Diagnostic Imaging Modality Of Choice Research Articles

Comprehensive Review of the Imaging Recommendations for Diagnosis, Staging, and Management of Thyroid Carcinoma.

Thyroid cancer is the most common head and neck cancer (HNC) in the world. In this article, we comprehensively cover baseline, posttreatment, and follow-up imaging recommendations for thyroid carcinomas along with the eighth edition of the tumor, node, metastasis (TNM) staging system proposed by the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC). We include characterization and risk stratification of thyroid nodules on ultrasound (US) proposed by various international bodies. Management guidelines (depending upon the type of thyroid carcinoma) based on the international consensus recommendations (mainly by the American Thyroid Association) are also extensively covered in this article, including the role of a radioiodine scan. The management of recurrent disease is also briefly elucidated in this article. In addition, we cover the risk factors and etiopathogenesis of thyroid carcinoma along with the non-imaging diagnostic workup essential for thyroid carcinoma management, including the significance of genetic mutations. US is the diagnostic imaging modality of choice, with US-guided fine needle aspiration (FNA) being the procedure of choice for tissue diagnosis. The roles of computed tomography (CT), magnetic resonance imaging (MRI), and fluorodeoxyglucose positron emission tomography/CT (FDG-PET/CT) in thyroid carcinoma staging are also specified. Through this article, we aim to provide a comprehensive reference guide for the radiologists and the clinicians in the pursuit of optimal care for patients with thyroid carcinoma.

Advances in diagnosis and management of canine insulinoma: a review

Insulinomas are the most common pancreatic tumours in dogs. Diagnosis of insulinoma requires the concurrent presence of hypoglycaemia and serum insulin levels within or above the upper limit of the reference range. The diagnostic imaging modality of choice is triple-phase contrast enhanced tomography. Surgical resection is generally the most effective treatment option, leading to prolonged survival; however, medical management becomes necessary for many dogs at some point. After surgery, dogs can live for a few years without clinical signs of hypoglycaemia, but eventually clinical hypoglycaemia frequently recurs due to the outgrowth of micrometastases that were undetected at the time of surgery. This review consolidates and provides updated recommendations from the veterinary literature on the diagnosis and management of canine insulinomas.

Management of Lumbar Pyogenic Spondylodiscitis in Germany: A Cross-Sectional Analysis of Spine Specialists

The incidence of pyogenic spondylodiscitis is increasing, and the disease is associated with considerable morbidity, mortality, long-term healthcare utilization and societal costs. Disease-specific treatment guidelines are lacking and there is little consensus regarding optimal conservative and surgical management. This cross-sectional survey of German specialist spinal surgeons sought to determine practice patterns and degree of consensus regarding the management of lumbar pyogenic spondylodiscitis (LPS). An electronic survey covering provider information, diagnostic approaches, treatment algorithms, and follow-up care of patients with LPS was distributed to members of the German Spine Society. Seventy-nine survey responses were included in the analysis. Magnetic resonance imaging is the diagnostic imaging modality of choice for 87% of respondents; 100% routinely measure C-reactive protein in suspected LPS and 70% routinely take blood cultures before therapy initiation; 41% believe that surgical biopsy to obtain microbiological diagnosis should be carried out in all cases of suspected LPS, whereas 23% believe that surgical biopsy should only be carried out when empirical antibiotic therapy proves ineffective; 38% believe an intraspinal empyema should always be surgically evacuated, regardless of spinal cord compression. The median intravenous antibiotic duration is 2weeks. The median total duration of the antibiotic therapy (intravenous and oral) is 8weeks. Magnetic resonance imaging is the preferred imaging modality for follow-up of both conservatively and operatively treated LPS. There exists considerable variation of care in the diagnosis, management, and follow-up of LPS among German spine specialists with little agreement on key aspects of care. Further research is required to understand this variation in clinical practice and to enhance the evidence base in LPS.

Normalization of global longitudinal strain after 20 squats in elite athletes

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction: Transthoracic echocardiography (TTE) is often the first diagnostic imaging modality of choice in athlete care to differentiate between physiological adaptation to sports and pathology. Left ventricular (LV) global longitudinal strain (GLS) has been suggested as a tool to detect early signs of myocardial diseases in athletes. However, low rates of myocardial deformation can also be associated with cardiac adaptation to sports. We hypothesized that observing decreased cardiac deformation in elite athletes may be a sign of an outspoken relaxed cardiac state, rather than pathology. Therefore, we investigated whether a short exercise bout can normalize strain values in elite athletes with abnormal resting GLS. Methods We prospectively enrolled elite athletes who participated in the ELITE (Evaluation of Lifetime Participation in Intensive Top-level Sports and Exercise) cohort. In short, ELITE is a prospective athlete cohort, which collects medical history, ECG, TTE and cardiac magnetic resonance (CMR) data in elite athletes (Olympic/Paralympic level or comparable). For this analysis, we analysed TTEs of asymptomatic athletes without cardiovascular disease and with a structurally normal heart on CMR. TTE (Vivid, GE) was performed in each athlete according to guidelines at rest. After a short exercise bout, consisting of 20 squats, additional GLS, LV ejection fraction (EF), and LV stroke volume (SV) measurements were assessed when heart-rate (HR) was comparable to HR during pre-exercise measurements. TTE data was assessed using EchoPAC (GE). GLS delta (pre- to post-exercise) for each athlete was calculated were plotted, using R. GLS ≥ -16% was considered decreased and -16% ≥ GLS > -18% borderline. Results Our population comprised 73 athletes (26% women), mean age (±SD) of 25.6 ± 6.5 years, BSA of 2 ± 0.2m2, and athletic disciplines road cycling (n = 28), soccer (n = 12), hockey (n = 8), swimming (n = 5), tennis (n = 5) and 8 miscellaneous sports (n = 15). Mean pre- and post-exercise GLS were -18.2 ± 2.1% vs -20.5 ± 2.0% (P < 0.001; Figure 1), EF 57 ± 4% vs 59 ± 6% (P = 0.006; Figure 1), SV 89 ± 20ml vs 99 ± 24ml (P = 0.008), and HR 56 ± 12bpm vs 56 ± 13bpm (P = 0.875). We observed an increase of myocardial deformation after a short bout of exercise: mean GLS delta of -2.3 ± 1.9%. Finally, we found a decreased strain in 14 athletes (19%), in which pre- and post-exercise GLS were -15.1 ± 0.8% and -18.6 ± 2.3%, P= <0.001, Figure 1). Only 1 athlete (1%, no other signs of cardiac pathology: MRI, biomarkers, complaints) had post-exercise decreased GLS. We found 9 athletes with a deteriorated cardiac deformation (delta GLS ≤ 0%), pre- and post-exercise GLS were -20.4 ± 1.4% and -19.9 ± 1.5% (maximal GLS post-exercise was -17.7%, Figure 1). Conclusion GLS normalizes in 99% of healthy (elite) athletes. In athletes with decreased GLS at rest, performing a short exercise bout is a pragmatic method to separate decreased GLS due to pathology from sport adaptation Abstract figure 1

Normalization of global longitudinal strain after a 30-seconds exercise bout in elite athletes

Abstract Background/Introduction Transthoracic echocardiography (TTE) is often the first diagnostic imaging modality of choice in athlete care to differentiate between physiological adaptation to sports and pathology. Mechanical strain as outcome measure, i.e. left ventricular (LV) global longitudinal strain (GLS), has been suggested as a tool to detect early signs of myocardial diseases in athletes. However, low or very low rates of myocardial deformation can also be associated with cardiac adaptation to sports. We hypothesize that observing decreased cardiac deformation in elite athletes may be a sign of an outspoken relaxed cardiac state, rather than pathology. Therefore, we investigated whether a short exercise bout can normalize strain values in elite athletes with abnormal resting GLS. Methods We prospectively enrolled elite athletes who participated in the ELITE (Evaluation of Lifetime Participation in Intensive Top-level Sports and Exercise) cohort. In short, ELITE is a prospective athlete cohort, which collects medical history, ECG, TTE and cardiac magnetic resonance (CMR) data in elite athletes (Olympic/Paralympic level or comparable). For this analysis, we analysed TTEs of asymptomatic athletes without cardiovascular disease and with a structurally normal heart on CMR. TTE (Vivid, GE) was performed in each athlete according to guidelines at rest. After a short exercise bout, consisting of 20 squats, additional measurements were performed when heart-rate (HR) was comparable to HR during pre-exercise measurements. TTE data was assessed using EchoPAC (GE). Paired t-tests were calculated for functional parameters; boxplots for pre- and post-exercise measurements; and GLS delta (pre- to post-exercise) for each athlete was calculated were plotted; using R. GLS ≥−16% was considered decreased and −16% ≥ GLS >−18% borderline. Results Our population comprised 51 athletes (35% women), with a mean age (±SD) of 26.4±5.2 years, and mean BSA of 2±0.3m2. Athletic disciplines consisted of road cycling (n=25), hockey (n=7), swimming (n=5), and 7 miscellaneous sports (n=14). We observed an increase of myocardial deformation after a short bout of exercise: mean GLS delta of 2.6±2% (pre- vs post-exercise GLS: −18.2±2.1% vs −20.8±1.9%; P≤0.001; Figure, A). Furthermore, mean LV stroke volumes were 94±19ml vs 103±23ml (P=0.020), ejection fractions (EF) 57±4% vs 60±4% (P≤0.001), and HR 55±10bpm vs 54±13bpm (P=0.8). Finally, we found a decreased strain in 8 athletes (16%), in 7 of which increased to normal values. Mean delta GLS was 4.5±2.2 (pre- vs post-exercise GLS: −14.9±1.1% vs −19.4±2.7%, P=0.002, Figure, B). The athlete who did not show an increase to normal GLS levels had a decreased LV EF (42%), but showed no other signs of cardiac pathology (MRI, biomarkers, complaints). Conclusion In athletes with abnormal GLS at rest, performing a short exercise bout may provide a pragmatic method to separate decreased GLS due to true pathology from sports adaptation. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Amsterdam Movement Sciences

MRI Study of Types of Internal Knee Derangements of Traumatic Knee

Abstract Background MRI is currently gold standard non-invasive diagnostic imaging modality of choice for nearly all clinical indications concerning the knee. MRI provides excellent visualization of the internal structures of the knee along with soft tissue structures and bone marrow abnormalities (1). Aim of the work determine diagnostic role of MRI in studying types of internal knee derangements of the traumatic knee. Patients and Methods A cross sectional study of thirty four patient of knee joint trauma who underwent MRI for internal derangement of knee at Radio-diagnosis department of Ain Shams University Hospitals in the period from October 2017 to march 2018. Results commonest lesion detected in our study was ACL tear detected in 24 patients.16 patients of with partial ACL tear and 8 patients with complete ACL tear, followed by knee joint effusion medial meniscus tear. Lateral meniscal injuries were less common when compared to medial meniscalinjuries. Conclusion MR imaging is the best non-invasive imaging modality for diagnosis of types of internal derangement of knee joint as it provides excellent visualization of the internal structures of the knee, soft tissue structures and, bone marrow abnormalities. Recommendation further studies with much more population and correlation with arthroscopy for more accurate results.

Should MRI replace mammography as the initial screening modality for asymptomatic women aged 18 – 45 years at high risk of developing breast cancer? A systematic review

Background: Breast cancer occurs in both men and women, although it is more prevalent among women. Mammography is generally the diagnostic imaging modality of choice, but it is limited in the detection of breast cancer in young women, aged 18-45 years due to the dense nature of their breast tissue.Aims and Objectives: This review explores whether MRI should replace mammography as the initial screening modality for asymptomatic women, aged 18-45 years at high risk of developing breast cancer. Materials and Methods: A systematic review of the literature was undertaken. A search of Medline, Pubmed central, Cinahl and Google scholar for English language literature from 2004 to 2015 was undertaken. Also a review of reference lists, author searching and review of NICE evidence base for exiting guidelines was done. Included studies were assessed for bias using STARD quality assessment tool and data were extracted systematically using a purposefully designed data extraction form. Result: From the seven included studies, 179 participants of the total population had breast cancer and a total of 199 breast cancer was detected by both modality used. MRI detected a total 148 breast cancers compared to 78 detected by mammography, and 10 interval cancer was reported. Sensitivity estimate from the included studies ranged from 25% to 100% while specificity ranged from 79% to 99%. MRI detected more breast cancer but had a moderate specificity compared to mammography as reported in the literature. Conclusion: In the absence of contraindication and accessibility, MRI should be used as the initial screening modality for asymptomatic women aged 18 – 45 years, at high risk of developing breast cancer. Asian Journal of Medical Sciences Vol.7(5) 2016 1-9

An unusual presentation of neutropenic enterocolitis (typhlitis)

A 40-year-old man who had refractory, very severe, aplastic anaemia 6 months after an unsuccessful allogenic stem-cell transplant, presented with neutropenic (0·1 × 109/L) septic shock. Examination showed a tender papule on his thigh. Extended-spectrum β-lactamase (ESBL)-producing Escherichia coli grew from the skin biopsy. Blood, urine, and stool cultures were all negative (no oganisms grew). CT showed many liver abscesses. The patient recovered after 6 weeks of ertapenem (1 g once a day) with teicoplanin (initially 200 mg once a day), remaining neutropenic throughout, but 12 days after fi nishing therapy he re-presented with pyrexia and additional skin lesions (fi gure A). Blood cultures grew the same ESBL-E coli as was isolated from the skin biopsy. CT showed pulmonary nodules suggestive of septic emboli with a healthy colon and biliary tract. PET showed uptake in the terminal ileum and wall-thickened caecum, con sistent with neutropenic enterocolitis (fi gure B). Neutropenic enterocolitis is a potentially life-threatening condition of the lower gastrointestinal tract (typically the caecum, in which it is termed typhlitis), where intestinal microbes invade the surrounding tissue of patients with neutropenia. Prevalence of this condition is rising because of liberal use of aggressive chemotherapy agents that damage the intestinal mucosa, and it is being increasingly recognised as a complication of stem-cell transplantation. Typhlitis usually produces a non-specifi c triad of fever, abdominal pain, and diarrhoea but can present as recrudescent fever or bacteraemia. Our patient’s presentation of skin (and probably liver and lung) septicemboli was unusual and emphasises the need for a high index of suspicion for this increasingly prevalent condition. Unexplained bacteraemia with enteric organisms in patients with neutropenia—especially if substantial and long lasting—should raise suspicion of typhlitis and trigger the necessary investigations, if another source for these organisms cannot be identifi ed. CT is regarded as the diagnostic imaging modality of choice for typhlitis, and usually shows bowel wall thickening of more than 4 mm. In our patient, CT did not show bowel wall thickening, but subsequent PET and ultrasonography both did. This diff erence shows that repeat imaging studies should be thought about for patients in whom the diagnosis of typhlitis is suspected. Management of typhlitis is predominantly conservative involving bowel rest, supportive measures, and correction of coagulopathies, thrombocytopenia, and neutropenia. Appropriate broad-spectrum antibiotics should be started promptly, but surgery is usually reserved for com plications such as perforation or if clinical deterioration continues despite conservative management. Our patient continued to receive ertapenem (1 g once a day) alongside teicoplanin (increased to 800 mg once a day) based on blood-culture sensitivities and allergy status. Unfortunately, he later died of complications arising from a second allogeneic transplant not connected with this episode of sepsis.

Is magnetic resonance imaging a viable alternative to ultrasound as the primary imaging modality in the diagnosis of paediatric appendicitis? A systematic review

BackgroundAppendicitis is the most common cause of acute abdominal pain requiring surgical intervention in paediatric patients. Ultrasound is generally the diagnostic imaging modality of choice, followed by CT, where paediatric appendicitis is suspected. However, high operator dependency and diagnostic restrictions related to anatomical and clinical presentation may limit consistency of application. This paper explores whether MRI is a viable alternative to ultrasound as the primary imaging modality. MethodA systematic review of the literature was undertaken. A search of Medline, Cinahl, PubMed Central and Google Scholar was undertaken supplemented by a review of reference lists, author searching and review of NICE evidence base for existing guidelines. Included studies were assessed for bias using the QUADAS-2 quality assessment tool and data were extracted systematically using a purposefully designed electronic data extraction proforma. ResultsSeven studies were included in final review. The age range of participants extended from 0 to 19 years. Only one study with a patient age range of 0–14 used sedation. Sensitivity estimates from the included studies ranged from 92% to 100% while specificity ranged from 89% to 100%. A significant variation in the number and type of sequences was noted between the studies. ConclusionMRI offers high sensitivity and specificity comparable to contrast enhanced CT and greater than ultrasound as reported in the literature. Where accessibility is not a restriction, MRI is a viable alternative to ultrasound in the assessment and diagnosis of paediatric appendicitis. Clinical practice recommendations have been provided to facilitate the translation of evidence into practice.

Where do we stand? Functional imaging in acute and chronic pulmonary embolism with state-of-the-art CT

Nowadays, CT pulmonary angiography (CTPA) is the diagnostic imaging modality of choice for acute and chronic pulmonary embolism (PE) in order to assess vascular anatomy and parenchymal morphology. Over the past decade, several prognostic CTPA markers associated with an increased risk of adverse clinical events and in-hospital mortality have been evaluated, namely cardiac chamber dimensions, obstruction scores, and visualization of iodinated contrast material in the lung parenchyma by dual-energy (DE) CTPA.This article reviews the current status and potential prognostic advantages of CTPA or DE CTPA with its recent developments for accessing right ventricular dysfunction and the assessment of first pass lung perfusion with DE CTPA in the diagnosis of acute and chronic PE.

Return to play after liver and spleen trauma.

Context:Sport-related spleen and liver injuries pose a challenge for the physician. Although rare, these injuries can have serious and even life-threatening outcomes if not accurately diagnosed and managed in a timely fashion. Currently, there are no evidence-based guidelines on duration and intensity of restricted activity and return to play after spleen and liver injury. In addition, there is controversy on follow-up imaging after injury.Evidence Acquisition:PubMed was searched using the terms splenic or spleen and trauma and hepatic or liver and trauma from 1980 to 2013. The citations from sentinel papers were also reviewed.Study Design:Clinical review.Level of Evidence:Level 3.Results:Ultrasound is ideal in the unstable athlete. Nonoperative management of blunt splenic and hepatic injuries is recommended for hemodynamically stable patients regardless of injury grade, patient age, or presence of associated injuries. Follow-up imaging is not routinely recommended unless clinically indicated. Athletes may engage in light activity for the first 3 months after injury and then gradual return to unrestricted activity as tolerated. High-level athletes may choose splenectomy or serial imaging for faster return to play.Conclusion:Intravenous contrast-enhanced computed tomography is the diagnostic imaging modality of choice in stable athletes with blunt abdominal trauma.Strength-of-Recommendation Taxonomy:C.

Imaging in otosclerosis: A pictorial review

Otosclerosis is an otodystrophy of the otic capsule and is a cause of conductive, mixed or sensorineural hearing loss in the 2nd to 4th decades of life. Otosclerosis is categorised into two types, fenestral and retrofenestral. Imaging plays an important role in the diagnosis and management of otosclerosis. High-resolution CT (HRCT) of the temporal bone using 1-mm (or less) thick sections is the modality of choice for assessment of the labyrinthine windows and cochlear capsules. MRI has limited application in the evaluation of the labyrinthine capsules but is useful for assessment of the cochlear lumen prior to cochlear implantation in patients with profound hearing loss. The treatment of fenestral otosclerosis is primarily surgical with stapedectomy and prosthesis insertion. Patients with retrofenestral otosclerosis and profound hearing loss are treated medically using fluorides, but may derive significant benefit from cochlear implantation. This pictorial review aims to acquaint the reader with the pathology and clinical features of otosclerosis, the classical imaging appearances on CT and MRI, a radiological checklist for preoperative CT evaluation of otosclerosis, imaging mimics and a few examples of post-stapedectomy imaging and complications. Teaching points • Otosclerosis causes conductive, sensorineural and mixed hearing loss in adults.• HRCT of the temporal bone is the diagnostic imaging modality of choice.• Stapedectomy is used to treat fenestral otosclerosis.• Fluorides and cochlear implantation are used to treat retrofenestral otosclerosis.

Risks, Benefits, and Risk Reduction Strategies in Thoracic CT Imaging

Chest computed tomography (CT) is a useful tool for diagnosing various thoracic conditions and has become the diagnostic imaging modality of choice for many diseases. Recent discussions about the radiation dose from CT have attracted the attention of medical professionals and the general public. This article discusses radiation dose with an emphasis on chest CT and on current techniques for patient dose reduction. Four techniques are discussed in detail, including tube current modulation, automatic exposure control, automatic tube voltage selection, and iterative image reconstruction. Adopting these techniques in routine clinical practice can dramatically reduce radiation dose levels.

Recent lessons for the management of bone and joint infections

The epidemiology and clinical manifestations of osteoarticular infections are changing primarily as a result of the emergence of community-acquired methicillin-resistant Staphylococcus aureus infections. Multifocal disease, venous thrombosis and pathologic fractures are manifestations of CA-MRSA osteomyelitis. MRI is the diagnostic imaging modality of choice for musculoskeletal infections. Nafcillin/oxacillin or cefazolin remains the antibiotic of choice for treating infections caused by MSSA. A β-lactam antibiotic is recommended for Kingella kingae. Vancomycin and clindamycin are the first line agents for treating osteomyelitis caused by CA-MRSA. A short course of parenteral antibiotics followed by appropriate oral antibiotics is equivalent to total course of parenteral antibiotics for most patients and avoids the risks associated with PICCs. Surgical drainage of subperiosteal abscesses and surrounding pyomyositis is common with S. aureus clones currently circulating. Collaboration with hematologists for managing patients with venous thromboses is recommended.

Association Between Follow-Up Magnetic Resonance Imaging and Clinical Status Among Patients With Spinal Infections.

Spinal infections, including paraspinal and/or epidural abscesses and vertebral discitis and osteomyelitis, can have devastating consequences. The diagnostic imaging modality of choice has traditionally been magnetic resonance imaging (MRI) given the very high sensitivity and specificity, although the role of MRI in follow-up of spinal infections and how this relates to follow-up clinical status is poorly understood. We sought to understand the relationship between follow-up MRI and clinical status. We conducted a retrospective review of adults with spinal infection to assess the relationship between follow-up MRI and clinical course. The degree of agreement between MRI and clinical follow-up was assessed using the Cohen kappa coefficient. A multinomial logistic regression model was applied to assess the impact of covariates in affecting the clinical outcome and MRI at follow-up independently. Ninety-eight patients met inclusion criteria during a 13-year period. We observed a lack of correlation between clinical follow-up status and MRI (κ = 0.065, P = 0.322). The McNemar-Bowker test for symmetry revealed that this disagreement was asymmetric (P < 0.001). Notably, clinical worsening was never associated with an improved MRI, and clinical improvement was overall not predictive of MRI result and vice versa. Routine follow-up MRI does not seem to correlate with clinical follow-up among patients with spinal infections. The use of MRI without new clinical indications in routine follow-up testing should be interpreted with caution.

Magnetic Resonance Imaging Applications in Early Rheumatoid Arthritis Diagnosis and Management

Early diagnosis and treatment have been recognized as essential for improving clinical outcomes in patients with rheumatoid arthritis (RA). Magnetic resonance imaging (MRI) is a sensitive modality that can assess both inflammatory and structural lesions. MRI can assist in following the disease course in patients treated with traditional disease-modifying antirheumatic drugs and biological therapies both in the clinic and in research trials. Therefore, it is anticipated that MRI becomes the diagnostic imaging modality of choice in RA clinical trials while remaining a useful tool for clinicians evaluating patients with RA.

Magnetic resonance cholangiopancreatography for the accurate diagnosis of biliary complications after liver transplantation: comparison with endoscopic retrograde cholangiography and percutaneous transhepatic cholangiography – long‐term follow‐up

Biliary complications after liver transplantation remain a serious cause of morbidity and mortality. Direct invasive cholangiographic techniques, endoscopic retrograde cholangiography (ERCP) or percutaneous transhepatic cholangiography (PTC), have procedure-related complications. Magnetic resonance cholangiopancreatography (MRCP) is non-invasive, safe, and accurate. The aim of this study was to evaluate MRCP in detecting biliary complications following liver transplantation and comparing findings with ERCP and PTC. Twenty-seven consecutive liver transplant recipients who presented with clinical and biochemical, ultrasonographic, or histological evidence of biliary complications were evaluated with MRCP. Patients were followed up for a median period of 36 months. The presence of a biliary complication was confirmed in 18 patients (66.6%): anastomotic biliary stricture in 12 (66.6%); diffuse intrahepatic biliary stricture in 5 (27.7%): ischemic (n = 3), recurrence of primary sclerosing cholangitis (n = 2), and choledocholithiasis in one. In nine patients (33.3%), MRCP was normal. Six patients underwent ERCP, and eight PTC. There was a statistically significant correlation between the MRCP and both ERCP and PTC (p = 0.01) findings. The sensitivity and specificity of the MRCP were 94.4% and 88.9%, respectively, and the positive and negative predictive values, 94.4% and 89.9%, respectively. MRCP is an accurate imaging tool for the assessment of biliary complications after liver transplantation. We recommend that MRCP be the diagnostic imaging modality of choice in this setting, reserving direct cholangiography for therapeutic procedures.

Left Ventricular Cardiac Hemangioma Presenting With Atypical Chest Pain

A 54-year-old male patient presented with atypical chest pain and exertional dyspnea. The physical examination and chest x-ray were unremarkable; the ECG showed sinus rhythm with left-axis deviation and a pathological Sokolow-Index with concomitant ST-depression in leads I, aVL, and V5–V6. Transthoracic echocardiography revealed the presence of a homogenously echodense, mobile left ventricular mass (dimensions: 15×12 mm) attached to the intraventricular septum (Figure, E). Cardiac magnetic resonance imaging was performed for tissue characterization: On T1-weighted imaging (Figure, A), the mass was isointense compared with the left ventricular myocardium, whereas on T2-weighted imaging (Figure, B), homogeneously bright signal intensity was found. No signs of infiltrative growth were seen. During first-pass infusion of a gadolinium-containing contrast agent, no relevant signal intensity increase could be detected; however, on postcontrast imaging (delayed enhancement technique), some contrast agent uptake was detected. Figure. A, T1-weighted imaging with fast-spin echo and blackblood suppression in 4-chamber view. The tumor has an intermediate signal …

58-Year-Old Man With Fatigue and Flank Pain

58-Year-Old Man With Fatigue and Flank Pain

Transesophageal Echocardiographic (TEE) Evaluation of Prosthetic Valves

TEE overcomes many of the imaging constraints associated with transthoracic echocardiography for the assessment of valvular anatomy and function. Additional imaging artifacts and constraints associated with prosthetic valves are minimized or overcome with TEE. As such, TEE allows assessment of prosthetic valve anatomy and function and paraprosthetic anatomy, and serves as the diagnostic imaging modality of choice for patients with suspected prosthesis dysfunction or endocarditis.