Intravenous Contrast Enhancement Research Articles

MR tomographic evaluation of the effectiveness of neoadjuvant chemotherapy for breast cancer based on pharmacokinetic numerical analysis of tumor uptake of paramagnetic contrast in intravenous contrast enhancement

Background. In clinical practice, MRI pathophysiological and pharmacokinetic models with calculations of contrast transport indicators are unacceptably little used.Aim of the study. To propose a pharmacokinetic technique for the quantitative assessment of primary tumors and metastases, the effectiveness of breast cancer chemotherapy (BC), from dynamic contrast enhancement MRI. Material and methods. 18 patients were included who underwent neoadjuvant chemotherapy (NACHT) in four cycles for breast cancer T1-3N0-1M0, followed by radical surgical removal of the tumor. According to the results of a three — year follow-up, patients with a relapse — free course (n = 11) formed group 1, and seven patients with detected metastatic lesions (3 in the liver, 2 in the lungs, 2 in the brain) — group 2. For the initial 120–180 s of MRI with contrast after the injection of a paramagnetic, the simplification is valid for concentrations in tumor and blood and for tranfer coefficient: d{СОПУХОЛЬ(t)} / dt = ККр-Оп * СКРОВЬ (t) , from which it is obvious: ККр-Оп = (СОПУХОЛЬ(Т)) / (∫CКРОВЬ(t) dt), which was used in all calculations of the contrast transfer constant. Gadobutrol contrast is 0.1M/10 kg of body weight, TR = 5.5–6 ms, TE = 2.5 ms. Results. If, after the first cycle of NACHT, the ККр-Оп of the primary breast cancer is < 0.22 ml/min/g of tissue, the probability of subsequent relapse-free course = 0.78. Similarly, a decrease in the KCr-Op Ккр-Оп of the sentinel lymph node after the first cycle of NAHT < 0.08 ml/min/g of tissue with a probability of 0.75 predicts a relapse-free course. Conclusion. The proposed method for calculating the ККр-Оп transfer coefficient allows obtaining additional diagnostic and prognostic information in patients with local and locally advanced forms of breast cancer.

Mitral valve calcinosis as an important finding during heart examination

BACKGROUND: Mitral valve calcinosis is a chronic degenerative process in the fibrous structures of the mitral valve. Advanced stages increase the risk of endocarditis and cardiac rhythm disturbances and contribute to cardiovascular mortality. The cause of mitral valve calcinosis is still controversial; however, the contribution of atherosclerosis to its development is currently undisputed. The prevalence of mitral valve calcinosis varies in different age groups and on average is higher in people with cardiovascular disease. AIM: To assess the prevalence of mitral valve calcinosis in patients undergoing computed tomography angiography and identify the relationship between aortic and mitral valve calcinosis and coronary calcium index and signs of remodeling. MATERIALS AND METHODS: A retrospective study of 336 patients who underwent computed tomography coronary angiography with intravenous contrast enhancement at the Lomonosov Moscow State University Clinic between November 13, 2020, and May 14, 2022, was conducted. RESULTS: The prevalence of aortic (16.4%) and mitral (11%) valve calcinosis was high in people undergoing cardiovascular examination, and a relationship was noted between valve calcinosis and coronary calcium index. CONCLUSION: The detection of mitral valve calcinosis in patients during routine examination is important in predicting further treatment and outcomes because valve calcinosis is an indirect indicator of coronary heart disease risk. Although valve calcinosis is usually an incidental examination finding, it may indicate a high cardiovascular risk and should prompt further evaluation, if clinically necessary.

Endovascular intervention using combined percutaneous access in a patient with recurrence of critical ischemia after repeated bypass operations on arteries of the lower extremities (clinical case)

Unsatisfactory long-term results of shunting operations on the arteries of the lower extremities are most often caused by a stenotic process followed by thrombosis in the anastomotic zone, especially in combination with the progression of the underlying disease and the spread of obstructive atherosclerotic lesions on the inflow and outflow arteries. A clinical case of endovascular treatment of a patient with peripheral arterial disease is presented, who previously underwent 3 reconstructive bypass operations on the arteries of the lower extremities within 15 months before hospitalization, but again sought medical help due to the recurrence of critical ischemia of the left lower extremity. Considering the high risk of repeated open surgery due to the patient’s comorbidity (diabetes mellitus and extensive Q-myocardial infarction, suffered after the first bypass surgery), as well as gross scar changes after previous vascular operations, it was decided to perform endovascular intervention using a non-standard combined percutaneous approach. Iliac artery stenosis and post-thrombotic occlusion of the popliteal artery in the area of the distal anastomosis of the femoral-popliteal bypass graft on the left side were detected on the preoperative MSCT with intravenous contrast enhancement. Because of the gross postoperative scars, we could not use standard percutaneous approaches through any of the femoral arteries. Access through the arteries of the upper limbs also did not ensure the operation on all affected segments due to the long distance to the intervention zone and absence of instruments of the required length. Therefore, in order to maximally solve the tasks of the operation, we simultaneously used an antegrade left transaxillary access and a transpedal retrograde access through the left foot artery. Thus, the patient underwent simultaneous balloon angioplasty of stenoses of the common and external iliac arteries on the left side by transaxillary access, as well as balloon angioplasty and implantation of a coronary drug-eluting stent in the popliteal artery in the area of the distal anastomosis of the femoral-popliteal bypass graft by retrograde transpedal access on the left. As a result, the magistral arterial blood flow of the limb and the function of the shunt were completely restored with a good angiographic and clinical result.The applied methods of endovascular treatment have shown high efficiency and can be recommended as an alternative to traditional vascular surgery.

The texture analysis of computed tomography studies in clear cell renal cell carcinoma: reproducibility of 2D and 3D segmentation

Background: Differentiation of tumor grade at the preoperative stage is of utmost importance for the modification of the treatment strategy and the extent of operation. However, the routine analysis of computed tomography (CT) data in clear cell renal cell carcinoma (ccRCC) does not allow for reliable determination of the tumor grade.
 Aim: To assess the reproducibility of the results of 2D and 3D segmentation of a kidney tumor in the cortico-medullary and nephrographic phases of CT studies, as well as the reproducibility of the first order texture parameters for 2D and 3D tumor segmentation in patients with verified ccRCC.
 Materials and methods: This retrospective study included the CT data of 50 patients with morphologically verified ccRCC obtained before their surgical treatment. The first patient group included the patients with the renal tumor size in the axial plane of ≥ 4 cm (28 patients, 29 CT studies), and the second patient group included those with the renal tumor size in axial plane of 4 cm (22 patients, 23 CT studies). Two radiologists independently performed segmentation of the renal tumor in the cortico-medullary and nephrographic phases of CT procedures done under a standard protocol with the bolus intravenous contrast enhancement. A two-dimensional region of interest (2D ROI) was selected by the investigators on a subjectively selected axial slice, where the tumor had the largest size. When forming a three-dimensional region of interest (3D ROI), the entire tumor volume was segmented. Next, the statistical analysis of the segmentation results and the results of calculation of the first order texture indices was performed with calculation of the intra-class correlation coefficient (ICC) to assess the strength of the data correlation. The ICC of ≥ 0.75 demonstrated the reproducibility of the segmentation results and the first order texture indices.
 Results: The 3D segmentation method for ccRCC demonstrated the best ROI reproducibility results, regardless of the tumor size and the phase of contrast enhancement, with the ICC values of 0.961 (95% confidence interval: 0.946–0.971) for the cortico-medullary phase and 0.969 (95% CI: 0.958–0.977) for the nephrographic phase. The 2D tumor segmentation method showed unsatisfactory ROI reproducibility, with the ICC values of ≤ 0.058; however, the unsatisfactory reproducibility of the segmentation results in the patients with ccRCC tumor size of ≥ 4 cm did not significantly affect the reproducibility of the Entropy and Energy texture indices (good to excellent correlation). With the 3D segmentation of ccRCC, most first-order texture metrics were reproducible, with the exception of the Kurtosis parameter. The Entropy and Energy scores in both patient groups demonstrated a high degree of reproducibility. In the 2D tumor segmentation, high reproducibility of the first order texture metrics was obtained for the Entropy and Energy indices.
 Conclusion: The 3D segmentation of the CT data for ccRCC has high reproducibility, the most first-order textural features were excellently reproducible when segmentations were performed in 3D. The 2D CT data segmentation method for ccRCC demonstrated low reproducibility; however, some of the first order texture indices were reproducible. Both segmentation methods can be used for the texture analysis of CT images.

Possibilities of modern methods of cardiac imaging in the diagnosis and preoperative planning of transposition of the great arteries in children: a prospective study

INTRODUCTION: Transposition of the great arteries (TGA) is the classic, most common and severe form of cyanotic congenital heart defects in children, which is characterized by a variety of anatomical and hemodynamic variants, combined with other cardiac anomalies and high infant mortality rates. The surgical treatment and the possibility of performing simultaneous correction of TGA depend on the anatomical and hemodynamic features of the TGA and the presence of combined intra- and extracardiac anomalies, which must be determined using cardiac imaging techniques on the preoperative stage.OBJECTIVE: To evaluate the capabilities of TTE and cardiac CT in the diagnosis and surgical planning of TGA in children.MATERIALS AND METHODS: The study included 29 children with an incoming diagnosis of transposition of the great arteries. The average age of the patients was 31 (14.5; 67) days. All children underwent TTE, 21 — cardiac CT with intravenous contrast enhancement, 6 — catheterization of the cardiac cavities with conventional angiography. Cardiac MRI was not performed due to the severe and unstable general condition of all patients and the significant risks from a longer stay in anesthesia. Capabilities of TTE and cardiac CT in determining combined intra- and extracardiac anomalies were assessed and compared. All data from TTE and cardiac CT were compared with the results of conventional angiography and intraoperative data. The interval between TTE, cardiac CT and angiography or surgery was less than 10 days.RESULTS: The accuracy of TTE and cardiac CT in TGA diagnosis and determining its type was 100% for both methods, however, with regard to determining combined intra- and extracardiac anomalies, the methods play a different role: the accuracy of cardiac CT in determining combined intracardiac anomalies in patients with TGA was 87.7% (AUC 89.3%), for TTE — 97.1% (AUC 97.3%). Comparing the capabilities of the techniques in determining intracardial anomalies, no statistically significant difference was obtained (p=0.092). The diagnostic accuracy of cardiac CT in determining concomitant anomalies of the great vessels and extracardiac pathology was 98% (AUC=98.9%). The sensitivity and specificity of TTE in the comprehensive assessment of concomitant extracardiac anomalies were 58% and 98%, respectively (accuracy 89.1%), AUC 81.1%. Comparing the capabilities of techniques in determining intracardial anomalies, cardiac CT showed to be a more accurate tool in comparison with TTE (p=0.041).DISCUSSION: Results of our study demonstrate the high efficiency of TTE in determining indications for emergency palliative correction of transposition of the great arteries, however, the method has limited diagnostic capabilities in assessing surgical risks when planning radical correction of the defect. Cardiac CT has proven to be a highly accurate tool both in making a diagnosis and in identifying combined intra- and extracardiac anomalies, which play a decisive role in planning open surgical correction of transposition of the great arteries in children.CONCLUSION: For patients with TMA and critical hypoxia, transthoracic echocardiography is the definitive diagnostic tool for planning endovascular repair. When planning open surgery, transthoracic echocardiography should be complemented by cardiac CT with ECG gating to assess the anatomy of the coronary arteries and possible associated extracardiac anomalies.

Machine Learning Classification of Body Part, Imaging Axis, and Intravenous Contrast Enhancement on CT Imaging.

Purpose: The development and evaluation of machine learning models that automatically identify the body part(s) imaged, axis of imaging, and the presence of intravenous contrast material of a CT series of images. Methods: This retrospective study included 6955 series from 1198 studies (501 female, 697 males, mean age 56.5years) obtained between January 2010 and September 2021. Each series was annotated by a trained board-certified radiologist with labels consisting of 16 body parts, 3 imaging axes, and whether an intravenous contrast agent was used. The studies were randomly assigned to the training, validation and testing sets with a proportion of 70%, 20% and 10%, respectively, to develop a 3D deep neural network for each classification task. External validation was conducted with a total of 35,272 series from 7 publicly available datasets. The classification accuracy for each series was independently assessed for each task to evaluate model performance. Results: The accuracies for identifying the body parts, imaging axes, and the presence of intravenous contrast were 96.0% (95% CI: 94.6%, 97.2%), 99.2% (95% CI: 98.5%, 99.7%), and 97.5% (95% CI: 96.4%, 98.5%) respectively. The generalizability of the models was demonstrated through external validation with accuracies of 89.7 - 97.8%, 98.6 - 100%, and 87.8 - 98.6% for the same tasks. Conclusions: The developed models demonstrated high performance on both internal and external testing in identifying key aspects of a CT series.

Diagnosis and treatment of the giant malignant peripheral nerve sheath tumor in the anterior mediastinum: A case report

INTRODUCTION: Malignant peripheral nerve sheath tumor (MPNST) occurs in young and middle-aged people, more frequently in those with the genetic disease known as neurofibromatosis type 1 (NF1). Approximately, 50% of people with MPNST have NF1 and 13% of people with NF1 will get MPNST during their lifetime.
 CASE REPORT: A 30-year-old patient after surgery for MPNST of the right hip in 2013 was observed. In 2017, a relapse was detected, and combined treatment was performed, including surgical excision of the relapse and postoperative distance radiotherapy with a total focal dose of 66 Gy. In 2018, MPNST of the left femoral nerve was diagnosed, and the tumor was excised. In 2020, a chest X-ray diagnosed a single focus of localized opacity in the anterior mediastinum, adjacent to the right lung. Computed tomography (CT) was performed to further verify the neoplasm, which revealed a single hypodense focus in the anterior mediastinum, adjacent to the right lung. According to histological examination of a tumor biopsy obtained by transthoracic ultrasound-guided biopsy, MPNST was verified. Magnetic resonance imaging (MRI) with intravenous contrast enhancement, including real-time MRI, was performed to assess the invasion of the mass into soft tissues and vessels and to plan surgical treatment. The following surgeries were done: right thoracotomy, removal of a neoplasm of the anterior mediastinum with resection of the upper lobe of the right lung, and marginal resections of the lower lobe of the right lung. This case demonstrates a rare localization and non-standard instrumental diagnosis of mediastinal MPNST. Apart from CT scanning, the patient underwent MRI of the thoracic organs. MRI allows assessing the invasion of the neoplasm into the surrounding tissues. This cannot always be achieved by CT scans, including those with contrast enhancement. Invasion is an important component in the planning of further surgical treatment tactics.
 CONCLUSIONS: MPNST is a tumor with an aggressive course and a poor prognosis due to resistance to therapy. This clinical case demonstrates a rare localized MPNST with a recurrent course and metastases to the lungs. The current radiological methods, such as CT and MRI, may be used effectively both for diagnosing MPNST and determining the appropriate surgical access to the lesion and the extent of surgery.

Intralobar pulmonary sequestration with a rare source of arterial supply

BACKGROUND: Pulmonary sequestration is one of the most common malformations of the lungs in clinical practice. However, difficulties are possible in the interpretation of the radiological data, which leads to a violation of the examination technique in such patients and, accordingly, to the lack of success of the therapy and proper routing.
 AIM: To demonstrate the clinical case of a patient with intralobar pulmonary sequestration, describing the characteristic radiographic picture, and suggesting research methodology for the identified features of the aberrant vessel.
 METHODS: Clinical and radiological data of a 27-year-old patient with acute respiratory symptoms and suspected abscessed pneumonia based on X-ray and computed tomography (CT) findings were presented. Due to the absence of clinical and radiological dynamics, atypical CT semiotics of abscesses, CT angiography of the thoracic aorta was performed after intravenous contrast enhancement with 80 ml of iodine-containing preparation (350 mg/mL).
 RESULTS: A pulmonary tissue thickening was revealed in the lower left lobe with lumpy clear contours, which consisted of a system of cystic cavities with contents, particularly well differentiated after contrast enhancement. On the native study, an additional vascular structure following from the subdiaphragmatic space was traced paravertebrally, which was the reason for extending the CT angiography scanning area to the epigastric region of the abdomen. A large-caliber arterial vessel was detected, which departed as a branch from the celiac trunk and passed to the above-described thickening of the pulmonary tissue. The combination of these signs is typical for intrapulmonary sequestration.
 CONCLUSIONS: The correct interpretation of the identified changes allowed the patient to be routed to a hospital with a thoracic surgery department, since the sequestration must be removed in the vast majority of cases to prevent recurrent inflammatory episodes. Extension of the scanning area below the diaphragm may be useful, since part of the sequesters is supplied with blood from the abdominal aorta and its visceral branches. This will prevent the need for repeat CT angiography, and information about the source of the blood supply is extremely important for surgeons.

Endoleak Detection after Endovascular Aortic Repair via Coded-Excitation Ultrasound-A Feasibility Study.

Endoleaks are the most common complication after endovascular aortic repair (EVAR). Their correct identification is one of the main objectives of surveillance protocols after EVAR. So far, computed tomography angiography (CTA), contrast-enhanced (CEUS) and Duplex ultrasound (DUS), as well as magnetic resonance angiography, have been investigated for their ability to detect endoleaks. In general, all technologies have distinct benefits and disadvantages, with CTA and CEUS emerging as the reference standard for surveillance after EVAR. However, they are both contrast-enhancer-dependent, and CTA additionally exposes patients to ionizing radiation. In the present study, we investigated B-Flow, a type of coded-excitation ultrasound that was specifically designed to optimize the visualization of blood flow, for its ability to detect endoleaks, and compared its performance to CEUS, CTA, and DUS. In total, 34 patients were included in the analysis that accumulated in 43 distinct B-Flow investigations. They underwent a total of 132 imaging investigations. Agreement between B-Flow and other imaging modalities was high (>80.0%), while inter-method reliability can be interpreted as good. However, with B-Flow, six and one endoleaks would have been missed compared to CEUS and CTA, respectively. Regarding endoleak classification, all metrics were lower but retained an adequate level of comparison. In a subset of patients requiring intervention, B-Flow had 100% accuracy regarding both endoleak detection and classification. Ultrasonography enables endoleak detection and classification without the need for pharmaceutical contrast enhancement or radiation. Ultrasound coded-excitation imaging in the application of B-Flow could further simplify surveillance after EVAR by offering adequate accuracy without requiring intravenous contrast enhancement. Our findings may promote subsequent investigations of coded-excitation imaging for endoleak detection and classification in the surveillance after EVAR.

Compensation pathways for venous drainage of the brain in superior sagittal sinus occlusion by parasagittal meningioma

This study aims to determine the existing pathways of collateral cerebral circulation in parasagittal meningiomas that cause superior sagittal sinus occlusion based on literature review and analysis of own clinical observations. Results of clinical and instrumental examination of 221 patients treated in Dnipropetrovsk Regional Clinical Hospital named after I.I. Mechnikov from 2000 to 2021 were subjected to retrospective and prospective analysis. Inclusion criteria were: patient age of 18+, parasagittal extracerebral tumor according to computed tomography/magnetic resonance imaging, histologically verified meningioma, superior sagittal sinus occlusion (type V-VI according to M.P. Sindou and J.E. Alvernia) according to selective cerebral angiography. This study is based on the analysis of examination of 43 patients who met the inclusion criteria. The selected patients were analyzed for demography (sex, age), brain computed tomography/magnetic resonance imaging before and after intravenous contrast enhancement, and computed tomography angiography and selective cerebral angiography data. Transformed venous drainage pathways were analyzed depending on the location of superior sagittal sinus occlusion by parasagittal meningioma: anterior, middle, or posterior third of the superior sagittal sinus. It was determined that preoperative diagnosis of parasagittal meningiomas that, based on brain computed tomography/magnetic resonance imaging, has signs of type V or VI superior sagittal sinus invasion according M.P. Sindou and J.E. Alvernia, must include selective cerebral angiography. Dynamic images of selective cerebral angiography in the venous phase allows to fully assess the established pathways of collateral blood flow and the blood flow direction. Information on collateral venous circulation in case of superior sagittal sinus occlusion by parasagittal meningioma is extremely important in a surgery planning. It helps avoiding iatrogenic damage to eloquent veins, which increases radical tumor removal with maintaining/improving a patient’s functional state in the early postoperative period and improving long-term treatment outcomes.

A familial case of <i>DICER1</i> syndrome in a patient with pleuropulmonary blastoma

Pleuropulmonary blastoma (PPB) is a very rare tumor of childhood that arises from the mesenchyme of the lung and is associated with mutations in the DICER1 gene. The present article describes a familial case of DICER1 syndrome in a patient aged 3 years and 11 months who underwent investigations and treatment for type II/III PPB of the lower lobe of the left lung at the Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology of Ministry of Healthcare of the Russian Federation. The patient's parents gave their consent to the use of their child's data, including photographs, for research purposes and in publications. The diagnosis was made based on the results of the pathology investigation of the tissue obtained by open biopsy. Furthermore, the diagnosis was confirmed by the review of histological specimens in the International PPB Registry (Minneapolis, USA). According to the data from the chest CT with intravenous contrast enhancement, the tumor was described as a mass consisting of cystic cavities of various calibers accumulating a contrast agent along the periphery, and a solid component. Specific combination treatment was based on the recommendations of the International PPB Registry and included chemotherapy according to the IVADo/IVA regimen and surgical treatment as a local control. Currently, specific treatment has been completed, the patient is alive with no signs of the disease, the follow-up period was 20 months. As regards the patient's family history, he has a sibling (older brother) who was diagnosed with a cystic nephroma at the age of 1 year and 4 months. Molecular genetic testing of the tumor tissues obtained from the patient (PPB) and his sibling (cystic nephroma) revealed pathogenic somatic variants in the DICER1 gene. Along with the somatic genetic variants, another pathogenic variant was found in both children, the germline status of which was confirmed. The germline variant in the DICER1 gene was inherited from the mother. Thus, the investigations confirmed a familial case of DICER1 syndrome. The case described in this article indicates that families in which DICER1 syndrome was found require special management aimed at early detection of tumors and non-tumor conditions associated with this syndrome in the carriers of pathogenic alleles.

Possibilities of Diffusion-Weighted MRI in Clarification of the Degree of Malignance of Recurrent Retroperitoneal Liposarcomas

Purpose: The aim of our study was to study the possibilities of DW-MRI in the differential diagnosis of recurrent retroperitoneal highly differentiated and dedifferentiated liposarcomas (WLS and DLS respectively). Material and methods: The study is based on the data of a retrospective study of 36 patients who underwent surgery on for retroperitoneal highly differentiated (n = 27) and dedifferentiated liposarcomas (n = 9). All patients received MRI of the abdominal cavity and pelvis without intravenous contrast enhancement with further assessment of size, shape, contours and structure. When analyzing DW-MRI and ADC maps, small soft tissue nodes were evaluated. Results: Morphological studies were performed in all patients. The results of the qualitative analysis showed statistically significant differences in the differential diagnosis of WLS recurrences from DPS in the presence of septa and pseudocapsule ( p = 0.0032 and p = 0.0028, respectively). The results of the study demonstrated differences in the ADC values in the solid component of recurrent tumors of WLS and DLS: the median ADC values in the WLS group were higher (1960×10 –6 mm 2 /s) than in the DLS group (1031×10 –6 mm 2 /s). The sensitivity of this sign in the differential diagnosis of WLS from DLS was 87.5 %, the specificity was 70 %.

PSUN260 Diabetic Myconecrosis: a Rare Complication of Uncontrolled Diabetes Mellitus

Abstract Introduction Spontaneous diabetic myonecrosis is a rare and underdiagnosed microvascular complication of long standing and poorly controlled diabetes mellitus. The pathogenesis of this infarction of the skeletal muscle appears to be related to vasculopathic changes without an atheroembolic event or occlusion of major arteries. The factors responsible for the acute onset of symptoms are unknown. Since the initial description in 1965, only 170 cases have been described, including 126 initial episodes and 44 episodes of recurrence, with a mean age at presentation of 45 years (range 20 to 67 years). Most of the patients have other microvascular complications. Characteristic symptoms at presentation include acute onset unilateral lower limb pain and swelling, most often in the thigh, without a history of trauma. Bilateral involvement is present in approximately 30% of the cases. Fever has been reported only in about 10% of cases. Case Report A 23-year-old female presented with ten days history of fever, left groin pain and inability to walk. Other than chronic fatigue, her review of symptoms was mostly negative. She denied any trauma. She had a history of poorly controlled type 1 diabetes mellitus (HbA1c 10.5%) with diabetic nephropathy (proteinuria),but no evidence of retinopathy or neuropathy. On examination, her left groin and proximal thigh were warm and tender to palpation without noticeable erythema or swelling. Labs showed elevated inflammatory markers. CT scan showed inguinal and retroperitoneal lymphadenopathy with subcutaneous edema of the visualized left lower extremity. Fevers persisted despite appropriate administration of antibiotics for cellulitis. Infectious workup was negative. A biopsy of her inguinal lymph node showed reactive changes. MRI of her left thigh showed large, confluent areas of intramuscular hypo enhancement compatible with diabetic myonecrosis. Her symptoms improved over the next 3-4 weeks with supportive care. Discussion Spontaneous diabetic myonecrosis is a very rare complication of uncontrolled diabetes. Knowledge about his condition is required to make the correct diagnosis and avoid the use of unnecessary laboratory tests and treatments. The presence of the characteristic clinical features such as pain and swelling in typically affected areas such as the thigh, will frequently suggest the diagnosis. MRI with intravenous contrast enhancement is the diagnostic imaging of choice and shows increased signal on T2-weighted images from muscle edema and areas of non-enhancement from myonecrosis. Treatment involves symptomatic management with rest, optimal glycemic control, analgesia, and low-dose aspirin, although the optimal treatment approach is uncertain. The short-term prognosis is good, but the recurrence rate remains high and long-term prognosis is poor given underlying poorly controlled diabetes. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Leukocoria in Children: Findings on CT and MRI of the Principal Causes

Leukocoria is the result of an alteration in the normal red reflex of the ocular fundus, secondary to an obstruction of the normal passage of light to the fundus of the eye that produces a white light reflex. There are many ocular pathologies that can present as leukocoria, among which retinoblastoma is the most frequent. Other causes include cataracts, Coats disease, persistent fetal vasculature, coloboma, retinopathy of prematurity, vitreous hemorrhage, astrocytic hamartoma, and ocular toxocariasis. Although in many situations the diagnosis of these pathologies is clinical or possible with the use of ocular sonography, in certain circumstances, CT or MR imaging may play a very important role in the differential diagnosis. In this review article, we propose that findings such as ocular size, the presence of calcifications, intravenous contrast enhancement, MR imaging signal intensity, CT density, and other pathology-specific findings, along with some clinical data, will guide us to the cause of leukocoria. Knowledge of the most prevalent ages of presentation of these pathologies assists with establishing the final diagnosis.Learning Objectives: To understand why leukocoria occurs, to list the major causes of leukocoria in children, and to recognize the imaging findings of the most frequent causes of leukocoria and apply them in the differential diagnosis

Features of Diagnosis and Treatment of Spontaneous Extraorganic Hematomas of the Soft Tissues of the Neck and Chest

The possibilities of computed tomography in the diagnosis of spontaneous hematomas (sh) of the soft tissues of the neck and chest and the features of their treatment are shown. Computed tomography with intravenous bolus contrast enhancement is the main method for diagnosing sh, which allows you to specify its exact localization, distribution, determine the structure and volume of the hematoma, the contrast agent exiting the contours of the vessel, and, taking into account the data obtained and the clinic, determines the tactics of treatment.Stable sh does not require surgical treatment. In the case of a large volume of chest hematoma, compression syndrome, hemothorax, drainage is indicated. Unstable sh dictate the need for angiography and, if necessary, endovascular embolization.

Assessment of exo- and endocrine function of pancreas following distal pancreatectomy

The assessment of pancreatic resection volume influence on exo- and endocrine pancreatic functions. The resected pancreatic volume influence was assessed in 47 patients: 31 (66%) patients after resections of pancreatic body and tail, and 16 (34%) patients after distal resections. The exocrine pancreatic function was assessed by pancreatic fecal elastase 1 as well as endocrine pancreatic function was assessed by C-peptide level measurement. Computed tomography with intravenous contrast enhancement and postprocessing was used for pre- and postoperative pancreatic volume assessment. All tests were performed before and 1, 3, and 6 months after surgery. Type of surgery had no influence on C-peptide and pancreatic fecal elastase 1 levels (p>0.05). Exo- and endocrine pancreatic functions markers tended to decrease in 1st month after surgery with consequent functions restoration towards 6 months after surgery. There were 15 (35.7%) patients from 42 patients with normal exocrine pancreatic function with a fecal elastase 1 level decrease to 114.7±61.8 μg/g; exocrine insuficiency remained only in 2 (4.8%) patients after 6 months after surgery. C-peptide concentration decrease before surgery to less than 1.1 ng/ml was noticed only in 8 (17%) patients. C-peptide concentration decreased in 30 (63.8%) patients in 1st month after surgery, but after 6 months after surgery, C-peptide level decrease was only in 7 (14.9%) patients. The exo- and endocrine function of the pancreas is restored in more than 80% of patients after DR. Probably it could be associated with the activation of the pancreatic compensatory abilities.

Commentary on “Management of Patients with Uncomplicated Symptomatic Isolated Mesenteric Artery Dissection: A Multicentre Experience”: Too Itchy Fingers

Isolated mesenteric artery dissection involves dissection of the coeliac trunk and/or superior mesenteric artery (SMA) and/or inferior mesenteric artery. The present study deals with acute isolated symptomatic SMA dissection,1 which is the type of dissection associated with the most severe clinical consequences.2 A prerequisite for diagnosis of these patients with acute abdominal pain is high resolution computed tomography (CT) with intravenous contrast enhancement and imaging in the arterial phase; otherwise, a large proportion of patients will go undiagnosed.

Indicators of lung function in children with chronic nonspecific lung diseases with pulmonary fibrosis

Introduction. The pathogenesis of most chronic nonspecific lung diseases (CNSLD) in children is based on a long-term inflammatory process, often leading to the formation of pulmonary fibrosis in the structurally altered tissue, which requires dynamic monitoring of patients, including the study of lung function.Aim. To assess the indicators of the lung function in children with chronic bronchopulmonary pathology accompanied by pulmonary fibrosis.Materials and methods. 84 children with CNSLD were examined. The main group consisted of 45 children with CNSLD with pulmonary fibrosis (bronchopulmonary dysplasia, congenital malformations of the lungs, chronic bronchitis, and post pneumonia fibrosis). The comparison group consisted of 39 children with CNSLD without pulmonary fibrosis. The average age of children in the study groups was 9,3±0,48 years. The patients underwent multispiral computed tomography of the lungs with a virtual bronchoscopy program and intravenous bolus contrast enhancement. Evaluation of lung function was carried out by spirometry.Results. In patients in remission, the average values of the ventilation capacity of the lungs in both groups were within the predicted values. However, in patients with fibrotic changes, pulmonary dysfunction was detected 2 times more often than in children with CNSLD without pulmonary fibrosis (35.5% and 15.4%, respectively, p<0.05). Restrictive ventilation disorders were diagnosed only in the group of patients with pulmonary fibrosis. In children with pulmonary fibrosis, the risk of reduced ventilation capacity is significantly higher than in children with CNSLD without pulmonary fibrosis (OR=3.04, 95% CI 1.049–8.78).Conclusion. The data obtained can serve as a prerequisite for further development of predicting the nature of the course of the disease, identifying “risk groups” for the development of fibrotic changes for a personalized approach to the treatment and follow-up of patients with CNSLD.

54-Year-Old Woman With Altered Mental Status and Abdominal Pain

54-Year-Old Woman With Altered Mental Status and Abdominal Pain

Development of adaptive stereotactic radiotherapy method in treatment of primary malignant glial tumors in the brain

At present, there are some scattered evidence data pertaining to the use of an adaptive technique of radiotherapy in treatment of malignant glial tumors of the brain. Our evidence data obtained in MRI in the course of treatment show that the initial treatment plan may become irrelevant due to some changes observed in the tumor configuration. In its turn, it bears witness to the topicality of developing and introducing adaptive methods and techniques in the brain tumor treatment, which are capable to increase efficacy and tolerability in patients with primary malignant tumors of the brain. Aim. Our aim has been to develop an adaptive stereotactic method of radiotherapy in treatment of primary malignant brain tumors, which shall be capable to increase efficacy and tolerability of radiation therapy as well as reduce radiation dose to normal structures in the brain. Materials and methods. Our method has been elaborated with recruiting a group of 10 patients diagnosed with primary glioblastoma G IV, which have received specialized treatment at the National Medical Research Centre for Oncology at the Ministry of Health, the Russian Federation, in the period 2021-2022. The average age of the above patients is 43,4 years. All patients have undergone microsurgery covering the total resection of the tumor (3 patients) and subtotal removal of the malignant tumor (7 patients). The average time interval between the surgery and radiotherapy is 32,5 days. Before treatment, an intravenous contrast enhancement MRI of the brain with an axial pitch of 1 mm has been conducted employing the contrast T1, contrast-free T1 and T2 FLAIR modes. Planning of radiotherapy for this sort of patients has been carried out employing BrainLab Elements и Varian Medical Systems Eclipse. The CTV was defined as a 2,0 cm margin around GTV with an anatomical correction. The CTV-to-PTV margin was 0,1 cm. Doses have been administered as follows: a single dose of 2 Gy up to a total dose of 60 Gy in 30 fractions. The brain has been MRI-scanned in all patients with the use of intravenously introduced contrast agents with an axial pitch of 1 mm employing enhanced contrast/contrast-free T1 sequences and T2 FLAIR to redefine the radiotherapy targets (GTV, CTV, PTV). At fraction 30 we have completed MRI in order to estimate the treatment outcome. In the average, the radiotherapy course has taken 42-45 days, holidays included. For the purpose of the radiation therapy, used have been the Novalis Tx Varian Tx linear accelerator of kinetic energy of the beam of 6 MeV. Results We have developed our own adaptive stereotactic method of radiotherapy to treat the primary malignant glial tumors in the brain, which is capable of tracing the configuration of the post-surgery cavity, the residual tumor and the brain structures in the course of radiotherapy and adapting the therapy plan thereto that makes possible to reduce tissue volumes exposed to radiation due to a decrease in the tumoral and peritumoral volumes of the tumor and post-operative cavity. Conclusion. Our analysis has shown that in the course of radiotherapy some anatomical changes in the tumor configuration are found. An adaptive approach applied to radiation therapy allows monitoring the above changing volumes and correcting the treatment plan.