a valid therapeutic option in selected patients.

Usefulness of multidetector computed tomography before and after pulmonary vein isolation

OBJECTIVE

To analyze the usefulness of multidetector computed tomography (MDCT) in the preprocedural evaluation and follow-up of patients undergoing radiofrequency ablation of pulmonary veins and the impact of the MDCT findings on the approach to treatment.

METHOD

We retrospectively analyzed 92 consecutive MDCT studies done in 80 patients between January 2011 and June 2013; 70 (76%) studies were done before a first ablation procedure and 22 (24%) were done in patients who had undergone an ablation procedure.

RESULTS

Findings were useful in 34% of the patients who underwent MDCT before the first ablation procedure and in 68% of the studies done after a procedure. The incidence of stroke associated with the ablation procedure was 3%, similar to the incidence recorded in our center before we started to use MDCT to evaluate the anatomy of the left atrium. All symptomatic patients had some pulmonary vein stenosis, and 80% had significant stenosis. Furthermore, the stenoses progressed very rapidly; treatment with balloon angioplasty was associated with early restenosis. Stenting was an alternative in cases of failed angioplasty.

CONCLUSION

In the preprocedural evaluation and postprocedural follow-up of patients undergoing pulmonary vein isolation, MDCT is useful for guiding treatment and detecting complications.

Accuracy of Area at Risk Quantification by Cardiac Magnetic Resonance According to the Myocardial Infarction Territory

INTRODUCTION AND OBJECTIVES

Area at risk (AAR) quantification is important to evaluate the efficacy of cardioprotective therapies. However, postinfarction AAR assessment could be influenced by the infarcted coronary territory. Our aim was to determine the accuracy of T₂-weighted short tau triple-inversion recovery (T₂W-STIR) cardiac magnetic resonance (CMR) imaging for accurate AAR quantification in anterior, lateral, and inferior myocardial infarctions.

METHODS

Acute reperfused myocardial infarction was experimentally induced in 12 pigs, with 40-minute occlusion of the left anterior descending (n = 4), left circumflex (n = 4), and right coronary arteries (n = 4). Perfusion CMR was performed during selective intracoronary gadolinium injection at the coronary occlusion site (in vivo criterion standard) and, additionally, a 7-day CMR, including T₂W-STIR sequences, was performed. Finally, all animals were sacrificed and underwent postmortem Evans blue staining (classic criterion standard).

RESULTS

The concordance between the CMR-based criterion standard and T₂W-STIR to quantify AAR was high for anterior and inferior infarctions (r = 0.73; P = .001; mean error = 0.50%; limits = -12.68%-13.68% and r = 0.87; P = .001; mean error = -1.5%; limits = -8.0%-5.8%, respectively). Conversely, the correlation for the circumflex territories was poor (r = 0.21, P = .37), showing a higher mean error and wider limits of agreement. A strong correlation between pathology and the CMR-based criterion standard was observed (r = 0.84, P < .001; mean error = 0.91%; limits = -7.55%-9.37%).

CONCLUSIONS

T₂W-STIR CMR sequences are accurate to determine the AAR for anterior and inferior infarctions; however, their accuracy for lateral infarctions is poor. These findings may have important implications for the design and interpretation of clinical trials evaluating the effectiveness of cardioprotective therapies.

Respiratory monitoring with electrical impedance tomography for lung protective ventilation and alveolar recruitment maneuver in a patient with a single lung transplant and early graft dysfunction

A case is presented on a patient who underwent left single lung transplantation for emphysema type COPD. There was early graft dysfunction gradeiii during the immediate postoperative period, which required the implantation of an extracorporeal membrane oxygenator (ECMO). Respirator ventilatory parameters were adjusted to avoid lung distension, low tidal volume (Vc) (280ml), high respiratory rates (20rpm), and a positive pressure at end expiration (PEEP) level of 8cmH2O. On monitoring the pulmonary tidal volume distribution by bedside electrical impedance tomography (EIT), it was noted that most of the tidal volume was distributed in the native lung emphysema. An alveolar recruitment manoeuvre was performed, under control of the EIT, that enabled the current volume and distribution and the pressures required to ventilate the transplanted lung to be observed.

In-hospital mortality risk factors for patients with cerebral vascular events in infectious endocarditis. A correlative study of clinical, echocardiographic, microbiologic and neuroimaging findings

OBJECTIVE

Cardiac complications in infectious endocarditis (IE) are seen in nearly 50% of cases, and systemic complications may occur. The aim of the present study was to determine the characteristics of inpatients with IE who suffered acute neurologic complications and the factors associated with early mortality.

METHODS

From January 2004 to May 2010, we reviewed clinical and imaging charts of all of the patients diagnosed with IE who presented a deficit suggesting a neurologic complication evaluated with Computed Tomography or Magnetic Resonance within the first week. This was a descriptive and retrolective study.

RESULTS

Among 325 cases with IE, we included 35 patients (10.7%) [19 males (54%), mean age 44-years-old]. The most common underlying cardiac disease was rheumatic valvulopathy (n=8, 22.8%). Twenty patients survived (57.2%, group A) and 15 patients died (42.8%, group B) during hospitalization. The main cause of death was septic shock (n=7, 20%). There was no statistical difference among groups concerning clinical presentation, vegetation size, infectious agent and vascular territory. The overall number of lesions was significantly higher in group B (3.1 vs. 1.6, p=0.005) and moderate to severe cerebral edema were more frequent (p=0.09). Sixteen patients (45.7%) (12 in group A and 4 in group B, p=0.05) were treated by cardiac surgery. Only two patients had a favorable outcome with conservative treatment (5.7%).

CONCLUSIONS

In patients with IE complicated with stroke, the number of lesions observed in neuroimaging examinations and conservative treatment were associated with higher in-hospital mortality.

Imaging Techniques in Acute Heart Failure

In recent years, imaging techniques have revolutionized the diagnosis of heart failure. In patients with a clinical picture of acute decompensation, prognosis is largely determined by early implementation of general measures and treatment of the underlying cause. Given its diagnostic yield and portability, ultrasound has become an essential tool in the setting of acute heart failure, and is currently found in all medical departments involved in the care of the critically ill patient. Cardiac magnetic resonance and computed tomography allow detailed characterization of multiple aspects of cardiac structure and function that were previously unavailable. This helps guide and monitor many of the treatment decisions in the acute heart failure population in an entirely noninvasive way. This article aims to review the usefulness of the imaging techniques that are clinically relevant in the context of an episode of acute heart failure. We discuss the indications and limitations of these techniques in detail and describe the general principles for the appropriate interpretation of results.