A Imagiologia do CHLC marcou presença no 30Th European Congress of Radiology, que decor-

reu no Áustria Center Vienna de 28 de Fevereiro a 4 de Março em Viena de Áustria.

Portugal foi um dos países organizadores com a China e Suíça.

O evento que marca a reunião anual da Sociedade Europeia de Radiologia, conhecida como

uma das reuniões mais inovadoras dentro da comunidade científica, contou com a presença

de mais de 75.502 membros dos 5 continentes de 157 países - Europa 50%, Ásia 23%,

América 7%, Brasil 16%, África 3% e Oceânia 1%, num total de mais de 25.000 participan-

tes, dos quais 296 portugueses, 105 Membros de Sociedades Institucionais, 300 exposito-

res num espaço com 26.000m2. Contou com 6,757abstracts, 3,475 posters, mais de 600

Sessões, 52 dedicadas em exclusivo a Radiographers.

Técnicos e Médicos Neurorradiologistas e Radiologistas do CHLC, assinalaram a sua presen-

ça com apresentação de comunicações e posters em representação Institucional.

Atendendo à qualidade do programa científico e à mais-valia que foi a frequência de cursos

e a participação em sessões científicas e Workshops, não poderíamos deixar de partilhar

este momento que foi para todos nós mais que uma simples aprendizagem, um complemen-

to que contribuirá para ampliar o conhecimento das diferentes vertentes que constituem a

Instituição Hospitalar numa perspetiva de otimizar e melhorar as nossas práticas.

A formação apesar do seu retorno personalizado é sempre institucional, pois as Instituições

são as pessoas “pessoas certas” e o valor acrescido que estas representam para a organiza-

ção e se reflete nos serviços que se presta.

Nesta Edição Especial ECR 2018, apresentamos uma seleção de alguns dos muitos temas

abordados, esperando que espelhe desde logo a reflexão da prática do que foi aprendido na

Academia.

Cristina Almeida

Coordenadora Técnica

Radiodiagnóstico e Neurorradiologia

Março 2018

Especial ECR2018

Authors: A.R. Costa1, I. Gomes1, A.S. Pimenta2, C. Oliveira1, C.M. Almeida3, G.N. Paulo1, J. Santos1; 1Coimbra/PT,

2Porto/PT, 3Lisboa/PT

Purpose: The number of Computed Tomography (CT) guided interventions had increased exponentially on the last decade.

The aim of this study was to analyse the frequency of examinations, protocols and patient dose values.

Methods and Materials: The study was carried out in three Portuguese centres of reference of excellence. Retrospective

analysis of the frequency of interventional CT procedures, patient data (age, gender and examination body region), expo-

sure parameters and dose values, in terms of CT Dose Index (CTDIvol) and Dose Length Product (DLP) were directly col-

lected from Picture Archiving and Communication System (PACS).

Results: Local DRLs were obtained for the most common interventional CT procedures per each center (76% chest, 10%

bone, 8% pelvic and 6% abdomen). Lung biopsy revealed to be the most frequent procedure. The exposure parameters

and dose values varies across the centers. The found acquisition modes for intervention CT are 2D in (axial and helical

mode) and CT fluoroscopy. The highest interventional acquisition dose values were found for CT fluoroscopy. The majority

of the obtained dose values are similar to other studies.

Conclusion: The first national approach of interventional CT dose values was performed. Different approaches to these

procedures were verified. A lack of standardisation of practice was identified justifying further research in order to protect

the staff and decrease the risk of patient’s over exposure and procedures complications.

►Coordenadora Técnica

Cristina Almeida

►Coordenador da

Neurorradiologia

João Reis

►Responsável da

Especialidade de

Radiodiagnóstico

Luísa Figueiredo

► Coordenação Editorial

Sandra Carmo

(Técnicos de Radiologia)

NÚCLEO DE INVESTIGAÇÃO DE DIAGNÓSTICO POR IMAGEM

Dose values in interventional computed tomography procedures: a

multicenter study

Página 2

Authors: N. Costa1, N. Bastati2, S. Pötter-Lang2, Z. Guengoern2, Y. Bican2, A. Ba-Ssalamah2; 1Lisbon/PT 2Vienna/AT

Purpose: The aim of the study was to create a scoring system based upon gadoxetic acid-enhanced magnetic resonance

imaging (gaMRI) features to predict the treatment response (TR) to chemotherapy.

Methods and Materials: This was a retrospective study of 30 consecutive patients (65.2±11.2years) with CRCLM, who

underwent gaMRI after chemotherapy and before hepatic resection. Metastases were classified according to a suggested

scoring system (0-6 points) in three groups of response: optimal (≤2 points); partial (2-4 points); and no-response (≥4

points). The scoring system comprised three features: overall homogeneity (homogeneous=0, mixed=1, heteroge-

neous=2); tumour-liver interface (sharp=0, mixed=1, ill defined=2); and peripheral rim enhancement (≤2 mm=0, 2-4

mm=1, ≥4 mm=2). Apparent diffusion coefficient (ADC) values were measured.The primary outcome was residual vital

tumour (RVT). The scoring system, response groups, and ADC values were calculated and compared with the RVT percen-

tage. Demographic, laboratory, and imaging findings were included in a multivariate statistical analysis. The three groups

of response were correlated with patient survival and the log-rank test was used to compare two survival distributions

(optimal/partial response vs no-response groups).

Results: Forty-one CRCLM showed good inter-observer agreement (κ=0.86). Multiple regression demonstrated an associa-

tion between RVT (32.9±11.2) and the scoring system (p<0.001), the response group (p<0.001), and the ADC values

(p<0.021). The survival distributions between optimal/partial response and no-response showed a trend to be different

(p=0.066).

Conclusion: gaMRI correlated well with our scoring system, different response groups, and ADC values in patients with

CRCLM treated with chemotherapy, and may be used to assess the RVT percentage.

Predicting the response of colorectal cancer liver metastases

(CRCLM) to preoperative chemotherapy using gadoxetic acid-

enhanced MRI

Prostate artery embolisation (PAE) for benign prostate obstruction

(BPO): the paradigm shift

Authors: Tiago Bilhim, Lisbon/PT

Learning Objectives:

1. To learn about the anatomy of male pelvic arteries relevant for selective embolisation of the prostate.

2. To understand what imaging modalities can be used for guidance inside the pelvis to find the prostate arteries.

3. To become familiar with clinical outcome and predictors of treatment response after prostate artery embolisation.

Abstract:

Prostate artery embolisation (PAE) has been proven to be safe and effective to relieve lower urinary tract symptoms

(LUTS) related to benign prostate obstruction (BPO). Knowledge of the anatomy of the prostate arteries (PAs) is cornersto-

ne for PAE. Pre-procedural CT-Angiography (CTA) and intraprocedural cone-beam CT (CBCT) have been proven to be relia-

ble tools to study the PAs. Identification of the PAs is generally performed under fluoroscopy. Developing alternatives are

the use of fusion imaging with the pre-procedural CTA images, overlay with the intra-procedural CBCT images and the use

of vessel-tracking software that automatically identifies the PAs. Up to 25% of patients may have clinical failure after PAE.

Most of these patients are nonresponders, with a minority being relapsers. Thus, it is very important to define predictors

of clinical outcome to help exclude those patients less likely to respond to PAE. Predictors of better clinical outcome that

have been identified include: younger age; lower baseline LUTS severity; patients under acute urinary retention; and ade-

nomatous-dominant BPO. Bilateral PAE has been proven to be better than unilateral PAE. MR-detected ischemia after

PAE, PSA values 24 hours after PAE, prostate volume reduction and clinical outcome have been shown to be correlated.

Prognostic quantification with perfusion imaging of the prostate, developing catheters and embolic agents/sizes are some

of the future directions in the investigative field of PAE on the path to inclusion in the guidelines for the management of

patients with symptomatic BPO.

Página 3 Especial ECR2018

Dr. João Reis Learn from my mistakes

Authors: Teresa Morais 1, Carolina Pinheiro1, Catarina Perry da Câmara1, Mariana C. Diogo1,2, Carla Conceição1

Purpose: To review illustrative cases of common mistakes made by neuroradiology residents, in order help prevent future

repetition of the same reading errors.

Materials and Methods: Pictorial review with illustrative cases of classic CT and MR perceptive and interpretive errors

made by young residents of brain, spine and head and neck regions. Reasons for the misreading of the examinations will

be explained, as will solutions for each case.

Results: An educational review of pitfalls often encountered in the reading of neuroradiological examinations is presented.

Cases include anatomical variants mistaken for pathological findings, misinterpretation of abnormal findings and other

miscellaneous pitfalls. In the first category, we show the brain MRI of neonatal vs. a child with age above 2 years old. In the

neonatal brain, unmyelinated white matter has a low signal intensity on T1 weighted images and high intensity on T2

weighted images. As myelination proceeds, the water content of white matter decreases, causing a reduction in signal in-

tensity on T2 weighted imaging. There is a corresponding increase in glycolipids, cholesterol and proteins, which causes an

increase in signal intensity on T1. Also in the first category, we show the difference between a osseous suture and a frac-

ture. In the bone evaluation, the knowledge of the appearance of normal sutures is essential to avoid misinterpretation.

The sutures are found in typical anatomical locations and are characteristically jagged in appearance. Sutures have corti-

cated edges whereas the edge of fractured skull bones are not corticated.

The misinterpretation of abnormal findings included pseudosubarachnoid hemorrhage, subacute hematoma for tumor and

the presence of intracranial fat. Pseudosubarachnoid hemorrhage is a sign related to apparent increased attenuation

within the basal cisterns which simulates a true subarachnoid hemorrhage. The most common cause is cerebral

edema where there is a decrease in parenchymal attenuation and engorgement and dilatation of the superficial venous

structures due to an increased intracranial pressure. The pseudosubarachnoid hemorrhage is usually seen in CT as a sym-

metrical density confined to the basal cisterns (i.e. no sulcal density) with a density of 30-40 HU (compared with true acute

subarachnoid hemorrhage ~ 60HU). The clinical context is also essential to help to differentiate between pseudosubarach-

noid hemorrhage and true acute subarachnoid hemorrhage.

In order to differentiate a tumor from a sub-acute hematoma ,the clinical history and review of previous examinations is

essential, especially in the presence of a hypodensity with surrounding edema in CT. Also the MRI can help in this differen-

tial diagnosis.

In the last category, we included images showing the presence of lipiodol contrast in the basal cisterns. Lipiodol is an oil-

based radio-opaque contrast agent used in the late years that appears as a hyperdensity in CT scans and should not be

mistaken with pathologic findings.

Conclusion: Reporting neuroradiology examinations has a learning curve, along which many mistakes are made. A review

of recurring mistakes of beginners helps alert to this entities and hopefully educate trainees.

Another potential cause of error is failure to complete a systematic search after discovering an abnormality (“satisfaction

of search”). An obvious finding that draws the immediate attention of the reader may drive the interpretation, leading to an

incomplete systematic interrogation of the entire exam. has been shown that the accuracy of detecting lesions is signifi-

cantly reduced for cases which have other abnormalities.

Authors: Teresa Morais1, Carolina Pinheiro1, Catarina Perry da Câmara1, Mariana C. Diogo1,2, Carla Conceição1

Purpose: Perivascular spaces (PVS) are normal anatomical variants that manifest as frequent incidental findings in brain

imaging. When presenting with classic characteristics, these are readily identifiable. However, cases with atypical imaging

features may be difficult to diagnose; furthermore, specific pathologies present with characteristic enlarged PVS. The aim

of this paper is to present differential diagnosis of enlarged PVS.

Materials and Methods: Pictorial review with illustrative CT and MR cases of classic, atypical and pathological PVS. Our

department’s Neuroradiology database was searched for educational examples of dilated PVS including normal variants,

pathological variants and metabolic conditions, as well as typical differential diagnosis such an neuroepithelial cysts and

infectious processes. Distinguishing features and clues to the diagnosis on MR and CT are discussed.

Results: The following cases are presented: normal and anatomical variants: normal PVS, enlarged PVS in typical loca-

tions, giant PVS, choroidal fissure cysts, arachnoid cysts, hippocampal cysts, Cystic tumors : DNET; metabolic / congenital

diseases such as hypomelanosis of Ito, Lowe syndrome and mucopolysaccharidosis; and infectious processes, such as

neurocysticercosis or cryptococcosis.

Conclusion: PVS are frequent incidental findings. Differential diagnosis varies widely from the same finding in adults, and

it is essential that the Neuroradiologist is aware of this in order to make the correct diagnosis.

Enlarged perivascular spaces in children - differential diagnosis

Página 4

Authors: luz, José Hugo; Bilhim, Tiago; Veloso, Filipe; Coimbra, Élia. Lisbon/PT

Purpose: The aim of this study is to compare the efficacy of portal vein embolization (PVE) using n-butyl-cyanoacrylate

(NBCA) versus polyvinyl alcohol (PVA) particles plus Coils in the induction of liver hypertrophy before major hepatectomies.

Ethics committee approval: The hospital review board and the local ethics committee approved the study protocol and all

patients enrolled signed/will sign the informed consent.

Methods and Materials: This is a randomized clinical trial, single site. Eighty consecutive patients with resectable liver tu-

mors and indication for preoperative PVE are randomized for one of two arms of the study (40 patients in each arm). The

primary endpoint is to compare the degree of hepatic hypertrophy, through computed tomography volumetry, at 14 and 28

days after PVE. The secondary endpoints are the comparative analysis of the two methods of PVE (regarding complica-

tions, cost, total procedure time, contrast media usage and radiation exposure) and the post-operative outcome

(accomplishment of the planned liver surgery, causes of hepatectomy suspension and incidence of liver failure).

Results: PVE with NBCA has shown a higher degree of hypertrophy (left lobe increase in size was 64 ± 23 % vs. 41 ± 12

with NBCA versus PVA plus coils). The amount of contrast medium used for the procedure was 111 ± 34 ml and 223 ± 43

ml, for NBCA and PVA plus coils, respectively. The trial is ongoing (still recruiting).

Conclusion: The trial is ongoing (still recruiting). PVE with NBCA seems more effective in promoting liver hypertrophy. The

overall PVE cost, procedure time and contrast media use was substantially lower when adopting the NBCA approach.

Randomized Clinical Trial of Portal Vein Embolization using N-butyl-

cyanoacrylate versus polyvinyl alcohol particles plus Coils for liver hypertro-

phy before major hepatectomies

Authors: C. Pinheiro, T. V. P. Morais, C. T. F. Perry da Câmara, C. Rios, M. C. Diogo, M. Ferreira

Background: The non atherosclerotic vasculopathies are an uncommon group of disorders, with diverse etiopathogenies,

involving younger patients when compared with atherosclerotic disease.

Clinical presentation varies from acute vascular events - ischemic or hemorrhagic- to uncharacteristic neurologic syndro-

mes.

Although the cerebral angiography is the gold standard diagnostic method due to its high sensibility, its specificity is low

mainly when compared to imaging evaluation of the arterial wall with carotid and vertebral ultrasound-doppler.

As a non-invasive exam, it is extremely useful, not only in the diagnosis, but also in the monitoring of these patients -

young patients who need a regular and extended evaluation.

We present six different examples of non-atherosclerotic vasculopathies namely, Moya-moya disease, vertebral artery

dissection in a patient with fibromuscular dysplasia, Takayasu arteritis, giant cells arteritis, sickle cell disease and radia-

tion-induced vasculopathy.

Conclusion: The ultrasound-doppler technique is an alternative exam to the cerebral angiography, with a high diagnostic

capacity (sensibility and specificity), being the method of excellence in the monitoring the arterial wall disease.

MRI, the image modality for the future: hybrid, diagnostic and therapeutic

Assessing non-atherosclerotic vasculopathies using doppler-ultrasound

Authors: Vitor Silva, Porto/PT

Learning Objectives:

1. To recognise MRI as an image modality with great clinical potential for diagnosis.

2.To learn about MRI/PET opportunities, challenges and new directions in clinical practice.

3.To understand the MRI potential to improve radiotherapy planning and treatment.

4. To be aware of MRI safety considerations and risks to promote best practices.

Abstract

Magnetic resonance (MR) is a medical imaging modality in permanent evolution. Nowadays, MR is becoming a hybrid

technique, functioning for diagnostic and therapeutic considering the superb soft tissue contrast. Dedicated hybrid posi-

tron emission tomography (PET) combined with MR - PET/MR have been recently introduced and these equipments have

the potential to combine the molecular and functional information of PET with MR excellent soft tissue contrast, percei-

ving better the localization of pathologies. PET/MR offers opportunities for more efficient, accurate and safe diagnoses.

MR can be used to therapeutic methods when combined to a hybrid linear accelerator (linac). MR will provide optimal soft

tissue contrast for image guidance in multiple sites in human body providing diagnostic quality images during treatment

delivery, and, consequently, permitting very accurate image guided adaptive radiotherapy. Associated to these new para-

digms on MR hybrid imaging, the knowledge of MR safety issues and considerations are fundamental for better practices.

Knowing how a MR scanner works and its inherent physics is vital. For its functioning, MR has three different types of

electromagnetic fields: (i) a static magnetic field; (ii) time varying gradient fields; and (iii) radiofrequency fields. These

have different risks and hazards. The MR potential for improving the health care provided to patients is proved by the com-

bination with other diagnostic and therapeutic imaging modalities.

Página 5 Especial ECR2018

Dr. João Reis

APRENDIZAGEM - O congresso apresentou mini-cursos

“hands on it”, simpósios sobre o estado da arte em várias

áreas e muitas outras formas de aquisição de novos

conhecimentos.

BERND HAMM – Presidente do ECR 2018, é Professor de

Radiologia e presidente dos 3 departamentos de Radiolo-

gia Charité, Humboldt-Universität zu Berlin e Freie Univer-

sität, é também Diretor Clínico de Centro Charité que inclui

Radiologia, Neurorradiologia, Medicina Nuclear e Física

Médica

CASEIRO ALVES - Primeiro português a ser distinguido com

a Medalha de Ouro da Sociedade Europeia de Radiologia

Gastrointestinal e Abdominal. Professor Catedrático da

Faculdade de Medicina da Universidade de Coimbra e

Diretor da Clínica Universitária de Imagiologia dos Hospi-

tais da Universidade de Coimbra. Entre outros cargos foi

Vice-Presidente da FNS, Presidente da Direção da Associa-

ção Nacional de Unidades de Diagnóstico por Imagem

(ANAUDI), Vice-presidente da Direção da Sociedade Portu-

guesa de Radiologia e Medicina Nuclear (SPRMN) e Presi-

dente do Colégio da Especialidade de Radiodiagnóstico da

Ordem dos Médicos.

DAILY Newspaper Congress ECR

ESTUDO- Espaço de estudo e partilha

FIGLMÜLLER - Com o famoso Schnitzel, uma receita com

mais de 100 anos.

GESTÃO - Um dos temas abordados contribuindo para

ampliar o conhecimento das diversas vertentes que consti-

tuem a Instituição Hospitalar numa perspectiva de optimi-

zar e racionalizar recursos.

HEALTH CARE - Diagnostico e terapêutica, cuidar e tratar

constituíram grande enfoque nas mais variadas áreas e

métodos de Imagem.

INVESTIGAÇÃO - O ECR espelha todo o trabalho de investi-

gação realizado pelos profissionais da Imagiologia em todo

o mundo, no rigor, determinação e tentativa de contribuir

para o desenvolvimento científico e em última análise para

a prestação de melhores cuidados de saúde aos pacien-

tes.

KAISERINE Elisabeth - Imperatriz consorte do Império Aus-

tríaco e a rainha consorte da Hungria devido ao seu casa-

mento com o imperador Francisco José I. Era conhecida

como "Sissi da Áustria e Hungria".

LECTURE - 3.000 “Honorary Lectures” dedicadas à Ciência

e Investigação

MULTIDISCIPLINARY SESSIONS- O conceito destas sessões

é promover uma abordagem multidisciplinar de deteção e

tratamento, integrando radiologistas e outros clínicos para

partilha de experiências. Os tópicos abordados foram: Neu-

roimagem, Realidade virtual, Realidade aumentada, Distúr-

bios de saúde mental, Tumores ósseos primários, Implanta-

ção da válvula aórtica transcatéter

NETWORKING - Redes, parceiros, partilha de experiências,

momentos de aprendizagem e crescimento pessoal foram

evidentes durante todo o ECR.

ORGANIZAÇÃO— Portugal, China e Suíça, 75.502 membros

de 157 países, mais de 25.000 participantes.

PORTUGAL– Um dos países organizadores

QUALIDADE - Auditoria às práticas médicas, segurança no

planeamento do design dos departamentos de Imagiologia,

segurança dos campos magnéticos, protecção radiológica,

utilização de novas tecnonologias para melhorar o workflow,

eficiência e qualidade dos serviços, foram temas abordados

nas diferentes sessões com enfoque na Qualidade.

REFRESHER COURSES - Cursos de atualização organizados

pelos vários subcomités científicos. Com base no tema da

sessão, alguns cursos foram apresentados em formato

"integrado" com um painel de discussão

SACHERTORTR - Bolo de chocolate, criado por Franz Sacher

em 1832 para o príncipe Metternich em Viena, capital da

Áustria. É uma das mais famosas especialidades gastronó-

micas da cidade.

TECNOLOGIA - A Exposição Técnica, alojada num espaço

com 26.000m2 acolheu cerca de 300 empresas, dando a

conhecer as últimas novidades em hardware e software

Imagiológico.

UPDATE - Update your skill, através de vários cursos com

componente prática e enfoque nas indicações, vantagens,

limitações e controvérsias das diferentes práticas. Foram

utilizados fantomas para aprender / treinar aspectos técni-

cos bem como a escolha do método adequado.

VIENA— Viena, capital mundial da música, onde se realizam

anualmente 15.000 concertos de todo o tipo e ordem de

grandeza. Não existe outra cidade onde tantos composito-

res exerceram influência: Mozart, Mahler, Haydn, Beethoven

e o rei das valsas, Johann Strauß. A Wiener Philharmoniker

e os Wiener Sängerknaben são destaques mundiais, a Ópe-

ra Vienense (Staatsoper) e a Sala Dourada (Goldene Musik-

vereinssaal) estão entre os melhores locais de encenação.

X – RAY - 8 de Novembro dia internacional da Radiologia

Z...

Cristina Almeida– Técnica Coordenadora DPI

Página 6

I magens ECR 2018