Detailed Anatomic Assessment Research Articles

Thoracic Incidental Findings in Preoperative Computed Tomography Evaluation for Transcatheter Aortic Valve Implantation (TAVI).

Many older patients with aortic stenosis are excluded from surgical intervention due to multiple comorbidities. For these patients, transcatheter aortic valve implantation (TAVI) is a viable treatment alternative. Cardiothoracic computed tomography (CT) provides detailed anatomic assessment of the aortic root structures for patient selection, preprocedural planning, and intraoperative decision-making; however, nonaortic incidental findings are frequently detected. The prevalence and clinical significance of these findings have not been well described. This retrospective study examined incidental findings in 209 consecutive patients (96 women and 113 men; mean age, 70 y) with aortic stenosis undergoing preoperative cardiothoracic CT evaluation for TAVI during a 3-year period. Incidental findings were recorded, and medical records were reviewed for follow-up diagnostic examinations. Incidental findings, both significant and nonsignificant, were observed in 85.6% of patients (179/209). Noncalcified pulmonary nodules were the most common incidental finding occurring in 59/209 (28.2%) patients, followed by pleural effusion and emphysema both of which occurred in 34/209 (16.3%) patients, respectively. Cardiothoracic CT obtained for evaluation before TAVI has a high frequency of incidental findings.

Diagnostic accuracy of multidetector computed tomography coronary angiography in 330 consecutive patients referred for balloon-expandable transcatheter aortic valve implantation

Purpose: The aim of this study was to assess the evaluability and diagnostic accuracy of the multidetector computed tomography (MDCT) coronary angiography in patients referred for transcatheter aortic valve implantation (TAVI). MDCT is playing an increasingly role in patients scheduled for TAVI, providing detailed anatomic assessment of the aortic root and valve annulus and of iliofemoral access. However, the diagnostic performance of MDCT coronary angiography has not been well investigated. Methods: 330 consecutive patients scheduled for invasive coronary angiography (ICA) and 64-slice MDCT for the screening protocol before TAVI were enrolled (42 patients with previous coronary artery bypass graft (CABG), 49 with previous coronary stenting, 233 without previous revascularizations). All MDCT coronary angiography were performed using the same data set dedicated to the standard MDCT evaluation of aortic annulus, obtained with retrospective ECG triggering. Coronary arteries evaluability by MDCT coronary angiography and its diagnostic accuracy parameters in comparison with ICA as gold standard were evaluated. Results: In the remaining 325 patients, the mean HR during the scan was 61±9 bpm. The MDCT evaluability of native coronary arteries was 95.6%. The leading cause of unevaluability was the beam-hardening artifact due to large coronary calcifications (109 cases), followed by slice misalignments (56 cases) due to HR variability or premature heart beats during the scan and motion artifacts (40 cases). In the segment-based analysis, sensibility, specificity, positive predictive value, negative predictive value and accuracy were 91%, 99.2%, 83.4%, 99.6% and 98.8%, respectively. MDCT correctly assessed the patency of all CABG, without graft classified as non evaluable. The MDCT evaluability of coronary stents was 82.1%. In the segment-based analysis, MDCT showed sensibility, specificity, positive predictive value, negative predictive value and accuracy for the detection of ≥ 50% luminal narrowing of 94.1%, 86.7%, 66.7%, 98.1% and 88.3%, respectively. Conclusions: MDCT coronary angiography allows to correctly rule out the presence of significant coronary stenosis in patients referred for TAVI, demonstrating and excellent negative predictive value also in patients with previous CABG or stents.

A detailed anatomical assessment of the lateral tongue extrinsic musculature, and proximity to the tongue mucosal surface. Does this confirm the current TNM T4a muscular subclassification?

The current T4a subclassification of the TNM staging system for oral malignancies has been criticised as based almost exclusively on anatomical data. The aim of this study was to provide anatomical confirmation of the muscular constraints of T4a classification of oral tongue tumours. A detailed anatomical study describing and measuring the adjacency of the named extrinsic tongue muscles to the lateral tongue surface was completed on the Visible Human Female (VHF). The distance of styloglossus and hyoglossus to the over lying mucosa were determined. The appearance, position, orientation and anatomical relationships of the lateral tongue extrinsic muscles, with comparison to their classical descriptions are described. The right VHF styloglossus was 1.3 mm (0.33-1.48) and left 2.91 mm (0.66-7.68) from the mucosal surface in the axial plane. The right VHF hyoglossus was 2.93 mm (1.48-4.96) and left 4.33 (1.68-8.71) from the mucosal surface in the axial line. In the lateral tongue, styloglossus and hyoglossus are very superficial. The inclusion criteria of hyoglossus and styloglossus in the T4a staging does not appear justified based upon their anatomical position.

What is mine? Behavioral and anatomical dissociations between somatoparaphrenia and anosognosia for hemiplegia.

We describe the clinical manifestations and the lesion patterns of five patients with somatoparaphrenia, the denial of ownership for a paralyzed limb, who showed the rare dissociation from anosognosia for hemiplegia. Similar cases have been only occasionally cited in the literature with scanty descriptions of their symptoms and no detailed anatomical assessment. All patients had extrapersonal and at least mild personal neglect. The lesions pattern was mainly subcortical, with a significant involvement of the right thalamus, the basal ganglia and the internal capsule. A formal comparison between the anatomical pattern previously associated with anosognosia in a study performed in 2005 by Berti and colleagues, and the lesion distribution of each patient clearly shows that our pure somatoparaphrenic patients had a sparing of most of the regions associated with anosognosia for hemiplegia. The behavioral dissociation between SP and anosognosia for hemiplegia, together with this new anatomical evidence, suggests that motor awareness is not sufficient to build up a sense of ownership and therefore these two cognitive abilities are at least in part functionally independent and qualitatively different.

What is Mine? Behavioral and Anatomical Dissociations between Somatoparaphrenia and Anosognosia for Hemiplegia

We describe the clinical manifestations and the lesion patterns of five patients with somatoparaphrenia, the denial of ownership for a paralyzed limb, who showed the rare dissociation from anosognosia for hemiplegia. Similar cases have been only occasionally cited in the literature with scanty descriptions of their symptoms and no detailed anatomical assessment. All patients had extrapersonal and at least mild personal neglect. The lesions pattern was mainly subcortical, with a significant involvement of the right thalamus, the basal ganglia and the internal capsule. A formal comparison between the anatomical pattern previously associated with anosognosia in a study performed in 2005 by Berti and colleagues, and the lesion distribution of each patient clearly shows that our pure somatoparaphrenic patients had a sparing of most of the regions associated with anosognosia for hemiplegia. The behavioral dissociation between SP and anosognosia for hemiplegia, together with this new anatomical evidence, suggests that motor awareness is not sufficient to build up a sense of ownership and therefore these two cognitive abilities are at least in part functionally independent and qualitatively different.

Diagnosis of Tetralogy of Fallot and Its Variants in the Late First and Early Second Trimester: Details of Initial Assessment and Comparison with Later Fetal Diagnosis

We sought to evaluate the completeness of echocardiographic diagnosis of fetal tetralogy of Fallot (fTOF) at 12-17 weeks gestation, and compare assessment and clinical outcomes to diagnoses made at >17 weeks gestation. We identified all fTOF diagnoses made in our experience from 2003 to 2008. Referral indication, anatomic detail by echocardiography and pregnancy outcomes were compared between fetuses diagnosed at ≤ 17 weeks (Group I) and >17 weeks gestation (Group II). A 10-point scoring tool was applied retrospectively to the echocardiograms at initial diagnosis (1 point each was ascribed to visualization of right ventricular outflow obstruction, pulmonary valve, pulmonary arteries including dimensions, pulmonary arterial flow, systemic and pulmonary venous anatomy, atrioventricular valves, ductus arteriosus, ductus flow, aortic arch morphology, sidedness and flow). There were 10 pregnancies in Group I (12-17 weeks) and 25 in Group II (mean gestation at diagnosis 23.5 ± 5.7). The most common reason for referral was extracardiac pathology in Group I (80%) and suspected fetal heart disease on obstetric ultrasound in Group II (64%). Transabdominal imaging was adequate in about half of Group I studies. Mean anatomic diagnosis score in Group I was 6.1(range 2.5-9) and Group II was 8.4 (range 6.5-10). Elective pregnancy termination occurred in 80% in Group I and 33% in Group II. fTOF can be diagnosed in first and early second trimesters with detailed anatomic assessment possible in most. Referral indication and pregnancy outcome differ considerably between early and later prenatal diagnosis of fTOF.

Real-time three-dimensional transthoracic echocardiography in daily practice: initial experience

Aim of the workTo evaluate the feasibility and possible additional value of transthoracic real-time three-dimensional echocardiography (RT3D-TTE) for the assessment of cardiac structures as compared to 2D-TTE.Methods320 patients (mean age 45 ± 8.4 years, 75% males) underwent 2D-TTE and RT3D-TTE using 3DQ-Q lab software for offline analysis. Volume quantification and functional assessment was performed in 90 patients for left ventricle and in 20 patients for right ventricle. Assessment of native (112 patients) and prosthetic (30 patients) valves morphology and functions was performed. RT3D-TTE was performed for evaluation of septal defects in 30 patients and intracardiac masses in 52 patients.ResultsRT3D-TTE assessment of left ventricle was feasible and reproducible in 86% of patients while for right ventricle, it was (55%). RT3D-TTE could define the surface anatomy of mitral valve optimally (100%), while for aortic and tricuspid was (88% and 81% respectively). Valve area could be planimetered in 100% for the mitral and in 80% for the aortic. RT3D-TTE provided a comprehensive anatomical and functional evaluation of prosthetic valves. RT3D-TTE enface visualization of septal defects allowed optimal assessment of shape, size, area and number of defects and evaluated the outcome post device closure. RT3D-TTE allowed looking inside the intracardiac masses through multiple sectioning, valuable anatomical delineation and volume calculation.ConclusionOur initial experience showed that the use of RT3D-TTE in the assessment of cardiac patients is feasible and allowed detailed anatomical and functional assessment of many cardiac disorders.

Clinical and gonadal features and early surgical management of 45,X/46,XY and 45,X/47,XYY chromosomal mosaicism presenting with genital anomalies

ObjectiveThe 45,X/46,XY and 45,X/47,XYY group of patients includes some of those previously diagnosed with ‘mixed gonadal dysgenesis’. Our aim was to establish the clinical and gonadal spectrum, and early surgical management, of patients with chromosomal mosaicism presenting with genital anomalies. Patients and methodsWe performed a retrospective review of patients with 45,X/46,XY or 45,X/47,XYY mosaicism presenting with genital ambiguity between 1988 and 2009. At least one gonadal biopsy or gonadectomy specimen was available for each patient. Gonadal histology was re-evaluated by a paediatric pathologist. ResultsOf 31 patients with 45,X/46,XY (n = 28) or 45,X/47,XYY (n = 3) mosaicism and genital anomalies, 19 (61%) were raised male. Histology of 46 gonads was available from patients who had undergone a gonadectomy or gonadal biopsy, at a median age of 9.5 months. 18 gonads were palpable at presentation, including 5 (28%) histologically unremarkable testes, 2 streak gonads, and 1 dysgenetic gonad with distinct areas of testicular and ovarian stroma but no oocytes. All intra-abdominal gonads were found to be dysgenetic testes (of which 2 were noted to have pre-malignant changes) or streaks, apart from 1 histologically unremarkable testis. 15 (48%) patients had other anomalies, most commonly cardiac and renal; 4 (13%) had a Turner phenotype. ConclusionThe anatomy and gonadal histology of 45,X/46,XY and 45,X/47,XYY individuals with genital ambiguity do not conform to a set pattern, and hence management of each patient should be individualized according to detailed anatomical and histological assessment.

Fenestrated cor triatriatum sinistrum: A case report

We present a 20-year-old male patient with cor triatriatum sinistrum with fenestrations and long-standing dyspnea on exertion, fatigue, and palpitation. An apical early to mid-systolic murmur of grade I-II/VI was heard on cardiac auscultation. Electrocardiography showed sinus rhythm and an incomplete right bundle branch block. Transthoracic echocardiography showed a membrane dividing the left atrium into two compartments. Transesophageal echocardiography showed a membrane with fenestrations originating from the left upper pulmonary vein, extending to the interatrial septum, and dividing the left atrium into two compartments as proximal and distal. Cardiac MR imaging for further detailed anatomical assessment demonstrated similar findings without additional anomaly. Medical follow-up was conducted due to no pressure gradient across the membrane.

High resolution MR for evaluation of lower urogenital tract malformations in infants and children: Feasibility and preliminary experiences

Introduction This retrospective study aimed to assess the value of supplementing heavily T2-weighted, high resolution MR-imaging for detailed anatomic assessment in paediatric lower urogenital tract (UGT) malformations. Patients/methods Sixteen patients (6 male and 10 female, median age = 1.8 years, range = 0–9 years) with suspected malformations of the lower UGT who were retrospectively identified from the PACS underwent a clinically indicated standard MR-urography study. In order to facilitate a better anatomic assessment of questioned specific lower UGT structures, an additional three-dimensional Constructive Interference in Steady State-sequence (3D-CISS) had been acquired in these patients. The final diagnosis was established by all imaging results and surgical or laprascopic findings. The findings from the CISS-sequence were compared to the results from standard MR-urography for complementary anatomic information and conspicuity. Results Diagnostic 3D-CISS image quality was achieved in all patients. The 3D-CISS confirmed an ectopic ureteral insertion in six patients and reliably excluded ectopic insertion in 10 patients, whereas conventional MR-urography showed an ectopic insertion of the ureter in one case. In six patients with retrovesical complex formations (suspicious for an ectopic cystic renal bud or a cystic genital structure) the 3D-CISS showed increased conspicuity scores for image quality. Conclusion The additional 3D-CISS-sequence increases the diagnostic yield in the pelvis in children with complex malformations of the lower UGT such as ectopic ureteral insertion or suspected cystic renal or genital malformations at only minimal additional time, compared to standard MR-urography.

MAGNETIC RESONANCE IMAGING OF THE CANINE OPTIC NERVE

We describe the magnetic resonance (MR) imaging aspects of normal canine optic nerve, the diameter of the optic nerve as measured on MR images, and optimal MR sequences for the evaluation of the optic nerve using a 0.2T MR unit. Three millimeter contiguous slides of the normal canine orbital region were acquired in transverse and dorsal oblique planes using a variety of tissue weighting sequences. It was apparent that detailed anatomic assessment of the optic nerve can be performed with low-field MR imaging, but none of the sequences provided unequivocal superior image quality of the optic nerve. The mean diameter of the optic nerve sheath complex was 3.7mm and of the optic nerve 1.7 mm. The intraorbital and intracanalicular parts of the optic nerve are consistently visible and differentiation between the optic nerve and optic nerve sheath complex is possible using low-field MR systems.

Usefulness of Magnetic Resonance Imaging Evaluation of Congenital Left Ventricular Aneurysms

Congenital left ventricular (LV) aneurysm is a rare malformation of unknown cause that is often associated with a poor prognosis. This study was undertaken to evaluate the usefulness of cardiac magnetic resonance imaging in patients with congenital LV aneurysms and to determine the relation between clinical manifestations and the morphologic and functional characteristics of the aneurysms. Among the 26 consecutive patients with congenital LV aneurysms included, the anomalies involved the apex or free wall in 15 and the submitral myocardium in 11. Cardiac magnetic resonance provided detailed anatomic and functional assessment of the aneurysms in all patients. Compared with submitral aneurysms, apical or free-wall aneurysms were larger (24 +/- 29 vs 3 +/- 2 ml/m(2), p = 0.02), were more frequently associated with scar tissue by myocardial delayed enhancement imaging (71% vs 0%, p = 0.03), and tended to be more commonly associated with symptoms (53% vs 18%, p = 0.08). Aneurysm volume but not location correlated with LV size (r = 0.735, p <0.0001) and the ejection fraction (r = 0.774, p <0.0001). Apical or free-wall aneurysms were resected in 5 patients, with no mortality. There was 1 death after aortic valve replacement in a patient with type B Niemann-Pick disease, which was not clearly related to the LV aneurysm. The remaining 25 patients are alive at a median age of 13.5 years. In conclusion, the experience with this cohort illustrates that cardiac magnetic resonance is well suited for the morphologic and functional evaluation of congenital LV aneurysms.

Intervenção coronariana percutânea em artéria coronariana única em paciente com angina instável de alto risco

In the present case, we report the performance of coronary angioplasty with stent implantation in the right coronary artery of a patient with high-risk unstable angina and single coronary artery originating from the right coronary sinus. The anterior descending and circumflex arteries originated separately from the proximal third of the right coronary artery. This is a rare coronary anomaly and few reports of percutaneous coronary intervention are found in the literature. This case illustrates the need for a detailed anatomical assessment of the course of the coronary arteries prior to the performance of a percutaneous transluminal angioplasty, with the purpose of preventing complications.

The role of magnetic resonance imaging in pediatric urology

Magnetic resonance imaging has emerged as a powerful diagnostic tool for the imaging of the pediatric genitourinary tract. The aim of this review is to familiarize the reader with the current applications and basic techniques utilizing magnetic resonance imaging in pediatric uroradiology. Magnetic resonance imaging can provide both a detailed anatomic and functional assessment of the pediatric genitourinary tract in a single study without the use of ionizing radiation. Magnetic resonance urography combines static and dynamic evaluation of the urinary tract following contrast administration and has been most often applied to the evaluation of hydronephrosis. In addition to unparalleled anatomic assessment, it allows for the evaluation of glomerular filtration rate, renal transit time, and differential renal function. It also provides unique insights into a wide range of obstructive uropathies and has been demonstrated to be useful in the evaluation of complex genitourinary anomalies. Magnetic resonance voiding cystourethrography has been used to rule out vesicoureteral reflux. Magnetic resonance imaging has also been demonstrated to be superior to nuclear scintigraphy for the diagnosis of pyelonephritis and renal scarring. Magnetic resonance imaging has emerged as a powerful tool for the diagnosis of pediatric genitourinary anomalies. It provides functional and anatomic assessment with a single procedure that in most cases is superior to conventional procedures. Magnetic resonance imaging will probably become the modality of choice for the imaging of pediatric genitourinary tract anomalies.

Existing Delays Following the Presentation of Ruptured Abdominal Aortic Aneurysm Allow Sufficient Time to Assess Patients for Endovascular Repair

Objectives The greatest benefit of endovascular AAA repair (EVAR) may be in the management of rupture (RAAA). However, the detailed anatomical assessment required for EVAR has lead to concerns of surgical delay and death during cross-sectional imaging. In this study, we prospectively assessed patients with RAAA and correlated time of hospital arrival with time of surgery or death to ascertain whether these concerns are justified. Methods All patients presenting with RAAA between October 2000 and December 2002 were included. The hospital arrival time, onset of surgery or time of death, were recorded, as were demographic and physiological parameters. Results One hundred consecutive patients were studied, median age 75 years (range 54–94). Seventy-nine patients underwent attempted conventional surgical repair and 21 were palliated. The median delay from arrival to operation was 159 min (range 16–1450 min). Mortality in the surgical group was not affected by the length of delay ( p=1.0) or by CT scanning ( p=0.34). The median time from arrival to death in the non-surgical group was 435 min (15 min–6 days). Conclusions Most patients who present with ruptured AAA experience a significant delay prior to surgery. This study suggests it is safe to assess the majority of RAAA patients for EVAR.

Anatomic and hemodynamic imaging using a new vector phased-array intracardiac catheter

Background: We used a new vector, phased-array intracardiac catheter (AcuNav) with complete 2-dimensional imaging and Doppler capabilities to describe a systematic approach for a detailed anatomic and hemodynamic cardiac assessment. Methods: In 14 dogs, the intracardiac echocardiographic catheter was inserted through an 11F venous access and placed in the right side of the heart to perform a comprehensive ultrasound examination of the heart. Results: Imaging was successful in all dogs. All 4 cardiac chambers and valves were imaged clearly in multiple orientations. Additional structures seen included the vena cavae, coronary sinus, right and left appendages, interarterial septum, coronary arteries, and all 4 pulmonary veins. Intra-abdominal structures, such as the aorta, liver, and hepatic veins were also visualized. A complete Doppler examination of intracardiac and paracardiac flows was also possible. Conclusion: AcuNav is a unique intracardiac imaging device, which allows comprehensive structural and functional cardiac assessment. (J Am Soc Echocardiogr 2002;15:349-55.)

Endovascular Treatment of Vertebrobasilar Aneurysms

In posterior circulation aneurysms, GDC endosaccular occlusion is the treatment of choice, when indicated. This report assessed anatomical, morphological and clinical criteria in the choice of vertebral or basilar artery occlusion in posterior circulation aneurysms, when GDC endosaccular treatment, with or without the "remodelling technique", is not indicated, as in giant or wide-neck aneurysms. Over five years we observed eleven patients harboring posterior circulation aneurysms with no indication for treatment with GDC, or only vertebral occlusion. In our experience, the endovascular occlusion of a single or both vertebral arteries or basilar artery, following a detailed anatomical and clinical assessment, has proved a good, reliable treatment in large or giant vertebrobasilar aneurysms or those without a neck.

Diagnostic imaging of the brain of blind and visually handicapped young children

In infants with delayed or absent visual maturation a neuroradiological investigation of the brain is commonly performed in addition to neurophysiological examinations. We report our preliminary experience with magnetic resonance imaging (MRI). MRI allows a detailed anatomical assessment and an evaluation of the myelination, including the optic radiation. Following severe perinatal hypoxic-ischemic injury periventricular leukomalacia in the parieto-occipital region was a common finding. The findings in infants with or without ocular abnormalities were heterogeneous, including normal findings, nonspecific delays of cerebral myelination as well as several malformations (such as corpus callosum hypoplasia, Aicardi syndrome, septo-optic dysplasia, migration disorders). In the individual case the neuroradiological findings do not allow to draw conclusions to the visual function and prognosis. In children with Leber congenital retinal amaurosis we have observed a normal myelination of the optic radiation. In many cases, particularly if a syndromic diagnosis is reached, neuro-imaging gives useful information for prognostic and genetic counselling.

An introduction to ultrasonography in oral surgery

The examination of postsurgical facial swelling is restricted largely to clinical techniques of evaluation, such as palpation. In experienced hands, such evaluation provides an understanding of the gross changes occurring as a result of oral surgery. However, a more detailed anatomic assessment was considered beneficial. High-resolution gray-scale ultrasonography was therefore employed in the examination of facial tissues before and after the standard surgical approach to removal of impacted third molar teeth. This study revealed that information concerning the site and dimensions of postsurgical edema and hematoma was readily obtainable with the techniques used.

Two-dimensional echocardiographic spectrum of ebstein's anomaly: Detailed anatomic assessment

This report details the two-dimensional echocardiographic assessment of 41 patients with Ebstein's anomaly. The anatomic spectrum of Ebstein's anomaly is correlated with surgical and autopsy observations in 66% of these patients. Morphologic abnormalities of the tricuspid valve and right heart structures were uniquely assessed by noninvasive two-dimensional echocardiographic examination. Features of the tricuspid valve that best related to decreased functional capacity were: 1) absence of the septal leaflet, and 2) pronounced tethering, restriction of motion and displacement of the anterior leaflet of the tricuspid valve. This 4 1/2 year experience suggests that two-dimensional echocardiography can replace angiography as the procedure of choice for diagnostic and morphologic assessment of Ebstein's anomaly. Cardiac catheterization is necessary only when specific hemodynamic questions or clinical inconsistencies exist.