JBR 2013-2

ORGANE DE LA SOCIETE ROYALE BELGE DE RADIOLOGIE (SRBR)

ORGAAN VAN DE KONINKLIJKE BELGISCHE VERENIGING VOOR RADIOLOGIE (KBVR)

DIAGNOSTIC AND INTERVENTIONAL IMAGING, RELATED IMAGING SCIENCES,AND CONTINUING EDUCATION

WETTEREN 1

2 Volume 96 Page 55-108

March-April

Bimonthly – 2013

P 702083

00a-Couv-2013.indd 1 25/04/13 16:18

Subscribers’ information

The JBR-BTR is published 6 times a year. Subscription of members of the Belgian Society of Radiology areincluded in membership dues and are handled by the Society. Non-members’ subscriptions are available fromthe ARSMB-KVBMG.The rate is valid to date and can be amended without notice according to fluctuation of printing and materialcosts. Annual subscriptions or single issue orders should be made promptly. The publishers cannot guaranteesupply of back issues. Change of address must be notified 60 days in advance.

RATES: Annual Single issueBelgium 150 € 38 €Other Countries 175 € 44 €All amounts are net and include postal and handling charges.

You are kindly invited to address all your correspondence to Mrs A. Hirsch and execute all payments to ARSMB-KVBMG (see below).

Instructies voor abonnees

Het JBR-BTR geeft 6 nummers uit per jaar. Het tarief is vatbaar voor wijzigingen zonder voorafgaand bericht, inverhouding tot de evolutie van de papierprijzen en loonkosten in de grafische nijverheid. Het abonnement vande leden van de Koninklijke Vereniging voor Radiologie is begrepen in de bijdrage van het lidgeld. De abon-nementen van niet-leden zijn te onderschrijven bij de KVBMG.Jaarabonnementen of bestellingen van losse nummers moet zo snel mogelijk gebeuren, de uitgever waarborgtde levering van de vorige nummers niet voor de abonnementen die te laat werden onderschreven. Deadresveranderingen moeten 60 dagen te voren gemeld worden.

TARIEF: Jaarlijks AfleveringBelgie 175 € 42 €Andere landen 200 € 49 €Verzendingskosten zijn inbegrepen.

U wordt vriendelijk verzocht alle briefwisseling te richten aan Mevr. A. Hirsch en alle betalingen te verrichten ophet banknummer van ARSMB-KVBMG (zie hieronder).

Instructions aux abonnés

Le JBR-BTR publie 6 fascicules par an. Les tarifs sont susceptibles de modifications sans préavis, en fonction del’évolution des prix du marché du papier et des travaux d’impression. Le prix de l’abonnement des membres dela Société Royale de Radiologie est inclus dans le montant de la cotisation. L’abonnement d’un non-membre està souscrire auprès de l’ARSMB.La souscription d’abonnement ou la commande de numéro isolé doit être exécutée rapidement, l’éditeur ne pouvant pas garantir la livraison d’éditions passées. Les changements d’adresse doivent être signalés 60 jours àl’avance.

TARIF: Annuel FasciculeBelgique 175 € 42 €Autres pays 200 € 49 €Envoi et port inclus.

Nous vous prions d’adresser toute correspondance à Mme A. Hirsch et d’effectuer tout paiement au compte del’ARSMB-KVBMG (voir ci-dessous).

Koninklijke Vereniging van de Belgische Medische Association Royale des Sociétés ScientifiquesWetenschappelijke Genootschappen – Médicales Belges –(KVBMG), vzw (ARSMB), asblW. Churchill-laan 11/30, B-1180 Brussel, België avenue W. Churchill 11/30, B-1180 Bruxelles, Belgiquetel.: (02) 374 25 55 tél.: (02) 374 25 55fax: (02) 374 96 28 fax: (02) 374 96 28

Webaddress: http://www.ulb.ac.be/medecine/loce/amb.htmE-mail: [email protected]

Bank Account: Post Office AccountFortis: 210-0251210-32 Giro: 000-0273502-59IBAN: BE 90210025121032 IBAN: BE 84000027350259BIC: GE BABEBB36A BIC: BPOTBEB1

02-voorblz-2013-2_Opmaak 1 23/04/13 13:22 Pagina 1

JBR-BTR � 96/2 � 2013

Journal Belge de � Belgisch Tijdschrift voor � RADIOLOGIE

Founded in 1907

A bimonthly journal devoted to diagnostic and interventional imaging,related imaging sciences, and continuing education

Contents

A spontaneous pre-anastomotic occlusion does not necessarily impair forearm native dialysis fistulas: echo-Doppler, 3D MR angiographic and digital subtraction angiographic imaging

N. Verbeeck, J.C. Pillet, F. Prospert, D. McIntyre, S. Lamy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Persistent facial swelling and tinnitus complicating septo rhinoplastYT. Van der Zijden, J. Claes, F.M. Vanhoenacker, G. Claes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Ultrasound contrast agent delivered per os first diagnoses pharyngoesophageal tumourE. Antypa, D.D. Cokkinos, I. Kalogeropoulos, D. Tomais, P.N. Piperopoulos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Giant idiopathic ulcer of esophagus in the context of acquired immunodeficiency syndrome (AIDS)C.A. Dragean, I. Bogdan, K. Azzouzzi, L.Goncette . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

PNET/Ewing’s sarcoma of the kidney: imaging findings in two casesP. De Visschere, A. De Potter, F. Claus, T. Mulkens, R. Oyen, A. Verbaeys, C. Maes, G. Villeirs . . . . . . . . . . . . . . . 75

The critical role of CT angiography in the detection and management of lower gastro-intestinal bleedingM. Aertsen, B. Termote, G. Souverijns, J. Vanrusselt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Imaging of epilepsy following electrical injuryC. Neugroschl, S. Berrada, J.-A. Elosegi, C. Winant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Primary liver lymphomaS. Khalid, S. Zaheer, M. Khalid, S. Zaheer, M. Sheeraz Alam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Multiple myeloma involving the cricoid cartilageB. Floré, R. Hermans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

IMAGES IN CLINICAL RADIOLOGY

Pancreas serous cystadenoma: typical imaging aspect of a rare tumorT. Kirchgesner, W. Bou Sleiman, X. Hamoir, D. Salovic, J. Kirsch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Traumatic urinary bladder rupture: the usefulness of CT cystographyP. Montigny, J. Pringot, M-F. Billemont, P. Matthys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Bilateral exostoses of the internal auditory canalL. Dewachter, F. Govaere, I. Crevits, R. De Man . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

Transient restricted diffusion in the splenium of the corpus callosum after brain surgeryM. Beltran-Marin, N. Sadeghi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

Appendicular intussusception with lymphoid hyperplasiaPh. Everarts, E. Vanderveken, M.O. Peny, B. De Bont . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

Agenesis of the infrarenal inferior vena cavaM. Devooghdt, N. Favoreel, B. van Holsbeeck, J. Marrannes, E. Laridon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Hemoptysis in a 39-year-old smokerI. Willekens, B. Ilsen, M. de Maeseneer, F. Vandenbroucke, J. de Mey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Unusual case of “airway hyperreactivity” in a child with an incomplete double aortic arch with atresia of the left aortic arch

M. Aertsen, E Bijnens . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

01-JBR-contents-13-2_Opmaak 1 25/04/13 13:48 Pagina 1

� The terms used for indexation of subjects were developed by the Radiological Society of North America (RSNA)over a period of years. Their use here is by permission of the RSNA. The terms may not be used in any otherindex, print or electronic, except by specific permission of RSNA.

�� Indexed in Index Medicus and in Zentralblatt Radiologie. Evaluated for Medline User, EMBASE and CANCERNET.Abstracted in Excerpta Medica Journals.

Annual General Assembly of the Royal Belgian Society of Radiology (RBRS), Tervuren, 26.01.2013Presidential Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 972012 Honorary Membership Nominees: Prof. Ph Grenier and Prof. J. Struyven . . . . . . . . . . . . . . . 97President-Elect Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99Closing Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100Abstract of papers presented at the RBRS Annual Symposium . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

News from the Universities8th Scientific Prize em. Prof. Dr A.L. Baert to laureate B. De Foer . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104Abstract of B. De Foer presentation: The value of MRI in the preoperative evaluation and the postoperative follow-up of middle ear cholesteatoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106Announcement of 9th Scientific Prize em. Prof. Dr A.L. Baert . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

News from the Museum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Forthcoming Courses and Meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Instructions to Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii

Subscribers information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . cii

Advertising index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ciii

01-JBR-contents-13-2_Opmaak 1 29/04/13 11:46 Pagina 2

Prix/Prijs Hosp. : Flacon 10 ml: € 29,90 - 15 ml : € 42,89 - 20 ml : € 51,86 - 60 ml : € 136,67 PFS 15 ml : € 42,92 - 20 ml : € 51,86

FDA Approves Dotarem® (gadoterate meglumine), first macrocyclic and ionic gadolinium‐based

contrast agent in USA (March 21, 2013)

DÉNOMINATION DU MÉDICAMENT : Dotarem 0,5 mmol/mL, solution injectable. COMPOSITION QUALITATIVE ET QUANTITATIVE : La substance active est l'acide gadotérique. Elle est présente sous forme de gadotérate de méglumine (0,5 mmoles de gadotérate de méglumine/mL). Flacon de 5 mL : Acide gadotérique 1396,6 mg Flacon ou seringue pré-remplie de 10 mL : Acide gadotérique 2793,2 mg Flacon ou seringue pré-remplie de 15 mL : Acide gadotérique 4189,8 mg Flacon ou seringue pré-remplie de 20 mL : Acide gadotérique 5586,4 mg Flacon de 60 mL : Acide gadotérique 16759,2 mg Pour la liste complète des excipients, voir rubrique 6.1. FORME PHARMACEUTIQUE : Solution injectable. Indications thérapeutiques : Chez l’adulte, l’enfant et le nourrisson : imagerie par résonance magnétique. IRM Cérébral et du rachis dont : Pathologies encéphaliques et rachidiennes : tumeurs cérébrales, tumeurs du rachis et des enveloppes, hernies discales, pathologie infectieuse. IRM du Corps entier dont : Pathologies abdominales : tumeurs hépatiques primitives et secondaires, tumeurs pancréatiques. Pathologies rénales : tumeurs et kystes rénaux, suivi de transplantations rénales. Pathologies pelviennes : tumeurs de l’utérus et des ovaires. Pathologies cardiaques : suivi d’infarctus et de transplantations cardiaques. Pathologies mammaires : tumeurs du sein, suivi d’implants. Pathologies ostéo-articulaires : tumeurs osseuses et des parties molles. IRM pour angiographie : Ce médicament est à usage diagnostique uniquement. Posologie et mode d'administration : Posologie : Dans la plupart des cas, la dose recommandée est de 0,1 mmol/kg soit 0,2 mL/kg chez l’adulte, l’enfant et le nourrisson. En neuroradiologie, la dose peut varier de 0,1 à 0,3 mmol/kg. En cas de doute diagnostique après injection de la dose de 0,1 mmol/kg, la dose supplémentaire de 0,2 mmol/kg permet d’orienter le schéma thérapeutique post-examen, dans le cas des tumeurs cérébrales. En angiographie, une deuxième injection de 0,1 mmol/kg peut être justifiée dans certains territoires. Populations particulières : Insuffisants rénaux : Dotarem ne doit être administré aux patients présentant une insuffisance rénale sévère (Débit de filtration glomérulaire DFG < 30mL/min/1,73 m²) et en période périopératoire de transplantation hépatique qu’après une évaluation approfondie du rapport bénéfice/risque et que si les informations diagnostiques sont indispensables et ne peuvent être obtenues au moyen d'une IRM sans rehaussement du contraste (voir rubrique 4.4). S’il est nécessaire d’administrer Dotarem, la dose ne doit pas excéder 0,1 mmol/kg de poids corporel. Ne pas administrer plus d’une dose au cours de l'examen IRM. En raison du manque d’information sur les administrations répétées, les injections de Dotarem ne doivent pas être réitérées sauf si l’intervalle entre les injections est d’au moins sept jours. Sujets âgés (à partir de 65 ans) : Aucune adaptation posologique n’est nécessaire. Utiliser avec prudence chez les sujets âgés (voir rubrique 4.4). Population pédiatrique : Nouveau-nés jusqu’à l’âge de 4 semaines et nourrissons jusqu’à l’âge d’un an : En raison de l’immaturité de la fonction rénale chez le nouveau-né jusqu’à l’âge de 4 semaines et chez le nourrisson jusqu’à l’âge d’un an, Dotarem ne doit être utilisé chez ces patients qu’après une évaluation attentive et à une dose n’excédant pas 0,1 mmol/kg de poids corporel. Ne pas administrer plus d’une dose au cours de l'examen IRM. En raison du manque d’information sur les administrations répétées, les injections de Dotarem ne doivent pas être réitérées, sauf si l’intervalle entre les injections est d’au moins sept jours. Dotarem n’est pas recommandé pour l’angiographie chez les enfants de moins de 18 ans en raison de données insuffisantes sur l’efficacité et la sécurité dans cette indication. Mode d’administration : Le produit doit être administré en injection intraveineuse stricte. Contre-indications : Hypersensibilité à l’acide gadotérique, à la méglumine ou à tout produit contenant du gadolinium. Effets indésirables : Les effets indésirables liés à l’utilisation de l’acide gadotérique sont généralement d’intensité légère à modérée et de nature transitoire. Une sensation de chaleur, de froid ou de douleur au site d’injection sont les réactions les plus fréquemment observées. Lors d’essais cliniques, des céphalées et des paresthésies ont été très fréquemment observées (> 1/10), et des nausées, des vomissements et des réactions cutanées telles qu’une éruption et un prurit l’ont été fréquemment (> 1/100 à < 1/10). Depuis la commercialisation, les effets indésirables les plus souvent rapportés à la suite de l’administration de l’acide gadotérique ont été des nausées, des vomissements, un prurit et des réactions d’hypersensibilité. Les réactions d’hypersensibilité les plus souvent observées ont été cutanées et ont été localisées, étendues ou généralisées. Ces réactions sont le plus souvent immédiates (pendant l’injection ou au cours de l’heure suivant le début de celle-ci) mais sont parfois retardées (une heure à plusieurs jours après l’injection), se présentant en ce cas sous forme de réactions cutanées. Les réactions immédiates se composent d’un ou plusieurs effets qui apparaissent simultanément ou séquentiellement et qui sont le plus souvent des réactions cutanées, respiratoires et/ou cardiovasculaires. Chaque signe peut être un signal d’alarme indiquant un choc débutant et peut très rarement aboutir au décès. Des cas isolés de fibrose systémique néphrogène (FSN) ont été décrits avec l’acide gadotérique, le plus souvent chez des patients ayant conjointement reçu d’autres produits de contraste contenant du gadolinium (voir rubrique 4.4). Les effets indésirables sont mentionnés ci-après par classe de système d’organe et par fréquence selon la convention suivante : très fréquent (≥ 1/10), fréquent (≥ 1/100 à < 1/10), peu fréquent (≥ 1/1000 à 1<1/100), rare (≥ 1/10 000 à < 1/1 000), très rare (< 1/10 000), fréquence indéterminée (ne peut être pas estimée sur la base des données disponibles). Les données présentées proviennent des essais cliniques disponibles ou d’une étude observationnelle qui a inclus 82 103 patients. Effets indésirables par classe de système d’organe : Affections du système immunitaire : Peu fréquent : Hypersensibilité, réaction anaphylactique, réaction anaphylactoïde. Affections psychiatriques. Très rare : agitation, anxiété. Affections du système nerveux : Très fréquent : paresthésies, céphalées. Rare : dysgueusie. Très rare : coma, convulsion, syncope, présyncope, sensations vertigineuses, parosmie, tremblements. Affections oculaires : Très rare : conjonctivite, hyperhémie oculaire, vision floue, larmoiement, œdème des paupières. Affections cardiaques : Très rare : arrêt cardiaque, bradycardie, tachycardie, troubles du rythme, palpitations. Affections vasculaires : Très rare : hypotension, hypertension, vasodilatation, Pâleur. Affections respiratoires, thoraciques et médiastinales : Très rare : arrêt respiratoire, œdème pulmonaire, bronchospasme, laryngospasme, œdème pharyngé, dyspnée, congestion nasale, éternuements, toux, gorge sèche. Affections gastro-intestinales : Fréquent : nausées, vomissements. Très rare : diarrhée, douleurs abdominales, hypersalivation. Affections de la peau et du tissu sous-cutané : Fréquents : prurit, érythème, éruption. Rare : urticaire, hyperhidrose. Très rare : eczéma, œdème de Quincke (angiœdème). Fréquence indéterminée : fibrose systémique néphrogénique. Affections musculo-squelettiques et systémiques. Très rare : contracture musculaire, faiblesse musculaire, dorsalgie. Troubles généraux et anomalies au site d’administration. Fréquents : sensation de chaleur, sensation de froid, douleur au site de l’injection. Très rare : malaise, douleur thoracique, gêne thoracique, fièvre, frissons, œdème du visage, asthénie, gêne au site d'injection, réaction au site de l’injection, œdème au site de l’injection, extravasation au site de l’injection, inflammation au site de l’injection (en cas d'extravasation), nécrose au site de l’injection (en cas d’extravasation), phlébite superficielle. Investigations : Très rare: diminution de la saturation en oxygène. Les effets indésirables suivants ont été observés avec d’autres produits de contraste pour IRM : Affections hématologiques et du système lymphatique. Hémolyse. Affections psychiatriques : Confusion : Affections oculaires : Cécité transitoire, douleur oculaire. Affections de l’oreille et du labyrinthe : Acouphène, otalgies. Affections respiratoires, thoraciques et médiastinales : Asthme. Affections gastro-intestinales : Bouche sèche. Affections de la peau et du tissu sous-cutané : Dermatose bulleuse. Affections du rein et des voies urinaires : Incontinence urinaire, nécrose tubulaire aiguë, insuffisance rénale aiguë. Investigations : Prolongation de PR à l’électrocardiogramme, augmentation de la sidérémie, augmentation de la bilirubinémie, augmentation de la ferritinémie, anomalie des explorations fonctionnelles hépatiques. Effets indésirables chez l'enfant : Les événements indésirables liés à l’acide gadotérique sont peu fréquents chez l’enfant. La probabilité de ces événements est identique chez l’enfant et l’adulte. TITULAIRE DE L'AUTORISATION DE MISE SUR LE MARCHE : Guerbet – B.P. 57400 – F-95943 Roissy CdG Cedex, France. NUMERO(S) D'AUTORISATION DE MISE SUR LE MARCHE : Boîte de 1 flacon de 5 mL : BE 184615. Boîte de 1 flacon de 10 mL : BE 149362. Boîte de 1 flacon de 15 mL : BE 149371. Boîte de 1 flacon de 20 mL : BE 149353. Boîte de 1 flacon de 60 mL : BE 226055. Boîte de 1 seringue pré-remplie de 10 mL : BE 254992. Boîte de 1 seringue pré-remplie de 15 mL : BE 169547. Boîte de 1 seringue pré-remplie de 20 mL : BE 169531. Délivrance : sur prescription médicale. Date de l’approbation du résumé des caractéristiques du produit : 23/01/2012. Date de l’approbation de l’information médicale : 03/04/2013. NAAM VAN HET GENEESMIDDEL : Dotarem 0,5 mmol/mL, oplossing voor injectie. KWALITATIEVE EN KWANTITATIEVE SAMENSTELLING : Het actieve bestanddeel is gadoteerzuur in de vorm van megluminegadoteraat (0,5 mmol megluminegadoteraat/mL). Injectieflacon van 5 mL : 1396,6 mg gadoteerzuur Injectieflacon of voorgevulde spuit van 10 mL : 2793,2 mg gadoteerzuur Injectieflacon of voorgevulde spuit van 15 mL :4189,8 mg gadoteerzuur Injectieflacon of voorgevulde spuit van 20 mL :5586,4 mg gadoteerzuur Injectieflacon van 60 mL : 16759,2 mg gadoteerzuur Voor een volledige lijst van hulpstoffen, zie rubriek 6.1. FARMACEUTISCHE VORM : Oplossing voor injectie. Therapeutische indicaties : Bij de volwassene, het kind en de zuigeling : Beeldvorming via Magnetische Resonantie (MRI). MRI van de hersenen en de ruggengraat waaronder : pathologie van de hersenen en de wervelkolom : hersentumoren, tumoren van de ruggengraat en de omhulsels, discus-hernia, infecties. MRI van het ganse lichaam waaronder : abdominale pathologieën : primaire en secundaire levertumoren, pancreastumoren, renale pathologieën : niertumoren en -kysten, opvolging van niertransplantaties, pathologieën van het bekken : tumoren van uterus en ovaria, cardiale pathologieën : opvolging van infarct en harttransplantaties, mammaire pathologieën : borsttumoren, opvolging van implantaten, osteo-articulaire pathologieën : tumoren van de beenderen en de weke delen. MRI voor angiografie. Dit geneesmiddel is uitsluitend voor diagnostisch gebruik. Dosering en wijze van toediening : Dosering : De gebruikelijke aanbevolen dosis is 0,1 mmol/kg, hetzij 0,2 mL/kg, zowel bij de volwassene, het kind als de zuigeling. Bij neuroradiologie kan de dosis variëren van 0,1 tot 0,3 mmol/kg. In geval van diagnostische twijfel na injectie van de dosis van 0,1 mmol/kg, laat de bijkomende dosis van 0,2 mmol/kg toe om, na het onderzoek, het therapeutische schema richting te geven in geval van cerebrale tumoren. Bij angiografie kan een tweede injectie van 0,1 mmol/kg gerechtvaardigd zijn voor bepaalde gebieden. Speciale populaties : Nierfunctiestoornis : Dotarem mag bij patiënten met een ernstige nierfunctiestoornis (glomerulaire filtratiesnelheid (GFR) < 30 mL/min/1,73 m²) en bij patiënten tijdens de perioperatieve levertransplantatieperiode alleen worden gebruikt na zorgvuldige afweging van de voordelen en risico’s en na overweging of de diagnostische informatie essentieel is en niet kan worden verkregen met niet-contrastversterkte MRI (zie rubriek 4.4). Indien het nodig is Dotarem te gebruiken dient de dosis niet groter te zijn dan 0,1 mmol/kg lichaamsgewicht. Niet meer dan één dosis mag worden gebruikt bij een MRI. Wegens het ontbreken van informatie over herhaalde toedieningen dient Dotarem niet herhaald te worden toegediend tenzij het interval tussen de injecties tenminste 7 dagen bedraagt. Ouderen (van 65 jaar en ouder) : Een dosisaanpassing wordt niet noodzakelijk geacht. Voorzichtigheid is geboden bij oudere patiënten (zie rubriek 4.4). Pediatrische populatie : Neonaten tot 4 weken oud en zuigelingen tot 1 jaar oud : Door de onvolgroeide nierfunctie bij neonaten tot 4 weken oud en zuigelingen tot 1 jaar mag Dotarem bij deze patiënten alleen na zorgvuldige overweging worden gebruikt met een dosis niet groter dan 0,1 mmol/kg lichaamsgewicht. Niet meer dan één dosis mag worden gebruikt bij een MRI. Wegens het ontbreken van informatie over herhaalde toedieningen dient Dotarem niet herhaald te worden toegediend tenzij het interval tussen de injecties ten minste 7 dagen bedraagt. Daar er onvoldoende gegevens bestaan over de doeltreffendheid en veiligheid in deze indicatie, is Dotarem niet aanbevolen voor angiografie bij kinderen onder 18 jaar. Wijze van toediening : Het product moet via intraveneuze injectie worden toegediend. Contra-indicaties : Overgevoeligheid voor gadoteerzuur, meglumine of andere geneesmiddelen die gadolinium bevatten. Bijwerkingen : De bijwerkingen gebonden aan het gebruik van gadoteerzuur zijn in het algemeen van lichte tot matige intensiteit en van voorbijgaande aard. Een gevoel van warmte, koude of pijn op de plaats van de injectie zijn de meest waargenomen reacties. Tijdens klinische onderzoeken zijn zeer vaak (>1/10) bijwerkingen zoals hoofdpijn en paresthesie waargenomen; bijwerkingen zoals misselijkheid, braken en huidreacties zoals erytheem en jeuk zijn vaak (> 1/100 - <1/10) waargenomen . Sinds het in de handel brengen zijn de vaakst gemelde bijwerkingen na de toediening van gadoteerzuur misselijkheid, braken, pruritus en overgevoeligheidsreacties. Bij overgevoeligheidsreacties zijn de vaakst waargenomen reacties huidreacties die plaatselijk uitgebreid of gegeneraliseerd kunnen zijn. Deze reacties doen zich meestal onmiddellijk voor (tijdens de injectie of binnen een uur na aanvang van de injectie) en soms vertraagd (een uur tot enkele dagen na de injectie) en presenteren zich als huidreacties. Onmiddellijke reacties zijn één of meer effecten die gelijktijdig of opeenvolgend optreden en meestal bestaan uit huidreacties, respiratoire en/of cardiovasculaire reacties. Elk teken kan een waarschuwing zijn van een beginnende shock die zeer zelden tot de dood leidt. Er zijn geïsoleerde gevallen gerapporteerd van nefrogene systemische fibrose (NSF) bij het gebruik van gadoteerzuur, waarvan de meeste bij patiënten die gelijktijdig andere gadoliniumhoudende contrastmiddelen toegediend kregen (zie rubriek 4.4). De bijwerkingen staan hierna vermeld per systeem-orgaanklasse en frequentie, overeenkomstig de volgende richtlijnen: zeer vaak (1/10), vaak (1/100 tot 1<1/10), soms (1/1.000 tot 1<1/100), zelden (1/10.000 tot <1/1.000), zeer zelden (<1/10.000), onbekend (kan niet worden ingeschat op basis van de beschikbare gegevens). Genoemde gegevens zijn afkomstig uit de beschikbare klinische studies , of uit een observationele studie bij 82.103 patiënten. Frequentie bijwerking per systeem-orgaanklasse : Immuunsysteemaandoeningen : Soms: overgevoeligheid, anafylactische reactie, anafylactoïde reactie. Psychiatrische stoornissen : Zeer zelden : agitatie, angst. Zenuwstelselaandoeningen : Zeer vaak : paresthesie, hoofdpijn. Zelden : dysgeusie. Zeer zelden : coma, convulsie, syncope, presyncope, duizeligheid, parosmie, tremor. Oogaandoeningen : Zeer zelden : conjunctivitis, oculaire hyperemie, wazig zicht, toegenomen tranenvloed, ooglidoedeem. Hartaandoeningen : Zeer zelden: hartstilstand, bradycardie, tachycardie, hartritmestoornissen, hartkloppingen. Bloedvataandoeningen : Zeer zelden : hypotensie, hypertensie, vaatverwijding, bleek zien. Ademhalingsstelsel-, borstkas- en mediastinumaandoeningen : Zeer zelden : ademhalingsstilstand, longoedeem, bronchospasme, laryngospasme, faryngeaal oedeem, dyspneu, verstopte neus, niesbuien, hoest, droge keel. Maagdarmstelselaandoeningen : Vaak : misselijkheid, braken. Zeer zelden : diarree, buikpijn, speekselvloed. Huid- en onderhuidaandoeningen : Vaak : pruritus, erytheem, uitslag. Zelden : urticaria, hyperhidrose. Zeer zelden : eczeem, angio-oedeem. Onbekend : nefrogene systemische fibrose. Skeletspierstelsel- en bindweefselaandoeningen. Zeer zelden : spiercontractuur, spierzwakte, rugpijn. Algemene aandoeningen en toedieningsplaatsstoornissen : Vaak : warmtesensatie, koudesensatie, pijn op de injectieplaats. Zeer zelden : malaise, thoracale pijn, ongemak op de borst, koorts, rillingen, oedeem van het gezicht, asthenie, ongemak op de injectieplaats, reactie op de injectieplaats, oedeem op de injectieplaats, extravasatie op de injectieplaats, ontsteking van de injectieplaats (in het geval van extravasatie), necrose ter hoogte van de injectieplaats (in het geval van extravasatie), oppervlakkige flebitis. Onderzoekingen : Zeer zelden : verminderde zuurstofsaturatie. De volgende bijwerkingen zijn gerapporteerd met andere intraveneuze contrastmiddelen voor MRI-onderzoek : Bloed- en lymfestelselaandoeningen : Hemolyse. Psychiatrische stoornissen : Verwarring : Oogaandoeningen. Voorbijgaande blindheid, oogpijn. Evenwichtsorgaan- en ooraandoeningen : Tinnitus, oorpijn. Ademhalingsstelsel-, borstkas- en mediastinumaandoeningen : Astma. Maagdarmstelselaandoeningen : Droge mond. Huid- en onderhuidaandoeningen : Bulleuze dermatitis. Nier- en urinewegaandoeningen : Urine-incontinentie, renale tubulusnecrose, acute nierinsufficiëntie. Onderzoekingen : PR-verlenging op het elektrocardiogram, verhoogd ijzergehalte in het bloed, verhoogd bilirubinegehalte in het bloed, verhoogd ferritinegehalte in het serum, afwijkende leverfunctietest. Bijwerkingen bij kinderen : Ongewenste voorvallen gerelateerd aan gadoteerzuur komen soms voor bij kinderen. Deze voorvallen zijn bij kinderen even vaak te verwachten als bij volwassenen. HOUDER VAN DE VERGUNNING VOOR HET IN DE HANDEL BRENGEN : GUERBET – B.P. 57400 - F-95943 Roissy CdG Cedex, France . NUMMER(S) VAN DE VERGUNNING VOOR HET IN DE HANDEL BRENGEN : Doos met 1 injectieflacon van 5 mL : BE 184615. Doos met 1 injectieflacon van 10 mL: BE 149362. Doos met 1 injectieflacon van 15 mL: BE 149371. Doos met 1 injectieflacon van 20 mL: BE 149353 . Doos met 1 injectieflacon van 60 mL: BE 226055. Doos met 1 voorgevulde spuit van 10 mL : BE 254992. Doos met 1 voorgevulde spuit van 15 mL : BE 169547. Doos met 1 voorgevulde spuit van 20 mL : BE 169531. Aflevering : op medisch voorschrift. Datum van de laatste goedkeuring van de SKP : 23/01/2012. Datum van goedkeuring van de medische informatie : 03/04/2013.

Sections of the Royal Belgian Radiological Society (SRBR-KBVR):

Abdominal and digestive imaging B. Op de Beeck, E. Danse

Bone and joints J.F. Nisolle, M. Shahabpour

Breast imaging M. Mortier, S. Murgo

Cardiac imaging R. Salgado, O. Ghekière

Cardiovascular and interventional radiology S. Heye, D. Henroteaux

Chest radiology B. Ghaye, W. De Wever

Head and neck radiology J. Widelec, R. Hermans

Neuroradiology M. Lemmerling, L. Tshibanda

Pediatric radiology B. Desprechins, L. Breysem

For addresses and particulars, see website at http://www.rbrs.org

Instructions to authors

The purpose of The Belgian Journal of Radio -logy is the publication of articles dealing withdiagnostic radiology and related imagingtechniques, therapeutic radiology, alliedsciences and continuing education. All — newand revised — manuscripts and correspon-dence should be addressed to JBR-BTR Edi to -rial Office, Avenue W. Churchill 11/30, B-1180Bruxelles, tel.: 02-374 25 55, fax: 32-2-374 96 28.Please note that the following instructions arebased on the “Uniform Requirements formanuscripts Submitted to Biomedical Jour -nals” adopted by the International Committeeof Medical Journal Editors (Radiology,1980,135: 239-243). It should however benoted that presentation modifications may beintroduced by the Editorial Office in order toconform with the JBR-BTR personal style.Authors should specify to which of the follow-ing headings their manuscript is intended:Original Article, Review Article, Case Report,Pictorial Essay, Continuing Education,Technical Note, Book Review, Opinion, Letterto the Editor, Comment, Meeting News, inMemoriam, News.Authors should consider the followingremarks and submit their manuscripts accord-ingly.All articles must contain substantive andspeci fic scientific material.– Original articles are articles dealing withone specific area of Radiology or alliedscience related through the personal expe-rience of the author.

– Review articles are special articles reportingthe experience of the author considered in

the general perspective of the literature overthe topic.

– Case reports are short descriptions of a par-ticular case providing a message directlylinked to an individual patient investigated.

– No more than one case should bedescribed in detail and clinical descriptionshould be kept to a minimum. Case reportsshould invest the usual headings of articlesbut should focus on the particular radiolog-ic procedure that contributed to the diagno-sis. References should be present, thoughlimited in number. Tables and acknowledge-ments are usually omitted.

– Pictorial essays are articles presentinginformation through illustrations and leg-ends. The presentation remarks stated inthe paragraph dealing with case reportsapply to pictorial essays.

– Continuing education articles are designedin accordance with the general guidelinesfor articles published in the JBR-BTR in par-ticular they are divided into introduction,material and methods, results, discussion,references, and are provided with anabstract.However, papers addressing the continuingeducation may have only additionnally totheir contents an introduction (stating theaim of the article and providing any back-ground information useful to understandwhy the topic is relevant, and describingthe subtopics covered by the study), refer-ences, and an abstract.Tables should be limited to a maximum ofone table per 6 pages of manuscript.Illustrations should also be limited to amaximum of one illustration (1010 cm)

(possibly made up of different parts) per3 pages of manuscript.All the material should be made availableto the JBR- BTR editorial office (2 copies ofthe manuscript with 2 sets of illustrations)with the corresponding diskette thoughthere will not be peer review.

– Images in Clinical Radiology are short(max. 1 typed page) case reports designedto illustrate with max. 3 figures a specificentity. The report should not includeabstract nor discussion but consist of asynthetic description of the clinical andradiological features as well as the finaldiagnosis and one major reference.Technical notes are short descriptions of aspecific technique, procedure or equipmentof interest to radiologists. Technical notesmay originate from radiologists havingexperience of the item presented or fromcommercial firms (these should contact theEditorial Office to obtain specific guidelinesfor publication). The manuscript lengthshould be inferior to 1 typed page, originallanguage should be English, the manu-script may be accompanied by maxi mum1 b/w figure, and include one major refer-ence.

– Book reviews should be limited to onetyped page, mention full references of thebook, including number of pages, of illus-trations (when available), and price. Theauthor should specify to whom the book isintended and give a personal appreciation.They will be publish ed with the initialletters of the signature.

(continued on p. VIII)

Editor: J. Pringot

Consulting Co-Editor: M. Castillo (USA)

Managing Editor: P. Seynaeve

Editorial Board: F. Avni, L. Breysem, N. Buls,B. Coulier, B. Daenen, E. Danse, H. Degryse,P. Demaerel, B. Ghaye, J. Gielen, P. Habibollahi,N. Hottat, M. Laureys, F. Lecouvet, M. Lemmerling,B. Lubicz, J.F. Monville, T. Mulkens, J.F. Nisolle, B. Opde Beeck, R. Oyen, S. Pans, V.P. Parashar (USA),P. Parizel, P. Peene, H. Rigauts, N. Sadeghi, P. Simoni,S. Sintzoff Jr, A. Snoeckx, J. Struyven, H. Thierens,P. Van Dyck, F. Vanhoenacker, Ph. Van Hover,J. Verschakelen, K. Verstraete.

Royal Belgian Society of Radiology:Http://www.rbrs.org

President: R. Hermans

Vice-President: D. Henroteaux

Past-President: J.F. De Wispelaere

General Secretaries: M. Lemort, J. Verschakelen

Meeting Secretaries: M. Spinhoven, Y. Lefebvre

Treasurers: D. Brisbois, A. Van Steen

Coordinator of continuing education: G. Villeirs

Coordinators of professional defence: C. Delcour,D. Bielen

Webmasters: J. de Mey, J. Struyven


1. NAAM VAN HET GENEESMIDDEL: MultiHance, 0.5 M oplossing voor injectie. 2. KWALITATIEVE EN KWANTITATIEVE SAMENSTELLING: 1 ml oplossing voor injectie bevat: 334 mg gadobeenzuur (0,5 M) als het dimeglumine-zout [gadobeendimeglumine 529 mg = gadobeenzuur 334 mg + meglumine 195 mg]. Voor hulpstoffen, zie 6.1.3. FARMACEUTISCHE VORM: Oplossing voor injectie. Heldere waterige oplossing, afgevuld in kleurloze glazen flacons. Osmolaliteit bij 37 ºC: 1,97 osmol/kg. Viscositeit bij 37 ºC: 5,3 mPa.s. 4. KLINISCHE GEGEVENS: Therapeutische indicaties: Dit geneesmiddel is uitsluitend bestemd voor diagnostisch gebruik. MultiHance is een paramagnetische contrastvloeistof die wordt gebruikt voor de magnetische resonantie tomografie (MRI) geïndiceerd voor: MRI van de lever voor de detectie van focale leverlaesies bij patiënten met bekende of verdachte primaire leverkanker(b.v. hepatocellulair carcinoom) of metastasen. MRI van de hersenen en het ruggenmerg, waar het de detectie van laesies verbetert en aanvullende diagnostische informatie kan geven op de informatie uit de niet contrast-versterkte MRI. Contrast-versterkte MR-angiografie (MRA) bij patiënten met verdachte of bekende vasculaire ziekten van de abdominale of perifere arteriën. Dosering en wijze van toediening: MRI van de lever: de aanbevolen dosis MultiHance bij volwassenen bedraagt 0,05 mmol/kg lichaamsgewicht, hetgeen overeenkomt met 0,1 ml/kg van de 0,5 M oplossing. MRI van de hersenen en het ruggenmerg: de aanbevolen dosis MultiHance bij volwassenen is 0,1 mmol/kg lichaamsgewicht hetgeen overeenkomt met 0,2 ml/kg van de 0,5 M oplossing. MRA: de aanbevolen dosis MultiHance bij volwassenen is 0,1 mmol/kg lichaamsgewicht hetgeen overeenkomt met 0,2 ml/kg van de 0,5 M oplossing. MultiHance moet onmiddellijk voor het gebruik in de injectiespuit worden opgezogen en mag niet worden verdund. Eventuele ongebruikte restanten contrastvloeistof moeten worden vernietigd, en mogen niet worden gebruikt voor ander MRI onderzoek. Om de mogelijke risico’s van extravasatie van MultiHance in het spierweefsel te voorkomen dient men erop toe te zien dat de i.v. naald of canule zorgvuldig in de vena wordt aangebracht. Lever en hersenen en ruggenmerg: de oplossing dient intraveneus te worden toegediend als bolus of als langzame injectie (10 ml/min.). MRA: de oplossing dient intraveneus als een bolus injectie te worden toegediend, handmatig of gebruikmakend van een automatisch injecteersysteem. Na de injectie dient een spoeling met fysiologische zoutoplossing plaats te vinden. Post-contrast tomogrammen acquisitie:

De veiligheid en de werkzaamheid van MultiHance zijn niet vastgesteld bij patiënten beneden 18 jaar. Het gebruik van MultiHance bij deze patiëntengroep wordt derhalve niet aanbevolen. Contra-indicaties: MultiHance dient niet te worden toegepast bij patiënten met een overgevoeligheid voor één van de bestanddelen. MultiHance mag eveneens niet worden toegepast bij patiënten die eerder allergische reacties of andere bijwerkingen ondervonden ten gevolge van andere gadoliniumchelaten. 5. HOUDER VAN DE VERGUNNING VOOR HET IN DE HANDEL BRENGEN: Bracco Imaging Deutschland GmbH, Max-Stromeyer-Straße 116, 78467 Konstanz, Duitsland.6. NUMMER VAN DE VERGUNNING VOOR HET IN DE HANDEL BRENGEN: MultiHance5 ml: BE199963, MultiHance 10 ml: BE199972, MultiHance 15 ml: BE19998, MultiHance 20 ml: BE199997. 7. DATUM VAN EERSTE VERLENING VAN DE VERGUNNING/HERNIEUWING VAN DE VERGUNNING: Datum eerste verlening van de vergunning: 22 juli 1997. Datum laatste renewal: 21 juli 2007. 8. DATUM VAN HERZIENING VAN DE TEKST: Augustus 2008. Goedkeuringsdatum: 09/2008.9. AFLEVERINGSWIJZE: Geneesmiddel op medisch voorschrift.

1. DENOMINATION: MultiHance 0,5 mmol/ml solution injectable. 2. COMPOSITION QUALITATIVE ET QUANTITATIVE: MultiHance 0,5 mmol/ml solution injectable. COMPOSITION QUALITATIVE ET QUANTITATIVE : 1 mL de solution contient : acide gadobénique 334 mg (0,5 M) sous forme de sel de diméglumine. [529 mg de gadobénate de diméglumine = 334 mg d’acide gadobénique + 195 mg de dimglumine]. Pour les excipients, cf. 6.1. 3. FORME PHARMACEUTIQUE: Solution injectable. Solution aqueuse limpide, incolore, remplie dans des flacons de verre incolore. Osmolalité à 37°C : 1,970 Osmol/kg. Viscosité à 37°C : 5,3 mPa.s.4. DONNEES CLINIQUES: Indications thérapeutiques: Ce médicament est à usage diagnostique uniquement. Produit de contraste paramagnétique utilisé dans l’imagerie par résonance magnétique (IRM) et indiqué dans : IRM du foie pour la détection des lésions hépatiques lorsqu’un cancer hépatique secondaire ou primitif (carcinome hépatocellulaire) est suspecté ou connu. IRM du cerveau et de la moelle épinière où il améliore la détection des lésions et apporte des informations diagnostiques supplémentaires comparativement à une IRM sans produit de contraste. Angiographie par résonance magnétique (ARM) où il améliore l’exactitude diagnostique pour la détection de la maladie vasculaire sténo-occlusive cliniquement significative lorsqu’une pathologie vasculaire des artères abdominales ou périphériques est suspectée ou connue. Posologie et mode d’administration: IRM du foie: La dose recommandée chez l’adulte est de 0,05 mmol/kg de poids corporel, soit 0,1 ml/kg de la solution 0,5 M. IRM du système nerveux central: La dose recommandée chez l’adulte est de0,1 mmol/kg de poids corporel, soit 0,2 ml/kg de la solution 0,5 M. ARM: La dose recommandée chez l’adulte est de 0,1 mmol/kg de poids corporel, soit 0,2 ml/kg de la solution 0,5 M. MultiHance doit être introduit dans la seringue immédiatement avant l’injection et ne doit pas être dilué. Tout reliquat éventuel doit être jeté et ne doit pas être utilisé pour d'autres examens IRM. Pour diminuer le risque d’extravasation de MultiHance dans les tissus mous environnants, il est conseillé de s’assurer de la bonne disposition de l’aiguille ou de la canule dans la veine. Foie et système nerveux central : le produit doit être administré par voie intraveineuse soit en bolus soit en injection lente (10 mL/min). ARM: le produit doit être administré par voie intraveineuse en bolus, soit manuellement soit à l’aide d’un injecteur automatique. L’injection doit être suivie d’un bolus de chlorure de sodium à 0,9%. Acquisition des images post-contraste:

La sécurité d’emploi et l’efficacité de MultiHance n’ont pas été établies chez les sujets de moins de 18 ans. Par conséquent, l’utilisation de MultiHance dans cette population n’est pas recommandée. Contre-indications: MultiHance est contre-indiqué chez les patients présentant une hypersensibilité à l’un de ses constituants. MultiHance ne doit pas être utilisé chez les patients ayant des antécédents d’allergie ou d’effet indésirable liés à d’autres chélates de gadolinium. 5. TITULAIRE DE L’AUTORISATION DE LA MISE SUR LE MARCHE: Bracco Imaging Deutschland GmbH Max-Stromeyer-Straße 116, 78467 Konstanz Allemagne. 6. NUMERO(S) D’AUTORISATION DE MISE SUR LE MARCHE: MultiHance 5 ml: BE199963, MultiHance 10 ml: BE199972, MultiHance 15 ml: BE199981, MultiHance 20 ml: BE199997. 7. DATE DE PREMIERE AUTORISATION/DE RENOUVELLEMENT DE L’AUTORISATION: Date de première autorisation: 22 juillet 1997. Date de dernier renouvellement: 21 juillet 2007. 8. DATE DE MISE A JOUR DU TEXTE: Août 2008. Date d’approbation: 09/2008. 9. STATUT LEGAL DE DELIVRANCE: Médicament soumis à préscription médicale.

Lever

Hersenen en ruggenmerg

MRA

Onmiddellijk na een bolus injectie.

Tussen de 40 en 120 minuten na de injectie, afhankelijk van de individuele tomografische behoefte.

Dynamische tomografie:

Vertraagde tomografie:

Tot 60 minuten na toediening.

Onmiddellijk na toediening, met scan vertraging die op basis van de testbolus of automatische bolus detectie techniek wordt berekend.Indien een automatische contrastdetectie puls-sequentie niet wordt gebruikt voor bolus timing, dan dient een test bolus injectie <2 ml van de oplossing gebruikt te worden om de geschikte scan vertraging te berekenen.

Foie

Système nerveux central

ARM

Immédiatement après l’injection en bolus

Entre 40 et 120 minutes après l’injection (IRM retardée), en fonction du type d’imagerie nécessaire

Imagerie dynamique

Imagerie retardée

Jusqu’à 60 minutes après administration

Immédiatement après l’administration, avec un délai d’acquisition calculé sur la base du bolus test ou par la technique de détection automatique du bolus.Si la détection automatique du contraste en séquence pulsée n’est pas utilisée, alors l’injection d’un bolus test de 2 mL de produit au maximum devra être réalisée pour calculer le timing d’acquisition adéquat.

www.bracco.com

MR Angiography with MultiHance® :

• MultiHance® is now also indicated for Contrast-enhanced MR-angiography where it improves the diagnostic accuracy for detecting clinically significant steno-occlusive vascular disease in patients with suspected or known vascular disease of the abdominal or peripheral arteries.(1)

• The recommended dose of MultiHance® injection in adult patients is 0.1 mmol/kg body weight. This corresponds to 0.2 mL/kg of the 0.5 M solution.(1)

Reference: 1. Multihance SpcPlease consult locally approved information.

MH_

MRA

_3-0

3-08

ADV

detection of significant steno-occlusive disease of the abdominal or peripheral arteries

– Opinion articles are special articles dealingwith controversial topics of specific concernto radiologists. They may include tables andfigu res, and must provide a references list.

– Letters to the Editor and their replies presentobjective and useful criticism over an articlepublished in one of the lest four issues of theJBR-BTR. They will be published with thename and address of the author. Referencesare necessary, tables and figures are acceptedbut acknowledgements are not appropriate.

– Meeting news are reports of national orinternational congresses, symposia andmeetings of radiology. Full references of themeeting, including date, place and summaryof the main topics should be mentioned. Textshould be kept to major facts. Figures, tables,refe rences and ac knowledgements shouldnot be included.

– In memoriams and News are essentiallydealt with in the Editorial Office. Con -tributions may however be submitted underthe form of letters addressed to the EditorialOffice which will check the adequacy of theinformation.

General Guidelinesfor Papers

Manuscript Requirements

Send 3 copies of the manuscript, includingtables and figures (1 original set + 2 copies ofthe text and 2 original sets + 1 copy of the illus-trations) and the corresponding diskette (seebelow Instructions for Electronic ManuscriptSubmission). In keeping with sound environ-mental and economic principles, the JBR-BTRencourages all authors to submit manuscriptsprinted on both sides of the page. The practicenot only will save paper but also will reduce theprice of postage required to mail the manu-script. Note that failure to provide an electronicversion of manuscript will result in costs to becharged to the author. The original set shouldmention the personal references of the author.The copies should be nameless (including thefigures). Each section of the manuscript beginson a new page in the following order: titre pagerunning title page + key-words, abstract, text,acknowledgements, references, tables and cap-tions for illustrations. Use English or one of thenational languages. In the latter case, anEnglish version of the titre, abstract, key-words,legends must neces sarily be provided. Notethat the author will be charged the costs oftranslation.Submitted manuscripts may not be covered bya previous copyright. The author will be heldresponsible for any litigation that might posse-bly ensue. Manuscripts will be submitted to areview Committee whose decision is final.Authors are usually notified within eight weeksas to the acceptability of their paper.

Instructions for Electronic Manuscript Submission

Please send an electronic version of your manuscript either a floppy disk or a CD-rom inconjunction with the traditional paper versionor separately as an e-mail with attachments [email protected]. Please follow the general instructions on style/arrangements and, in particular, the referencestyle as given in the present “Instructions toAuthors”.Note, however, that while the paper version ofthe manuscript must be presented in the tradi-tional double spaced format, the electronic ver-sion will be typeset and should not contain anyextraneous instructions.For exemple: use hard carriage returns only atthe end of paragraphs and display lines (e.g.titles, subheadings); do not use an extra hardreturn between paragraphs; do not use tabs orextra space at the start of a paragraph or for listentries; do not indent runover lines in refer-ences; turn off line spacing; turn off hyphen-

ation and justification; do not specify pagesbreaks, page numbers, or headers; do not spec-ify typeface. Care should be taken to correctlyenter “one“ (1) and longer case “el“ (l), as wellas “zero” (O) and capital “o“ (O).Illustrations and tables will be handled conven-tionally. However, figures and table legendsshould be included at the end of the electronicfile. Nonstandard characters (Greek letters,mathematical symbols, etc.) should be codedconsistently throughout the text. Please make alist of such characters and provide a listing ofthe codes used.Note that disks and CD-roms will not bereturned to authors.

Title

– Keep it short and relevant.– Title must be followed by the surname(s) and

first name(s) (for computer processing pur-poses, 2 initial letters only will be admitted)of all authors.

– The position held by the authors, their aca-demic degrees, the name of the institution towhich they belong and/or from which thearticle originates and the name of the depart-ment Head (if required) must be indicated atthe bottom of the first page.

– The titIe in the national language of the textshould be noted after the key-words.

– A running title in English should be providedon a separate page.

– Two copies of a blind titre page are included,giving only the titre (without the authorsnames) for use in the review process.

Abstract and Key-words

Written in English exclusively, the abstractshould head the manuscript and summarize theaim, the methods, results and conclusions. Itshould not exceed 200 words for major papersand 100 words for the other studies.No abbreviation or references are used in theabstract.Three to six key-words from the terms usedin the JBR-BTR Subject Index (and/or themost recent three-year cumulative index ofRadiology) should be listed.

Text

The text should be clearly divided in thefollowing sections: introduction, material andmethods, results, discussion and conclusion.Abbreviations should be defined in anexplanato ry note before being used as such.The definitive text should be typed on one sideonly of a standard size (A4) typewriting paper,in doublespacing throughout and have at least3 cm margins.The manuscript should not be longer than16 typewritten pages, including references andsummary for a major paper unless otherwiseagreed by the Editor (one typewritten page isequivalent to approximately 250 words) and nolonger than 6 typewritten pages for the othertypes of work.

Specific guest editorials

Specific guest editorials are invited papers writ-ten by selected distinguished specialists. Theyshould summarize in concise the stase of theart in one specific field of medical imaging orrelated sciences in no more than 8 typewrittenpages, including either 1 table or illustration(drawing or graph). The bibliography should notexceed 12-15 recent and/or fundamental refer-ences.

References

References should be numbered consecutivelyin the order in which they appear in the text.Their number should be kept down to 20 formajor papers and 8 for case reports and otherpapers.

They should be given as follows:a) abridged titles of periodicals should conform

to those in the Index Medicus. All authors arelisted when six or fewer; when seven ormore authors, the first three are listed, fol-lowed by “et al.”.Ex.: Bomsel F., Couchard M., Henry E.:

Respiratory distress in the newborn.J Belge Radiol, 1980, 63: 89-107.

b) in the case of books, references should indi-cate: the authors of the chapter, the title ofthe chapter, the title of the book, the editor(s),publisher, edition, city, year and specificpages.– Ex.: Isengrin P.: Radiologie stomacale. 3e

édition, Arscia, Bruxelies, 1974, p. 22.– Ex.: Weinstein L., Swartz M.N.: Patho genic

properties of invading micro orga -nisms. In: Pathologic physiology:mechanisms of disease. Edited bySodeman W.A. Jr, Sodeman W.A.,Cds. Printed by Saunders,Philadelphia, 1974, pp. 457-472.

Quote the name and address of the author towhom the reprints will be sent, at the end of thereferences.

Corresponding author and Reprints

The name and address of the correspondingauthor to should be mentioned affer thereferen ces.25 reprints, are offered free by the JBR-BTR.

Tables

Tables should be presented on a separate pageand numbered in Roman numerals in the orderin which they are cited in the text. They shouldhave an English title and legend. Abbreviationsshould be defined in a foot note.Only commonly admitted measurement stan-dards should be used.

Figures and Legends

Illustrations should be restricted to the mini-mum required to show the essentiel featuresdescrib ed in the paper. They must be mentionedin the text.Two complete unmounted sets of original fig-ures in labeled envelopes should be provided.All figu re parts relating to one patient shouldhave the same figure number. Use capital let-ters A, B, C, in the ieft longer corner to distin-guish figures from one set.Figures should be marked on the back with anarabic numeral indicating the sequence inwhich they are to be referred to, with a lightlypencilled “top“ indicating their topside and thename of the first author. Never use ink on frontor back of any figure. For uniformity purposes,points of interest should be showed on the fig-ures with removable (Letraset) arrows or/andletters, or should be indicated on an accompa-nying photocopy of the figures, in order toenable our services to use their own characters.Images should be uniform in size and magnifi-cation.1. RadiographsCost and number: depending on the lengthof the manuscript (a total of 2 to 6 times 14 �15 cm is availabie free of charge).Presentation: glossy prints, no larger than18/24 cm.It is advisable for films to be centered on thezone of major interest and they should begrouped. Arrows should indicate the importantpoints.2. Photographs and drawingsFour-colour illustrations will be printed at theexpense of the authors.Drawing and graphs should be of professionalquality. They should illustrate — not duplicate— data given in the text.Legends are typed separately and preceded bythe number of the corresponding illustration.Note that illustrations will not be returned toauthors.

(*) Pr J. PRINGOT, Avenue W. Churchill 11/30, B-1180 Bruxelles, Belgique (tél.: 02-374.25.55, fax: 02-374.96.28, e-mail: [email protected]).


At GE, we are committed to helping increase access to healthcare while improving its quality and lowering its cost. Just like physicians everywhere. So by investing in new innovations, we are empowering the world’s healthcare professionals to do what they do best: caring for patients around the world. Every day, doctors are bringing better health to more people — and GE Healthcare technologies are behind them.

© 2010 General Electric Company

GE Healthcare

GE_Hmag_Ads_1029.indd 3 10/29/10 5:38 PM

When Dr. Emily Chan walked into the operating room,she already knew what to expect—she had, after all,been following the progress of her patient’s mitral valvedisease for years.

Utilizing volumetric imaging and volume color Dopplerquantification through eSie PISA™ volume analysis, Dr.Chan was able to confidently proceed with surgery forher patient’s asymptomatic mitral valve regurgitation.Measurements of the effective regurgitant orifice area,

Answers for life.

www.siemens.com/ultrasound

regurgitant volumes, and regurgitant fractions madewithout 2D geometric assumptions provided the extrainsight and assurance she needed to schedule the surgery.

Siemens develops ultrasound solutions that provide vitalinformation about the heart: detailed spatial resolutionof intricate structures, real-time visualization of bloodflow, and full-volume images made without stitchingor gating. We pioneer ultrasound so that you can treatpatients with confidence.

Siemens. The Ultrasound Pioneers.

A91US-9226-A1-4A00

© 2012, Siemens Medical Solutions USA, Inc.

The first time she touched his heart,she wasn’t wearing gloves.

AD HEALTHCARE 4/2012_Opmaak 1 10/04/12 10:16 Pagina 1

Best practice for patients sufferingfrom end-stage renal disease waitingfor kidney transplantation or not ishemodialysis via a native arterio -venous fistula created surgically intheir non-dominant wrist. Most dysfunctions of this type of fistulaare linked to venous steno-occlusivelesions but, sometimes, the problemis due to a deficiency in the arterialblood supply as is the case, in partic-ular, with pre-anastomotic occlu-sions.

A pre-anastomotic arterial tightstenosis or occlusion will generallyentail a thrombosis of the drainingvein of the fistula. If this thrombosisis not treated rapidly, it will proveextremely pernicious for the venousendothelium and will alter the permeability of the shunt in the longterm.

In some circumstances, in spite ofa major or complete pre-anastomot-ic obstacle, the venous segment ofthe fistula may remain permeablethanks to the implication of arterialcollaterals and, in particular, the palmar arches. The blood flow sup-plied to the draining vein by these collaterals may even allow efficientdialysis without any concomitantdevelopment of a clinical steal phenomenon. The echo-Doppler(USD), 3D magnetic angiographic(3D MRA) and digital subtractionangiographic (DSA) characteristicsof these types of shunt are detailedin this paper, as well as a clinical

our Institution, we have been awareof the particulars of his shunt. It dis-plays indeed an uncommon feature:a juxta pre-anastomotic occlusion ofthe radial artery (Fig. 1) and a retro-grade feeding of its outflow vein viaradial, ulnopalmar and interosseousarterial collaterals. The diameter ofthe pre-anastomotic radial artery isreduced, considering it is a shuntfeeding artery, to 3 mm and theDoppler spectrum of the vesselshows a drop of the mean circulato-ry velocity to 20 cm/s. Subsequently,the artery blood flow is extremelydiminished at 90 mL/min (Fig. 2). Thepre-anastomotic radial arterial collat-erals, which will be shown on themagnetic documents, explain thepersistence of a positive diastolicflow and the absence of a “to-and-fro” type phenomenon as it can beobserved at the level of the acutelyoccluded arteries. The relatively

sign we have encountered in two ofthe three patients mentioned.

Case reports

Our first patient is a 48-year-oldman with end-stage renal diseasecaused by focal and segmental hyali-nosis who has been hemodialysedsince 1986 via a radiocephalic fistulain his left wrist. The dialysis sessionshave always been unremarkable.Since 2003, when we established anannual systematic monitoring pro-gram of dialysis fistulas by USD in

JBR–BTR, 2013, 96: 55-64.

A SPONTANEOUS PRE-ANASTOMOTIC OCCLUSION DOES NOT NECES-SARILY IMPAIR FOREARM NATIVE DIALYSIS FISTULAS: ECHO-DOPPLER,3D MR ANGIOGRAPHIC AND DIGITAL SUBTRACTION ANGIOGRAPHICIMAGINGN. Verbeeck1, J.C. Pillet2, F. Prospert3, D. McIntyre4, S. Lamy4

Renal transplantation is the choice treatment of end-stage renal disease. When it is not indicated or not immediate-ly feasible, hemodialysis must be performed, preferably via a native arteriovenous fistula in the forearm.A pre-anastomotic occlusion of this type of fistula is often accompanied by a thrombosis of its draining vein. In someinstances, the venous segment may remain permeable thanks to the development of arterial collateral pathways andmay even allow efficient dialysis without any clinical syndrome of distal steal.We present the echo-Doppler, magnetic and angiographic characteristics of three of these collateralized shunts thathave remained functional, in one of the cases following a percutaneous dilation.

Key-word: Fistula, arteriovenous.

From: 1. Dpt of Radiology, 2. Dpt of Vascular Surgery, 3. Dpt of Nephrology, 4. Dpt ofUrology, Centre Hospitalier de Luxembourg, Luxembourg, Grand Duchy ofLuxembourg.Address for correspondence: Dr N. Verbeeck, M.D., Service de Radiologie, CentreHospitalier de Luxembourg, rue Barblé 4, L-1210 Luxembourg, Grand Duchy ofLuxembourg. E-mail: [email protected]

Fig. 1. — Color Doppler of the pre-anastomotic radial arterywith partial signal void due to parietal calcifications (short thinarrows), of the arterial occlusion (long thin arrow) and of thefree venous side of the shunt (thick arrow); colored spots in frontof the long thin arrow are due to small caliber muscular collat-erals of the proximal radial artery.

verbeeck-_Opmaak 1 25/04/13 15:28 Pagina 55

hypertrophic ulnar and interosseousarteries feeding the post-anastomot-ic radial artery in a retrograde fash-ion display logically increased, lowresistive flows (Fig. 3A and B). Thepost-anastomotic radial artery flux isreversed as expected, positive atdiastole and emphasized with a400 mL/min flow measured at thelevel of the anatomic snuffbox(Fig. 4). At the anastomosis betweenthe post-anastomotic radial arteryand the draining vein, we observe a3 mm diameter substenosis with alocal acceleration at 160 cm/s(Fig. 5). The venous outflow at midforearm proves quite correct at630 mL/min (Fig. 6). The aforemen-tioned substenosis will be moni-tored by USD half-yearly and willundergo treatment only if itbecomes significant and alters the

Clinically, and rather strangely (cf.infra), an auscultation of the fistulaproves uneventful: the loudest bruitis heard at the level of the anastomo-sis and a decreased bruit is per-ceived at mid forearm level. No bruitis identified at the level of the palmof the hand.

Our second patient is a 31-year-old man who benefited from a radio-cephalic fistula in his left wrist in1988. A juvenile nephronophtisis hadcaused his end-stage renal disease.The characteristics of his shunt havebeen known since 2003 (cf. supra).He too displays, at USD, a juxta pre-anastomotic occlusion of the radialartery in addition to a high bifurcationof the brachial artery, an anatomicvariant which is nowadays consid-ered as a relative contraindication tothe creation of a distal fistula. The

quality of the dialysis sessions,which is not the case presently. Wealso have access to a sequential“TRICKS” (cf. Discussion) 3D MRAfor the same patient. An early phaseconfirms the abnormally thinappearance of the pre-anastomoticradial artery and its distal occlusion.It also pinpoints the relative hyper-trophy of the ulnar and interosseousarteries that feed the fistula retro-gradely via the muscular collaterals,the palmar arches, and the post-anastomotic radial artery (Fig. 7). Animmediately subsequent sequencedisplays the pre-anastomotic radialmuscular collaterals very preciselyas well as the substenosed “caudal”anastomosis, which is clearly over-estimated. Moreover, it confirms theperfect patency of the caudal portionof the draining vein (Fig. 8).

56 JBR–BTR, 2013, 96 (2)

Fig. 3. — Ulnar (A) and interosseous (B) triplex: the enhanced flows (thick arrows) and the low resistive Doppler waves (thinarrows).

Fig. 2. — Pre-anastomotic radial artery triplex: the thin dia -meter (3 mm) of the vessel (thick arrow), its reduced meanvelocity at 20 cm/s (long thin arrow) and its low flow at90 mL/min (short thin arrow).

Fig. 4. — Triplex of the anatomic snuffbox, the hand being atleft: the inverted flow (positive, in the direction of the probe) inthe post-anastomotic radial artery, at 400 mL/min (arrow).

A B


flows of his ulnar and interosseousarteries are markedly emphasizedwith a pronounced diastolic compo-nent. The muscular collaterals areclearly identified (Fig. 9A) and theirflows display identical features(Fig. 9B). An inverted post-anasto-motic radial arterial flow, measuredat 1.2 L/min, confirms the blooddiversion (Fig. 10). The venous out-flow in the forearm is excellent at940 mL/min (Fig. 11). The correlationwith the “TRICKS” 3D MRA imagesis very good. Please note that thiswas our first test, performed in 2008,with tuning parameters that had notyet been fully optimized. Whatever itbe, we can visualize quite perfectlythe thin radial artery with its occlud-ed end (Fig. 12), the ulnar andinterosseous collaterals, and thepost-anastomotic radial artery thatfeeds the venous outflow segment ina retrograde fashion (Fig. 13). On aclinical level, the auscultation of theshunt reveals a maximum bruit atthe level of the anastomosis, as ithappens classically. Nevertheless,and contrary to the “normal” fistulasthat reveal a softened bruit at midforearm and an absence of bruit atpalmar level, an unequivocal palmarmurmur is detected here. It is lessstrong than at the anastomosis butits intensity is superior to that of thebruit perceived at the level of themid radial vein.

Our last patient is a 50-year-oldman who has developed an end-stage renal disease caused by extramembranous glomerulonephritis.He was 30, when a radiocephalic fis-tula was created surgically in his leftwrist. Since his fistula had maturedrapidly, he was dialyzed uneventfullyuntil recently when problems of flow

DIALYSIS FISTULAS — VERBEECK et al 57

Fig. 8. — A few seconds later, another“TRICKS” sequence clearly depicts thepre-anastomotic radial artery occlusion(red circle), the muscular arterial collater-als (white arrows), some of which beingof pre-anastomotic radial origin (yellowarrow), the post-anastomotic substeno-sis, which is over-estimated (red arrow),and the patent venous outflow tract (bluearrows).

Fig. 5. — Triplex view of the substenosed anastomosisbetween the post-anastomotic radial artery and the drainingvein of the shunt: 3 mm residual lumen (thick arrow) with a localacceleration at 160 cm/s (long thin arrow).

Fig. 6. — Triplex of the excellent, cardiopetal, radial vein flow,at 630 mL/min (arrow).

Fig. 7. — Early “TRICKS” magneticsequence: the thin pre-anastomotic radialartery (long white arrow) and its distalocclusion (red arrow), the enlarged ulnar(thick white arrow) and interosseous (yellow arrow) arteries with the palmararches (green arrow) retrogradely feed-ing the post-anastomotic radial artery(blue arrow).


were noticed during hemodialysissessions. Since 2003 (cf. supra), wehave been aware of the peculiars ofhis fistula, i.e. and once again a pre-anastomotic occlusion of the radial

artery with blood diversion along theulnar and interosseous arteries. AUSD reveals, besides the well-known pre-anastomotic radial occlu-sion and blood diversions, a signifi-

58 JBR–BTR, 2013, 96 (2)

Fig. 9. — Color Doppler at the level of the anastomosis zone(A): the muscular collaterals which are difficult to distinguishfrom the stardust artifact in this single plane view.Triplex of a muscular arterial collateral (B): identical systolo-

diastolic flow (arrow) to the one of the ulnar artery.

Fig. 10. — Triplex of the radial artery at the level of the snuff-box (the wrist being at left): retrograde, cardiopetal flux at1.2 L/min (arrow).

Fig. 11. — Triplex of the radial draining vein of the fistula:excellent flow at 940 mL/min (arrow).

B

A

Fig. 12. — Early “TRICKS” magneticsequence: the thin proximal radial artery(white arrow), its pre-anastomotic occlu-sion (red arrow) and the early filling ofthe draining radial vein (blue arrow). Thespiral signal between the arterial occlu-sion and the draining vein is due to tinymuscular arterial collaterals (yellowarrow).


cant stenosis at the junctionbetween the post-anastomotic radialartery and the radial draining veinwith a velocity increased to morethan 5 m/s (Figs. 14A and B). This

(Fig. 15). Since a percutaneous treat-ment can possibly be suggested, thepatient does not undergo 3D MRAbut is directed to the angiographysuite. The prograde left brachialartery puncture confirms the pre-anastomotic radial occlusion andidentifies the ulnar and interosseouscollaterals (Fig. 16). A slightly laterphase demonstrates the retrogradeopacification of the post-anastomot-ic radial artery and its “caudal”stenosis; moreover, this phaseensures that the first centimeters ofthe radial draining vein are patent(Fig. 17). A second brachial arterialinjection, focusing the images on thehand, identifies the arterial muscularand palmar collaterals very precisely(Fig. 18); the same happens with theselective ulnar injection, with aneven greater precision (Fig. 19). Anopacification of the radial artery atmid forearm displays the occlusionquite clearly and objectifies the muscular collaterals of the vessel

severe “caudal” stenosis entails avenous outflow drop to 250 mL/min,which is a clearly insufficient valueexplaining the difficulties encoun-tered during the dialysis sessions


Fig. 14. — Color Doppler at the level of the anastomosisbetween the post-anastomotic radial artery and the radial vein(A) reveals a tight stenosis (arrows).Triplex of the severe stenosis (B): as high as 6 m/s speeds can

be depicted (arrow); aliasing (star) is inevitable with this high-frequency probe (Nyquist-Shannon theorem).

Fig. 13. — Another “TRICKS” view, inan oblique plane, a few seconds later: theenlarged ulnar (red arrows) andinterosseous (yellow arrow) arteries, thepalmar arches (green arrow), the post-anastomotic radial artery (white arrow)and the draining vein (blue arrow).

Fig. 15. — Due to the caudal arterio-venous stenosis, the flowof the draining radial vein drops to 250 mL/min (arrow) and thisis not enough for correct dialysis (triplex view).

B

A


that feeds retrogradely its distalcounterpart which has remained permeable (Fig. 20). We then decideto treat the “caudal” anastomoticstenosis in order to restore a correctvenous outflow; for that purpose we

angiographic result (Fig. 22). A USDcheck performed three months afterthe intervention displays the patencyof the dilated zone measuring 4 mmin diameter (Fig. 23A) and an excel-lent downstream venous outflow at

puncture the post-anastomoticdraining vein in the retrograde direc-tion and get through the obstaclewith a guide wire. A 5 mm diameterdilation balloon is then inflated(Fig. 21) with a good post-procedural

60 JBR–BTR, 2013, 96 (2)

Fig. 17.— Same DSA sequence, two seconds later: retrogradefilling of the post-anastomotic radial artery (thick arrow) and ofits cranial stenosis (circle); the long arrows indicate the drainingradial vein.

Fig. 19. — Selective ulnar artery prograde injection (gray cir-cle): the direction of the flow (curved arrow) through the palmar arches and the millimetric muscular arterial branches (stars).

Fig. 16. — DSA (prograde injection in the brachial artery): thepre-anastomotic radial arterial occlusion (long white arrow) withthe enlarged ulnar and interosseous arteries (thick black andwhite arrows, respectively).

Fig. 18.— A second brachial artery injection clearly shows thepalmar arches (arrows) and the ulno-interosseous muscular collateral arteries (stars).


900 mL/min (Fig. 23B). Finally, acareful auscultation of the fistulareveals, just like in the secondpatient, a definitive palmar murmurwhich intensity is higher than theone detected at mid forearm.

consequence, to higher rates ofmetabolic and vascular alterationsthat prove toxic for the renal func-tion, such as diabetes and arterialhypertension (1).

Renal transplantation is themethod of choice for the treatmentof end-stage renal disease. When it isnot indicated or not immediately fea-sible, scientific consensus recom-mends hemodialysis via a nativearterial fistula constructed surgicallyin the non-dominant forearm, a tech-nique initiated in 1966 by Brescia,Cimino and Appell. Please note thatif the surgeon questions the reliabil-ity of the vascular network beforecreating the shunt, they can behelped by the radiologist, who willperform a mapping and a functionalUSD (2). Surgical fistulas in the armare a second choice. Indeed, if theymature faster, they are shorter-livedand generate more excessive flows,ischemias and aneurysmal transfor-mations. Fistulas created with apolytetrafluoroethylene (PTFE) graftshould be a third choice only. Theyentail real infection risks and theirrate of stenosis, in particular at thesite of the prosthetic venous anasto-mosis, is very high. The doublelumen catheter should only be usedin case of emergency or as a lastsolution because of its numerousinfectious and thrombotic complica-tions (3). Also note that peritonealdialysis can be an alternative inselected cases and for a rather shortperiod (1).

Discussion

Nowadays, the number of end-stage renal disease patients isincreasing steadily. This increase isdue to population aging and, as a


Fig. 22.— Prograde brachial artery injection, showing a betterfilling of the radial draining vein (arrows), after dilation.

Fig. 20. — Selective radial artery injection at mid-forearm(gray circle): the artery pre-anastomotic occlusion (long arrow)and its muscular arterial collaterals (stars) feeding the vessel’scaudal counterpart, which is difficult to see. The thick arrow indi-cates the venous outflow.

Fig. 21.— Venous retrograde approach with a 7F sheath (thickarrow): a 0.018 guide wire is passed through the stenosis. Thegray circle indicates the 5 mm-thick balloon biting the stenosis,during the first phase of inflation.


So, efficient dialysis must ideallybe ensured by wrist fistulas of theradiocephalic side-to-end type,though other arteriovenous combi-nations are possible. In order toachieve efficient blood purification,the draining vein must have a dia -meter of at least 6 mm, be located ata maximal depth of 6 mm and thefistula flow must exceed 600 mL/min.The length of the vein to be punc-tured must be equal to 10 cm ortwice 4 cm at least (4). In our westerncountries we are used to waitinguntil the shunt has matured com-pletely, after about six weeks, beforeperforming the first punctures (1).

Any clinical anomaly, any difficul-ty in cannulating, inefficient bloodpurification or prolonged bleedingsafter hemodialysis must require acontrol USD to look for abnormali-ties within the shunt (1). Should thisexamination prove inconclusive, 3DMRA or even DSA can be performed.

frequently diabetic. Juxta pre-anas-tomotic stenoses or occlusions canalso be spotted quite easily (6, 7, 8).They are generally considered toresult from a technical surgical errorwhen they impair the shunt soonafter its construction (6).

A pre-anastomotic arterial occlu-sion may entail a thrombosis of thefistula venous segment. This throm-bosis must be treated without anydelay because the inflammatorycontact between the thrombus andthe wall of the vessel will exert a per-nicious effect on the permeability ofthe vein in the long term (1, 3). Theclot must be resected surgically orsucked up percutaneously and a newanastomosis must be constructedsome centimeters upstream (9).

In some instances, in spite of ajuxta pre-anastomotic tight stenosisor occlusion of the radial artery, thefistula will keep functioning thanksto the development of arterial collat-eral pathways, essentially the super-ficial and deep palmar arches, fed bythe ulnar artery, which supply thevenous outflow tract via a post- anastomotic radial artery invertedflux (10, 11, 12). This reversed feed-ing of the post-anastomotic radialartery is also ensured by small cal-iber muscular arterial branches ofulnar, radial or interosseous origin.The venous blood flow ensured bythe arterial collaterals sometimesremains sufficient (i.e. 600 mL/min atleast) to ensure adequate dialysiswithout any clinical distal steal. Suchuncommon asymptomatic cases area reason, together with that of morenumerous clinically “silent” venousstenoses which flow is also main-tained, which motivate, in ourInstitution, an annual USD assess-ment of the patients without any bio-logical anomaly during dialysis andwithout cannulation problems (6).We must notice however that a verycareful auscultation of the shuntsometimes enables the detection ofits anomaly: if, similarly to the casesof the radiocephalic fistulas withoutstenosis, the maximum bruit can beheard right above the anastomosis,in the presence of a pre-anastomoticobstacle, an “auscultatory interposi-tion” can be heard, in the sense thata palmar bruit appears whose inten-sity lies between the one audible atthe anastomosis and the one thatcan be perceived at mid forearm. Inone of our cases (case 1) we havenot been able to observe this signand we cannot offer any logicalexplanation for this situation.

These cases of fistulas that havekept functioning in spite of sponta-

Detectable lesions are essentiallyintrinsic venous stenoses generatedby turbulences and repeated punc-tures or resulting from former centralcatheterizations (1). As a reminder,note that a venous stricture is considered significant in a dialysisfistula if it reduces the lumen of thevessel by more than 50% or if theresidual diameter of the vein is lessthan 2.7 mm (3, 5). USD proves par-ticularly successful in detectingextrinsic compressions, partialthromboses or central disorderslinked with the cardiac function. Onthe other hand, it is a bit less efficientthan 3D MRA or DSA to assesslesions of the central veins (6).

In some cases, the dysfunction ofthe shunt will be of arterial origin.Any type of arterial obstacle can bedetected by USD, 3D MRA or DSA:from the central stenoses, whoseorigin is rather atheromatous to themore distal ones, whose etiology is

62 JBR–BTR, 2013, 96 (2)

Fig. 23. — B-mode of the dilated “caudal” anastomosis (A)(red arrows), three months after intervention: a correct diameterof 4 mm (thick white arrow) between the post-anastomotic radial artery (thin white arrow) and the first centimeter of thedraining vein (star)…allows an excellent venous outflow (B) (triplex view) at

900 mL/min (arrow) and so, correct dialysis.

B

A


neous pre-anastomotic occlusionshould be put in parallel with thosewhere the juxta pre-anastomoticobstacle is created surgically inorder to reduce the blood flux of theshunts in excess flow (13). Thanks tothis technique, the excess flow thatis detrimental, in the long term, forthe cardiac function will be curbedby ligating the pre-anastomotic radi-al artery after ensuring first, by USDfor instance, that the palmar archesare efficient and that the drainingvein does not display any stenosis.

Our three cases of fistulas withoutany associated clinical steal but withspontaneous juxta pre-anastomoticobstacle and “salvaging” arterial col-laterals occurred in relatively young(mean age at shunt creation: 19),non-smoking, non-diabetic patientswhose arterial networks were, inprinciple, in good shape. We canthen suppose that both the correctstate of the arterial system and thecongenital richness of its intercon-nections are prerequisites to this distinctive type of evolution.

USD is neither expensive nortraumatic. It is easily available anddetects pre-anastomotic obstaclesaccurately, as we have under-lined (3). It should be mainly per-formed with a high frequency(12 MHz) probe. Such an examina-tion being very observer-dependent,extreme care will be required for acorrect adjustment of the focal dis-tance and of the gains (in B-mode, inpulsed Doppler and in color Doppler)as well as of the Doppler angle ofinsonation (ideally between 30 and60°), of the size of the gate (i.e. 2/3 ofthe diameter of the vessel) and of thepulse repetition frequency (PRF).This must be done without anyinconsiderate pressure on the trans-ducer, especially in the venous seg-ment of the fistula (6). In case of pre-anastomotic arterial stenosis wevisualize the narrowing directly andwe detect a local increase of velocityto more than 3 m/s accompanied bya widening of the Doppler spectrumand an enhancement of the stardustartifact which is normally spottedaround the arteriovenous anasto-moses (5, 6). A pre-anastomotic radi-al arterial occlusion is clearly visibleand the Doppler displays adecreased circulatory velocity at thelevel of the mid artery whose out-flow has collapsed. The arterial flowimmediately upstream the obstacledoes not turn into a “to-and-fro”type as it can be observed at thelevel of the acutely occluded arteriesor at the neck of the false arterialaneurysms (14) because of the

the study of dialysis fistulas and theliterature does not mention any caseof spontaneous juxta pre-anasto-motic obstacle described by thismethod. A multisection angio-scan-ner study should certainly prove out-standing in these peculiar examplesbut it should be reserved to centersthat do not have an angio suitebecause of radiation exposure (7).

It is quite clear that DSA keeps itsplace in our diagnostic arsenal (1, 3).It is rather expensive and also moretraumatic, all the more since theusual retrograde venous accessremains more limited in our cases.Most often indeed the direct arterialaccess proves necessary in order toidentify blood diversions, amongothers ulnopalmar ones. Whatever itbe and thanks to its excellent spatialresolution, this examination enablesa perfect measurement of the inten-sity of the obstacles. The impressiveframe rates of present machinesmake it quite easy to quantify thebalance of flows. Possible thrombican be diagnosed too with, in thiscase, but it is also true for 3D MRA,inferior possibilities to those of aUSD, at least as far as the venoussystem is concerned. From time totime and in spite of the fast framerates of modern machines, preciseestimation of the fistula will be hampered by arteriovenous super-positions. Different angiographicincidences will then be most signifi-cant. Should the difficulty persist, anechography machine will be broughtinto the angio suite in order to solvethe problem quite easily. Let us notneglect the importance of the dilu-tion of the iodinated contrast product if a residual renal function isto be preserved (16).

The treatment of juxta pre-anasto-mosis occluded fistulas remains thearmed standby as far as there existsno significant clinical phenomenonof steal and as far as the venous out-flow enables efficient dialysis. Incases where the opposite is true, aswe mentioned above, a new anasto-mosis will have to be constructedsome centimeters upstream the for-mer one after a possible thrombosishas been treated (3, 9).

One of our three patients (case 3)presented with a pre-anastomoticocclusion next to a tight stenosis ofthe post-anastomotic radial arterywith, as a consequence, a weakvenous outflow, inadequate for dialysis. Basing ourselves onP. Bourquelot’s experience, we optedfor a percutaneous dilation of thestenosis, a simple gesture per-formed through venous retrograde

presence of the muscular collaterals.These arterial collaterals are easilydetected by color Doppler (theirsteady courses differentiate themfrom stardust artifacts) and a retro-grade flow can be identified at thelevel of the post-anastomotic radialartery. The condition of the venousdrainage must be scrutinized closely,of course, and its outflow can remainnormal. Please note that the bloodflow is calculated automatically inrecent machines by using the classi-cal formula: outflow (in mL/min) =average blood velocity x (πD²/4) × 60where D represents the vessel diam-eter in cm (6).

As far as macrocyclic chelates areused at a minimal dose in order toavoid a systemic nephrogenic fibro-sis and maintain a possible residualrenal function, the gadoliniumenhanced 3D MRA will prove almostas non traumatic as USD (15). Theformer is nevertheless more expen-sive and less available. On our 3Tesla MRI machine we use the TimeResolved Imaging Contrast KineticS(“TRICKS“, GE Healthcare) technique,with 3D sequential acquisition, com-bining good spatial (about 2 mm)and temporal (one acquisition everyseven seconds) resolutions. Theexamination is completed in minutesand identifies stenoses and blooddiversions well though it has a tendency to overestimate the for-mer (8). This tendency is, in ourexperience, less marked than whenthe magnetic technique of the Timeof Flight (“TOF”) is used without anycontrast material. If it proves moredelicate to detect venous thrombi inthe “TRICKS” sequences than in theUSD ones, our opinion is that theformer surpasses the latter for theclose analysis of the central veins.Finally, in the case of radiocephalicfistulas in the wrist, and as far as itconcerns the machine we use cur-rently, the size limit of the magneticstudy area (48 cm) often preventsvisualizing the entire fistula. Thiscompels us to perform two differentexaminations: one focusing on thethorax and the other on the upperlimb. Should the study of the shuntbe performed in two steps, we carryout the distal study in the“Superman” position (the patientlying prone or supine) in order to getthe most precise images possiblewithout any wrap-around artifacts asthey can be observed in examina-tions performed in the supine position with the patient’s armsalongside their body (8).

We do not have any practicalexperience of CO2 angiography in



puncture, which enabled us torestore a correct venous outflowwithout any secondary clinical stealphenomenon. If a steal hadoccurred, we would have resorted toligating the distal radial artery and toconstructing a new cephalic anasto-mosis. We will also select thismethod should a restenosis appear,for it seems more perennial thanpercutaneous dilation (9).

Conclusion

In some cases the juxta pre-anas-tomotic arterial occlusion of a radio-cephalic dialysis fistula does notinduce a thrombosis of the drainingvein thanks to the development ofarterial collateral pathways.

More rarely, the blood flow sup-plied by these collaterals to thevenous segment of the shuntremains high enough to enable efficient dialysis, without the occur-rence of any clinical phenomenon ofdistal steal.

Several imaging modalities areavailable to examine the situationthoroughly and even to treat theproblem: USD, which is very observ-er-dependent but non-invasive, notexpensive, and widely available, 3DMRA and DSA.

stenosis of direct wrist autogenousradial-cephalic arteriovenous access-es for dialysis. J Vasc Surg, 2011, 53:108-114.

10. McGill R.L., Marcus R.J., Healy D.A.,et al.: Collateralization of the palmararch by a failing radiocephalic fistula:an underappreciated complication ofCimino fistula anatomy. J VascAccess, 2006, 7: 35-37.

11. Knops N., Beek E.: Salvage of a radio-cephalic fistula by the palmar arch.Nephrol Dial Transpl Plus, 2008, 5:326-328.

12. Yilmaz C., Ozcan K., Kalaycioglu S., etal.: Maintenance of normal radio-cephalic fistula flow via the ulnarartery in a patient with occlusion ofthe radial artery. J Ultrasound Med,2009, 28: 1593-1595.

13. Bourquelot P., Gaudric J., Turmel-Rodrigues L., et al.: Proximal radialartery ligation (PRAL) for reduction offlow in autogenous radial cephalicaccesses for haemodialysis. Eur JVasc Endovasc Surg, 2010, 40: 94-99.

14. Rohren E.M., Kliewer M.A.,Carroll B.A., et al.: A spectrum ofDoppler waveforms in the carotid andvertebral arteries. AJR, 2003, 181:1695-1704.

15. Société Française de Radiologie.Utilisation des produits de contrasteen Imagerie Médicale (updated01/09/2011). www.sfrnet.org

16. Turmel-Rodrigues L., Boutin J.M.,Camiade C., et al.: Percutaneous dila-tion of the radial artery in nonmatur-ing autogenous radial-cephalic fistu-las for haemodialysis. Nephrol DialTranspl, 2009, 24: 3782-3788.

References

1. The National Kidney Foundation-Kidney Disease Outcomes Quality:Guidelines for Hemodialysis, 2006Updates. www.kidney.org

2. Ferring M., Henderson J., Wilmink A.,et al.: Vascular ultrasound for the pre-operative evaluation prior to arterio-venous fistula formation for haemo-dialysis. Nephrol Dial Transpl, 2008,23: 1809-1815.

3. L’abord vasculaire pour hémodialyse.Association Française des Infirmier(e)sde Dialyse, transplantation etNéphrologie. Paris, Editions Masson,2004.

4. Franco G. Place de l’écho-Doppler.Cours-Congrès de Bruxelles, Belgique,2011. www.sfav.org

5. Pichot O. Diagnostic des sténoses parultrasonographie. Cours-Congrès deBruxelles, Belgique, 2011. www.sfav.org

6. Verbeeck N., Prospert F., McIntyre D.,et al.: Dialysis arteriovenous fistulas:The critical role of color Dopplerultrasound. JBR-BTR, 2011, 94: 266-277.

7. Heye S., Maleux G., Claes K., et al.:Stenosis detection in nativehemodialysis fistulas with MDCTangiography. AJR, 2009, 192: 1079-1084.

8. Stepansky F., Hecht E.M., Rivera R., etal.: Dynamic MR angiography ofupper extremity vascular disease:Pictorial review. RadioGraphics, 2008,28, e28.

9. Long B., Brichart N., Lermusiaux P., etal.: Management of perianastomotic

64 JBR–BTR, 2013, 96 (2)

Advertising Index

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PagesGUERBET. . . . . . . . . . . . . . . . . . . . . . . . . . . III, IVBRACCO. . . . . . . . . . . . . . . . . . . . . . . . . . . . VI, VIIGE MEDICAL SYSTEMS . . . . . . . . . . . . . . . XISIEMENS . . . . . . . . . . . . . . . . . . . . . . . . . . . XIIAVNET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CIV


Septorhinoplasty (SRP) is a com-monly performed procedure for cor-rection of esthetic and/or functional deformities of the nasal bony and cartilaginous structures. Complica-tions after SRP are relatively uncom-mon and most often have an infec-tious origin or result from inadequate surgical planning or from poor tech-nique.

The formation of a traumatic arte-riovenous fistula (AVF) is often seen at specific anatomic locations (e.g. caroticocavernous fistulae) and has rarely been associated to SRP. We report such an unusual case of an AVF originating from a terminal branch of the facial artery.

Case report

A 47-year-old male underwent en-donasal SRP for correction of an ob-structing nasal pyramid and nasal septal deviation. The patient’s histo-ry included hiatus hernia, aspirin in-tolerance and bronchial hyperreac-tivity without evidence of sinonasal inflammatory disease. Oral omepra-zole and salmeterol/fluticason intake was used as chronic medications. No other systemic or vascular condi-tions were present.

The surgical procedure involved a septal correction with osteotomy of the maxillary crest, removal of a cartilaginous and bony hump, para-median and lateral osteotomies in-volving external stab incisions mid-way between medial canthus and nasal dorsum. Afterwards nasal

facial soft tissue swelling a localized swelling at the left medial canthus had become evident. The swelling was well-confined, painless, without signs of inflammation or hematoma (Fig. 1). In addition, the presence of a pulse synchronous pulsation of the swollen area was very striking. Rhino scopy and nasal endoscopy were normal. Clinically, an arterio-venous fistula formation was sus-pected and the patient was referred for Doppler Ultrasound evaluation, confirming the vascular nature of the lesion with mixed arteriovenous flow (Fig. 2). The high diastolic flow in the arterial component of the lesion re-flected a potential communication with the internal carotid artery (“low-resistance cerebral circulation”).

For optimal therapy planning the patient underwent conventional an-giography. Selective angiography of both external and internal carotid ar-teries showed the vascular anatomy of the AVF with the arterial feeders

splints and thermoplastic external nasal splint were placed.

The immediate postoperative course was uneventful and the pa-tient was discharged the next day.

At postoperative control one week later the splints were removed and symmetrical regressing facial swell-ing and hematoma was visible. How-ever, the patient mentioned a dis-crete, pounding tinnitus that was present since day one after surgery. Since no clinical explanation could be found at that time, no specific action was undertaken until the next control visit one week later. At that time and after further regression of

JBR–BTR, 2013, 96: 65-68.

Persistent faCial swelling and tinnitus ComPliCating sePtorhinoPlastYT. Van der Zijden1, J. Claes2,3, F.M. Vanhoenacker4,5, G. Claes6

septorhinoplasty (srP) is commonly performed for correcting nasal bony and cartilaginous deformities. traumatic arteriovenous fistula (aVf) is often seen at specific anatomic locations and has rarely been associated to srP. we report such an unusual case where an aVf developed from a terminal branch of the facial artery.after septorhinoplasty a patient reported pulsatile tinnitus, starting one day after surgery. swelling on the left side of the nasal pyramid was still present two weeks after the procedure. Clinically, a traumatic aVf was suspected which was confirmed by subsequent doppler ultrasound examination and angiography. the lesion had developed an important venous pouch and arterial contribution was from the internal carotid as well as external carotid system bilaterally. Complete resection was done by external approach.

Keywords: arteriovenous malformations – nose.

From: 1. Dept of Medical Imaging, University Hospital Antwerp, Antwerp, 2. ENT Dept University Hospital Antwerp, 3. ENT Dept AZ St Maarten Duffel, 4. Dept of Medical Imaging University Hospitals Antwerp and Ghent, 5. Dept of Medical Imaging AZ St Maarten Duffel, 6. ENT Dept University Hospital Antwerp, Belgium.Address for correspondence: Dr T. Van der Zijden, Dept of Medical Imaging, University Hospital Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium.E-mail: [email protected]

Fig. 1. — Clinical picture of the patient showing a well-defined, pulsatile soft tissue swelling at the left medial canthus (white arrow).

van der zijden-CS5-OK.indd 65 25/04/13 11:22

66 JBR–BTR, 2013, 96 (2)

Fig. 2. — Doppler ultrasound of the nose. Color Doppler ultra-sound image (A) obtained at the level of the clinical swelling confirms the vascular nature of the lesion. The high diastolic flow in the arterial component on pulsed Doppler (B) reflects a potential communication with the internal carotid artery system.

Fig. 3. — Selective angiography (internal carotid artery, ICA, and external carotid artery, ECA) shows the vascular anatomy of the AVF with arterial feeders (thin black arrows) and venous pouch (thick white arrows) with draining veins.

The AVF is fed from the left internal maxillary artery through a hypertrophied infra-orbital artery (A – left ECA injection, lateral view) and from the left ophthalmic artery through the dorsal nasal artery (B – left ICA injection, lateral view). Right ECA injection (C – anteroposterior view) show feeding from the left angular artery through the right facial artery, using right to left collaterals. The venous outflow of the fistula is mainly through the right angular vein and frontal veins (D – anteroposterior view, left ECA injection late arterial phase).

A

A

B

B

C

D


COMPLICATED SEPTORHINOPLASTY — VAN DER ZIJDEN et al 67

and the venous pouch with draining veins (Fig. 3). On the left side the AVF was fed from the left internal maxil-lary artery by a hypertrophied infra-orbital artery and from the left oph-thalmic artery by the dorsal nasal artery. Across small right to left col-laterals the feeding left angular ar-tery was supplied by the right facial artery and right ophthalmic artery. The venous outflow was mainly through the right angular vein and frontal veins.

Because of the easy surgical ac-cess and the difficult direct arterial approach for femoral (transarterial) treatment, surgery was performed to treat this condition.

Through an external skin incision the venous pouch was exposed in the subcutaneous plane. Several feeding arteries were coagulated and transected, and the pouch was removed (Fig. 4). Pathologic exam of the resected tissue confirmed the vascular nature of the lesion. The further postoperative course was un-eventful and the patient remained without complaints until the last fol-low-up visit four months after the surgical procedure.

discussion

Arteriovenous fistulas (AVFs) are uncommon vascular lesions with abnormal communications between arteries and veins resulting in shunt-ing of blood. Mostly, they are acquired after trauma (including sur-gery), due to rupture of an arterial aneurysm or due to erosion in neo-plasms.

Most of the AVF’s in head and neck region are intracranial, i.e. caroticocavernous fistulas and dural AVF’s. AVF formation in the facial

eral routes is the orbital plexus, which connects the ophthalmic ar-tery with facial, middle meningeal, maxillary and ethmoidal arteries (5). It is known that in some cases of in-ternal carotid artery occlusion collat-eral connections between external carotid artery and the intracranial and orbital circulation may develop. The blood supply to the ipsilateral eye and even to the ipsilateral brain hemisphere can depend solely on retrograde filling of the ophthalmic artery (6). During embolization pro-cedures or due to high-flow shunts, these potentially collateral pathways can become more prominent (7).

In the case of clinical suspicion of a superficially located AVF, due to its low cost and wide availability, color Doppler ultrasound is the first-line imaging technique to confirm the vascular nature of the lesion. It also demonstrates arterial flow in the feeding arteries, turbulent flow at the junction between artery and vein and high-velocity arterialized flow within the draining veins (8). However, catheter angiography is often needed for more precise vascular mapping of feeding arteries, nidus and draining veins (1). Angiography is very useful in showing the sometimes complex anatomy of the AVF in order to plan an adequate treatment strategy. It is very important to visualize the en-tire nidus with all feeding vessels, including other possible collateral feeders, and draining vessels. A proper angio graphy protocol in the case of a facial AVF includes arterio-grams of both the external and inter-nal carotid arteries (9, 10).

A specific treatment choice is al-ways a trade-off between benefits and risks. A femoral transarterial em-bolization is preferred in a case with

area after surgery has been de-scribed (1, 2). We did – however – not find a similar case to the current case after a medline search, using the search terms “rhinoplasty, sep-toplasty, rhinosurgery, rhino sur-gery”, combined with “arteriove-nous”. Descriptions exist of AVF formation through direct damage of the anterior ethmoidal artery (2). This in our opinion was not the un-derlying mechanism in our case, since there were no SRP-related peroperative or postoperative signs suggestive of any other than pre-septal localization of vascular trauma.

Caroticocavernous AVF has been described as an unusual and dramat-ic complication of nasal surgery (3). It is clear from the clinical presenta-tion and angiographic findings in our case that it is not comparable to a traumatic carotico-cavernous AVF.

We believe that in our case a direct trauma of the left angular ar-tery has been the primary vascular lesion, caused by transcutaneous left lateral osteotomy.

Pulsatile tinnitus is a known early sign of AVF of the midface, nose or sinuses (4). The tinnitus in our case was also the first sign and we believe to be explained by bony sound con-duction of the turbulent flow at the AVF.

The development of the venous pouch and its typical clinical presen-tation in our case have possibly been delayed by the use of external nasal splints and masked by the immedi-ate normal postoperative swelling.

The arterial contribution to the fis-tula from both internal and external carotid artery is striking. Several anastomotic routes between extra-cranial and intracranial circulation exist. One of these possible collat-

Fig. 4. — Peroperative images during (A) and post resection (B) of the lesion showing the venous pouch measuring about 1 cm with the coagulated entry points of the feeding arteries.

A B


68 JBR–BTR, 2013, 96 (2)

good arterial access, with no danger-ous interconnections with the inter-nal carotid artery system, and easily accessible collateral feeders. Anoth-er embolic therapeutic approach could be by direct or femoral trans-venous approach. The embolization could be done by glue, non-adhesive liquid embolic agents, coils, particles or a combination of the aforemen-tioned embolic agents. In compari-son with surgery endovascular ther-apy has higher rates of recurrence. Direct transcutaneous injection of a sclerosing agent is in selected cases possible as well.

Surgical treatment of a sinonasal AVF is a valuable option whenever its location allows radical resection. It may be the only option of treat-ment in those cases where emboliza-tion is not feasible or has failed. Re-section of the venous pouch and all feeding arteries is of utmost impor-tance, since reformation of AVF has been described after incomplete re-section (10).

In conclusion, AVF developing from a terminal branch of the facial

history and management. Plast Reconstr Surg, 1998, 102: 643-654.

5. Liebeskind D.S.: Collateral circulation. Stroke, 2003, 34: 2279-2284.

6. Countee R.W., Vijayanathan T.: External carotid artery in internal carotid artery occlusion. Angio-graphic, therapeutic, and prognostic considerations. Stroke, 1979, 10: 450-460.

7. Geibprasert S., Pongpech S., Amstrong D., Krings T.: Dangerous extracranial-intracranial anastomo-ses and supply to the cranial nerves: vessels the neurointerventionalist needs to know. AJNR Am J Neuroradiol, 2009, 30: 1459-1468.

8. Venkatanarasimha N., Freeman S.: Ultrasound features of arteriovenous fistula. AJR Am J Roentgenol, 2010, 194: W540.

9. González S.B., Busquets J.C., Figueiras R.G., et al.: Imaging arterio-venous fistulas. AJR Am J Roentgenol, 2009, 193: 1425-1433.

10. Komiyama M., Nishikawa M., Kitano S., et al.: Non-traumatic arte-riovenous fistulas of the scalp treated by a combination of embolization and surgical removal. Neurol Med Chir (Tokyo), 1996, 36: 162-165.

artery after SRP is unusual. Feeders were recruited from both internal and external carotid arteries. Dop-pler-ultrasound is an excellent first-line imaging technique for confirm-ing the vascular nature of a lesion. For treatment strategy planning catheter angiography, including an-giograms of both the external and internal arteries, provides more pre-cise vascular mapping. Visualizing the entire nidus with all feeding and draining vessels is very important.

references

1. Saini A., Jackson J.E.: Arterio venous fistulas of the facial artery after mandibular surgery: Treatment by embolization. AJR, 2008, 190: W35- 40.

2. Wagner G.A.: Epistaxis. J Otolaryngol, 1978, 7: 545-548.

3. Pothula V.B., Reddy K.T., Nixon T.E.: Carotico-cavernous fistula following septorhinoplasty. J Laryngol Otol, 1999, 113: 844-846.

4. Kohout M.P., Hansen M., Pribaz J.J., Mulliken J.B.: Arteriovenous malfor-mations of the head and neck: natural


Ultrasound (US) contrast agentshave been used extensively duringthe last years for imaging variousparts of the body. Their commonestway of administration is intra-venously. However, they have alsobeen given intracavitarily for specificindications. Oral administration ofthese agents has been described sofar in medical literature only as workin progress. As far as we know, thisis the first case report in which oraladministration of a US contrastagent has aided in the patient’s diag-nosis. We present the case of apatient with a cervical mass, inwhom the clinical diagnosis beforesonography was that of a thyroidgoiter and computed tomography(CT) diagnosis was that of a cervicalabscess. Oral administration ofSonoVue (sulphur hexafluoride) ledto directing sonographic diagnosisto that of a pharyngeal tumour. Thiswas confirmed on barium swallowand endoscopy guided biopsy.

Case report

A 25-year-old man presented tothe Emergency Department of ourHospital complaining of dysphagiaand weight loss (12 kg in 3 months).Physical examination revealed a cervical mass initially presumed torepresent thyroid goiter. A cervicalCT scan already performed had diag-nosed a retropharyngeal abscess.Cervical US showed a soft tissuemass which displaced the thyroidanteriorly but did not arise from thegland otherwise normal parenchy-ma. This space occupying lesion con-tained gas and was sonographicallypresumed to originate from thedeformed oesophagus. It showedareas of rich vascularity on colorDoppler (Fig. 1). With the patient’s

placed. These findings were attrib-uted to the presence of the mass andpossibly of enlarged lymphnodes.Barium pooled in the piriform sinus-es, as a result of abnormal pharyn-geal motility. These findings wereconsistent with malignancy.Two days later an upper gastroin-

testinal tract endoscopy examinationwas performed. The pharyngeallumen appeared concentricallystenosed. Biopsy specimens wereobtained. Pathology study diag-nosed squamous cell carcinoma ofthe oesophagus, extending to thepharynx, of intermediate to high dif-ferentiation with keratinisation andinfiltration of the chorion.

informed consent, US contrast agentSonoVue was given per os (one dropin 20 mL of tap water). SubsequentUS scan showed the contrast agentcoursing along the pharynx andoesophagus. The lower pharyngealand upper oesophageal wall wasirregularly thickened and the lumenwas stenosed (Fig. 2).On the following day, a barium

swallow examination showed alarge mass occupying the lowerpharynx at the level of the piriformsinuses and part of the upperoesophagus with irregular mucosalderangement (Fig. 3). The retropha-ryngeal space was increased and thehypopharynx was anteriorly dis-

JBR–BTR, 2013, 96: 69-71.

ULTRASOUND CONTRAST AGENT DELIVERED PER OS FIRST DIAGNOSESPHARYNGOESOPHAGEAL TUMOURE. Antypa, D.D. Cokkinos, I. Kalogeropoulos, D. Tomais, P.N. Piperopoulos1

Oral administration of ultrasound contrast agents has been described very little so far in medical literature. Theseagents are mainly administered intravenously and, less commonly, intracavitarily. We present the case of a patientwith a cervical mass in whom sonographic examination with per os administration of SonoVue led to the diagnosisof a pharyngoesophageal tumour. The diagnosis was confirmed on barium swallow and endoscopy-guided biopsy.

Key-word: Ultrasound (US), contrast media.

From: 1. Radiology Department, Evangelismos Hospital, Athens, Greece.Address for correspondence: Dr D.D. Cokkinos, M.D., Dorylaiou 5, 11521 Athens,Greece. E-mail: [email protected]

Fig. 1.— Transverse US scan of the cervix shows a large masswith focal areas of rich vascularity. It does not arise from the thyroid but displaces it anteriorly (arrows).

antypa-_Opmaak 1 25/04/13 11:20 Pagina 69

Discussion

US contrast agents consist of gas-filled microbubbles contained in ashell of proteins, lipids or poly-mers (1). Their diameter is approxi-mately 3-5 µm, (about the diameterof a red blood cell). They are usuallyadministered intravenously and,being too big to pass through theendothelial vessel wall, they remainin the lumen of blood vessels (2).These agents are used extensivelyintravenously for the safe imaginginvestigation of many body organswith excellent toleration (3). For twoof the most commonly used drugscontaining perflutren and sulphurhexafluoride microspheres, there arevery low rates of anaphylactoid reactions (1:7000 or 0.014%) (4-6).These are lower than the respectiverates of CT contrast agent adversereactions (0.035%-0.095%) (4, 7, 8).Intravenous contrast enhanced ultra-sound (CEUS) is avoided as a pre-caution only in patients with seriouscardiopulmonary compromise (9). However, these drugs are also

administered intracavitarily for spe-cific indications, such as vesico -ureteral reflux studies in children (10),follow up of renal transplant recipi-ents (11) and percutaneous drainageprocedures. They allow visualisationof the drainage duct location postintraductal injection, determining if adrainage duct is correctly positionedor obstructed, as well as depictingthe shape of the biliary tree (12) anddiagnosing biliary leakage post T-

helpful to this patient by correctlyredirecting his diagnostic path.In conclusion, we believe that this

case is an example suggesting thevaluable usage of US contrastagents following other administra-tion routes, besides intravenousinjection. It is a fast, non-expensiveand easy to perform examinationwhich can aid to the patient’s diag-nostic pathway.

References

1. Morin S.H., Lim A.K.P., Cobbold J.F.L.,Taylor-Robinson S.D. Use of secondgeneration contrast enhanced ultra-sound in the assessment of focal liverlesions. World J Gastroenterol, 2007,13: 5963-5970.

2. Brannigan M., Burns P.N., Wilson S.R.:Blood flow patterns in focal liverlesions at microbubble-enhanced US.Radiographics, 2004, 24: 921-935.

3. Seitz K., Bernatik T., Strobel D., etal.: Contrast-enhanced ultrasound(CEUS) for the characterization offocal liver lesions in clinical practice(DEGUM Multicenter Trial): CEUS vs.MRI – a prospective comparison in269 patients. Ultraschall Med, 2010,31: 492-499.

4. Wilson S.R., Burns P.N.: Microbubble-enhanced US in body imaging: whatrole? Radiology, 2010, 257: 24-39.

5. Kitzman D.W., Goldman M.E.,Gillam L.D., Cohen J.L.,Aurigemma G.P., Gottdiener J.S.:Efficacy and safety of the novel ultra-sound contrast agent perflutren(definity) in patients with suboptimalbaseline left ventricular echocardio-graphic images. Am J Cardiol, 2000,86: 669-674.

tube removal (13). In general, UScontrast agents can be instilled intoany sonographically accessible bodycavity, with other clinical applica-tions including abscesses, pancreat-ic pseudocysts or other pancreatitiscomplications, intestinal or other fis-tulas, gastrooesophageal reflux, aswell as stenoses of the gastric andintestinal lumen (14). So far, onlywork in progress in this field hasbeen published (15).Other examples of various admin-

istration methods of contrast agentsin imaging include the use of lowosmolality iodinated contrast media,such as iohexol, either intravenously(e.g. for contrast enhanced CT) ororally (e.g. for pass-through exami-nations of the gastrointestinal tractor bowel opacification in CT exami-nations) (16).Since sulphur hexafluoride is

manufactured for intravenous useand oral administration is off-label,this was explained to the patientwho gave his consent. No adversereaction occurred post oral adminis-tration of this US contrast agent. Thediagnoses which had been suggest-ed up to that point (thyroid goiterand abscess) changed immediatelyby imaging a pharyngeal/oeso -phageal mass causing narrowing oftheir lumen. The diagnosis was con-firmed on the next day by bariumswallow, while endoscopy-aidedbiopsy performed two days laterresulted in specific definition of thetumour’s histology. Therefore, oraladministration of SonoVue proved

70 JBR–BTR, 2013, 96 (2)

Fig. 2. — Sagittal (left) and transverse (right) images of cervi-cal US with oral administration of SonoVue. Irregular stenosis ofthe pharynx (arrow) and the upper oesophagus (double arrows)is noted. Curved arrow indicates normal oesophagus.

Fig. 3. — Left sagittal (left) and frontal (right) radiographsobtained during barium swallow examination. A large mass displaces the pharynx anteriorly, with irregularity of themucosa. Barium is pooling in the right (arrow) and left (curvedarrow) piriform sinuses.


6. Piscaglia F., Bolondi L.: Italian Societyfor Ultrasound in Medicine andBiology (SIUMB) Study Group onUltrasound Contrast Agents. The safe-ty of Sonovue in abdominal applica-tions: retrospective analysis of 23188investigations. Ultrasound Med Biol,2006, 32: 1369-1375.

7. International Collaborative Study ofSevere Anaphylaxis. Risk of anaphy-laxis in a hospital population in rela-tion to the use of various drugs: aninternational study. Pharmaco epide -miol Drug Saf, 2003, 12: 195-202.

8. Cochran S.T., Bomyea K., Sayre J.W.:Trends in adverse events after IVadministration of contrast media.AJR, 2001, 176: 1385-1388.

9. Main M.L., Goldman J.H.,Grayburn P.A.: Thinking Outside the“Box”-The Ultrasound Contrast

ultrasound in the diagnosis of biliaryleakage following T-tube removal.J Clin Ultrasound, 2010, 38: 38-40.

14. Piscaglia F., Nolsøe C., Dietrich C.F., etal.: The EFSUMB Guidelines andRecommendations on the ClinicalPractice of Contrast Enhanced Ultra -sound (CEUS): update 2011 on non-hepatic applications. Ultraschall Med,2012, 33(1): 33-59.

15. Heinzmann A., Müller T., Leitlein J.,Braun B., Kubicka S., Blank W.:Endocavitary contrast enhancedultrasound (CEUS)-work in progress.Ultraschall Med, 2012, 33: 76-84.

16. Horton K.M., Fishman E.K.,Gayler B.J.: The use of iohexol as oralcontrast for computed tomography ofthe abdomen and pelvis. ComputAssist Tomogr, 2008, 32: 207-209.

Controversy. J Am Coll Cardiol, 2007,50: 2434-2437.

10. Quaia E.: Microbubble ultrasoundcontrast agents: an update. EurRadiol, 2007, 17: 1995-2008.

11. Kmetec A., Bren A.F., Kandus A.,Fettich J., Buturovic-Ponikvar J.:Contrast-enhanced ultrasound void-ing cystography as a screening exam-ination for vesicoureteral reflux in thefollow-up of renal transplant recipi-ents: a new approach. Nephrol DialTransplant, 2001, 16: 120-123.

12. Ignee A., Baum U., Schuessler G.,Dietrich C.F.: Contrast enhanced ultra-sound-guided percutaneous cholan-giography and cholangiodrainage(CEUS-PTCD). Endoscopy, 2009, 41:725-726.

13. Mao R., Xu E.J., Li K., Zheng R.Q.:Usefulness of contrast enhanced

US CONTRAST AGENT PER OS — ANTYPA et al 71

ANNOUNCEMENT FROM THE MUSEUM

Some copies of the book “A transparent skull. An illustrated history of neuroradiology” published in 2007 are still available. The book was awarded in 2011 the prize Fr. Doncheere from the Royal Belgian Academy of Medicine.For information: info@radiology_museum.be


Fig. 2. — Coronary reconstructionenhanced CT scan – ulceration U (inferiorof tracheal bifurcation T) and esophagusE (between ulceration and the aorta AO).

Acquired immunodeficiency syn-drome is associated with digestivemanifestations, especially at le levelof esophagus, and the principal clinical symptom is odynophagia.The diagnosis of this entity is anassociation between three techni -ques: radiological, endoscopic andpathological. The radiological find-ings give en etiological orientation.The endoscopy confirms the radio-logical aspects and allows the simplebiopsy or brushing. The final diagno-sis and the type of esophageal ulcersare confirmed by the pathologicalexam.

Case report

A 28-year-old male patient knownwith AIDS (the disease was diagnosedat the age 13 years, with a verticaltransmission) and treated for recur-rent oral ulcerations. The patient wasadmitted in our institution for severeulcero-necrotic stomatitis, pansinu -sitis and inflammatory syndrome.After the therapy the patient describ -ed the persistence of odynophagiaand dysphagia. The radiological exploration start-

ed with an enhanced CT of the tho-rax. On the mediastinal window, wasidentify a structure presenting adigestive wall and containing air sit-uated at the level of posterior medi-astinal floor on the right side of themiddle segment of thoracic esopha-gus (Fig. 1). This structure was inter-preted like a parietal thickening ofthe esophagus with probably ulcera-tion (Fig. 2).The esophagography confirmed

the presence of a single giant ulcer,with the topography at the level of

JBR–BTR, 2013, 96: 72-74.

GIANT IDIOPATHIC ULCER OF ESOPHAGUS IN THE CONTEXT OF ACQUIREDIMMUNODEFICIENCY SYNDROME (AIDS)C.A. Dragean¹, I. Bogdan¹, K. Azzouzzi², L.Goncette¹

The giant ulcer of esophagus is a rare entity in the context of human immunodeficiency syndrome. In front of thistype of ulceration the radiologist must to distinguish between two types of ulcers HIV, cytomegalovirus (CMV). Thedifferential diagnosis is necessary for orientation of the therapy and is the result of association between radiologi-cal, endoscopic and pathological findings.

Key-words: Acquired immunodeficiency syndrome (AIDS) – Peptic ulcer.

From: 1. Department of Radiology, 2. Department of Gastroenterology, UniversitéCatholique de Louvain, Cliniques Universitaires Saint Luc, Brussels, Belgium.Address for correspondence: Dr C. Dragean, M.D., Department of Radiology, UniversitéCatholique de Louvain, Cliniques Universitaires Saint Luc, Avenue Hippocrate 10, B-1200 Brussels, Belgium.

Fig. 1.— Axial contrast-enhancement CT scan reveals digestivestructure (U) on the right side of esophagus (E).

dragean-_Opmaak 1 25/04/13 11:25 Pagina 72

GIANT IDIOPATHIC ULCER OF ESOPHAGUS — DRAGEAN et al 73

postero-lateral wall of middle thora -cic esophagus. This ulcer has an ovalshape and measure 10 cm on thelong axis. The deep part of the ulcer-ation was irregular and on theperiphery was surrounded by a radi-olucent rim which represents theoedema (Fig. 3).The diagnosis suggested by the

radiologist is giant idiopathicesophageal ulcer related with theHIV status versus infectious ulcercaused by cytomegalovirus (CMV).These radiological findings were

correlated with the endoscopicviews, which demonstrated the pres-ence of ulcers of esophagus (Fig. 4),one very large.The endoscopic examination was

completed with the biopsy and thehistological exams. The biopsiesindicated the presence of epitheliumof Malpighi with the inflammatoryreaction and at the level of ulcerationthe presence of a fibrous membraneassociated with an inflammatoryinfiltration. The coloration PAS andthe immuno-histochemical tests (forCMV and herpes virus) were nega-tives.The final diagnosis after the corre-

lation between the three techniqueswas idiopathic giant ulcer of esopha-gus related with the HIV status.

esophagitis), herpes esophagitis andcandida esophagitis. The first twoentities of this group are the princi-pal’s differentials diagnosis on theHIV patient with acute digestive syn-drome. The radiological findings in the

infectious esophagitis are:

HIV esophagitis

Single giant ulcer (5-10 cm) ormultiples ulcers one or more aregiant and the others smallest, withthe topography on the middle seg-ment of thoracic esophagus. On theesophagogram we will identifiedone or more ulcers, the giant ulcer isprofound with the oval shape andsurrounded by rim of oedema.

Cytomegalovirus esophagitis

On this type of infectious esopha -gitis at the patient with AIDS theesophagography demonstrated thepresence of multiples ulcers, one ormores are large (2-5 cm), super -ficial (7), with the topography on thedistal thoracic esophagus or at thelevel eso-gastric junction.

Herpes esophagitis

The herpes simplex is anothercause of infectious esophagitis at the

Discussion

The symptom of odynophagia(painful swallowing) at the HIVpatients associated with the maculo-papular rash with the topography onthe face, superior part of the trunkand the upper limbs (1, 2), with theulceration at the level of oral cavityand the pharynx and rarely with thehematemesis, are the elements ofacute digestive syndrome in AIDS.These manifestations are correlatedwith a long term evolution or a sero-conversion syndrome (3, 4).This syndrome and the radiological

finding impose the differential diag-nosis between multiples etiologicalfactors, which can be divided in twogroups: infectious esophagitis andnon-infectious esophagitis. The non-infectious esophagitis are represent-ed by: drug-induced esophagitis,radiation-induced esophagitis,eosino philic esophagitis, Crohn dis-ease of the esophagus, tuberculosis,graft-versus-host disease, “mechani-cal” esophagitis (nasogastric intuba-tion). In the group of infectious esopha -

gitis are included (5, 6): giant idio-pathic esophageal ulcer in the HIVpatient (HIV esophagitis), cyto -megalo virus esophagitis (CMV

Fig. 3. — Esophagogram shows a giant ulcer on the middleesophagus with the rim of oedema.

Fig. 4. — Endoscopic image of esophagus – giant profoundposterior ulcer.


74 JBR–BTR, 2013, 96 (2)

patients immuno-compromised. Onthe radiological exam we find multi-ples small superficial ulcers at thelevel of superior esophagus.

Candida esophagitis

Double-contrast esophagogramshows multiples discrete plaque-likelongitudinal lesions separated by thenormal mucosa on the superior andmiddle esophagus.In Table I are indicated the criteria

of radiological differential diagnosisbetween these four types ofesophagitis, these criteria confirmradiological diagnosis for ourpatient.In all the cases of ulcers of esoph-

agus this radiological aspects mustto be confirmed by endoscopic examassociated with biopsies, brushingand histo-pathological and immuno-logical exams.The study of Wilcox (8) described

the endoscopic characteristics forthe idiopathic esophageal ulcer(IEU): -more than 1 ulceration, forthe majority the greatest dimensionwere > 1 cm, and in the 34% were> 2 cm, localisation in the middleoesophagus is dominant and thesecond place is for the distal oesoph-agus, the majority of the lesions wassuperficial or intermediate in the

gus in HIV-infected patients: a review.Int J STD AIDS, 1996, 7: 77-81.

3. Sor S., Levine M.S., Kowalski T.E.,Laufer I., Rubesin S.E., Herlinger H.:Giant ulcers of the esophagus inpatients with human immunodefi-ciency virus: clinical, radiographic,and pathologic findings. Radiology,1995, 194: 447-451.

4. Siegmund B., Moos V.,Loddenkemper C., Wahnschaffe U.,Engelmann E., Zeitz M., Schneider T.:Esophageal giant ulcer in primaryhuman immunodeficiency virusinfection is associated with an infil -tration of activated T cells. Scand JGastroenterol, 2007, 42: 890-895.

5. Levine M.S., Rubesin S.E.: Diseasesof the esophagus: diagnosis withesophagography. Radiology, 2005,237: 414-427.

6. Wilcox C.M.: Esophageal disease inthe acquired immunodeficiency syn-drome: etiology, diagnosis, and man-agement. Am J Med, 1992, 92: 412-421.

7. Balthazar E.J., Megibow A.J.,Hulnick D., Cho K.C., Beranbaum E.:Cytomegalovirus esophagitis in AIDS:radiographic features in 16 patients.AJR, 1987, 149: 919-923.

8. Wilcox C.M., Schwartz D.A.:Endoscopic Characterization of Idio -pathic Esophageal UlcerationAssociated with Human Immuno -deficiency Virus Infection. J ClinGastroenterologie, 1993, 16: 251-256.

depth, and the profound ulcerationswere found in 7% of the cases.

Conclusion

The odynophagia associated withthe giant esophageal ulcers is anentity which was described and recognized at the HIV patients andneeds the differentiation betweenHIV esophagitis and CMV esophagi-tis. The presence of maculo-papularrash on the upper superior part ofthe body and the oro-pharyngealulcerations are the supplementarycriteria in the favour of the diagnosisof idiopathic giant ulcer of esopha-gus related with the HIV.The barium esophagogram

aspects for the diagnosis of giantesophageal ulcer on the HIV patientare: large, profound and single ulcer-ation on the middle thoracic esopha-gus.

References

1. Levine M.S., Loercher G., Katzka D.A.,Herlinger H., Rubesin S.E., Laufer I.:Giant, human immunodeficiencyvirus-related ulcers in the esophagus.Radiology, 1991, 180: 323-326.

2. Ehrenpreis E.D. and Bober D.I.:Idiopathic ulcerations of the oesopha-

Table I. — Differential diagnosis of infectious esophagitis.

HIV CMV HERPESVIRUS

CANDIDA ALBICANS

Topography Middle T. ES.

Inferior T. ES. +/- GOjunction

Superior ES Superior and middle T. ES.

Number of lesion

Single orMultiples

Multiples Multiples Multiples

Dimension Giant(5-10 cm)

Giant (3-5 cm)+/- smalls

Smalls Smalls

Shape Oval Oval Oval or round Linear, with the longitudinaldisposition

Depth Profound Superficial Superficial Superficial

Note: – ES: Esophagus– T. ES: Thoracic esophagus– GO junction: Gastro-esophageal junction.


Primitive Neuroectodermal Tumor(PNET) or Ewing’s sarcoma of pri-mary renal origin is a very rare enti-ty with aggressive behavior. Affectedpatients are adolescents or youngadults, with variable and aspecificclinical presentation. In most casesthe presence of a renal tumoral massis assessed with ultrasound or com-puted tomography, but the diagnosisof PNET/Ewing’s sarcoma is usuallymade only on histopathology afternephrectomy, based on immunohis-tochemical and cytogenetic tests. Wereport on the CT-imaging findings intwo cases of renal PNET/Ewing’s sarcoma.

Case presentations

In 2011 two new cases ofPNET/Ewing’s sarcoma of primaryrenal origin were diagnosed at ourinstitutions and treated with radicalnephrectomy including regionallymph node dissection and adjuvantchemotherapy. The patients were a24-year-old female (Fig. 1) and a 26-year-old male (Fig. 2) presentingwith vague abdominal pain andwithout remarkable clinical records.The histopathology reports revealedsmall round blue cells with Homer-Wright type rosette formation onhematoxylin and eosin staining,largely positive immunohistochemi-cal staining for CD99 and EWSrearrangement (EWS-FLI1 transloca-tion) on fluorescent in situ hybridiza-tion (FISH). The abdominal CT find-ings were retrospectively reviewed.In both cases unenhanced CT scanswere performed followed by at least

PNET/Ewing’s sarcoma of the kid-ney typically occurs in adolescentsand young adults with a reportedmedian age of 24-27 years (1, 3). Theclinical presentation is variable andaspecific with patients complainingof flank pain (85%), palpable abdom-inal mass (60%), hematuria (37%) orweight loss (8%) (1, 4). Histopathology is essential to the

diagnosis of renal PNET/Ewing’s sarcoma (2-4). Microscopically PNET/Ewing’s sarcoma is characterized bysmall round tumor cells with typicalHomer-Wright rosette-like growthpattern (2, 3, 5). Overexpression ofthe surface membrane CD99 is asuggestive diagnostic clue onimmunohistochemistry but the finaldiagnosis of PNET/Ewing’s sarcomais based on cytogenetic analysis(FISH and PCR) revealing EWS generearrangement, including thet(11;22)(q24;q12) translocation (1-3,5). It remains unclear whether or notEwing’s sarcoma and PNET are distinct entities since they have similar biologic, pathological andmolecular findings (2, 5). In the WHOclassification they are considered asone entity, presumed to originatefrom one common precursor (theneural cells in the kidney or theembryonic neural crest cells thatmigrate into the kidney) probablyblocked in a different stage of differ-entiation (3-5). PNET shows moremature neural cells than Ewing’s sarcoma as demonstrated by theexpression of neural immuno -histochemical markers such as NSE,vimentin, synaptophysin and S-100 (1). Imaging findings in PNET/Ewing’s

sarcoma are variable and nonspecific.The CT-appearance of PNET/Ewing’ssarcoma is characterized by a largerenal mass with heterogeneous con-trast enhancement, necrotic or hem-orrhagic areas and sometimes calci-fications (1). However, the radiologi-cal features are indistinguishablefrom other primary, malignant renalparenchymal tumors or urothelialcancer (1, 2, 4). Other tumors thatmay be considered in the differential

2 postcontrast scans including axial,coronal and sagittal multiplanarreconstructions in the venous phase.In both cases, the tumor was locatedat the upper pole of the kidney andhad a maximum size of about 10 cmdiameter. One tumor was ill-definedand showed tumor extension intothe renal vein and inferior vena cava.The second tumor was sharplydemarcated from the normalparenchyma and showed no vascu-lar tumor thrombus. Both tumorsconsisted of solid components withhemorrhagic, cystic and necroticareas, resulting in heterogeneousattenuation numbers on unen-hanced and contrast-enhanced CTscans. The solid componentsshowed moderate enhancement. Thetumors were at least partially sur-rounded by a small rim of healthyrenal cortex. In one case, the tumorshowed sparse and diffuse microcal-cifications, histologically confirmedas dystrophic calcifications in necro-sis. Enlarged retroperitoneal lymphnodes were noted in one patient,proven non-metastatic followingregional lymphadenectomy.

Discussion

PNET/Ewing’s sarcoma of the kid-ney is an exceedingly rare entity,only about 50 cases were reported inliterature (1, 2). The true incidencehowever, may have been underesti-mated as the number of case reportsis increasing in recent years, proba-bly due to advanced immunohisto-chemistry, enabling better character-ization of renal tumors (1).

JBR–BTR, 2012, 95: 75-77.

PNET/EWING’S SARCOMA OF THE KIDNEY: IMAGING FINDINGS IN TWOCASESP. De Visschere1, A. De Potter2, F. Claus3, T. Mulkens4, R. Oyen3, A. Verbaeys5, C. Maes6, G. Villeirs1

The CT-imaging findings of primary renal PNET/Ewing’s sarcoma in two patients were retrospectively assessed. Alarge renal mass with heterogenous contrast enhancement and necrotic and hemorrhagic areas were the predomi-nant characteristics. In adolescents or young adults presenting with a large renal mass, PNET/Ewing’s sarcoma maybe included in the differential diagnosis.

From: 1. Department of Radiology, Ghent University Hospital, Ghent, Belgium,2. Department of Pathology, Ghent University Hospital, Ghent, Belgium, 3. Departmentof Radiology, University Hospitals Leuven, Leuven, Belgium, 4. Department ofRadiology, Heilig-Hartziekenhuis, Lier, Belgium, 5. Department of Urology, GhentUniversity Hospital, Ghent, Belgium, 6. Department of Urology, Heilig-Hartziekenhuis,Lier, Belgium.Address of correspondence: Dr P. De Visschere, M.D., Department of Radiology, Divisionof Genitourinary Radiology and Mammography, Ghent University Hospital, -1 DWG Li,De Pintelaan 185, B-9000 Ghent, Belgium. E-mail: [email protected]

de visschere-_Opmaak 1 4/04/13 10:04 Pagina 75

diagnosis include rhabdomyosarco-ma, Wilms’ tumor, carcinoid tumor,neuroblastoma, lymphoma, des -moplastic small round cell tumorand nephroblastoma (1, 3, 5). Sinceno pathognomonic features ofPNET/Ewing’s sarcoma have beendescribed, it is difficult to preopera-tively diagnose this entity (1, 4).Nevertheless, in adolescents oryoung adults presenting with a renalmass, PNET/Ewing’s sarcoma maybe included in the differential diag-nosis and a preoperative fine needleaspiration or core needle biopsy canbe taken into consideration (3).Most PNET/Ewing’s sarcomas

have an aggressive behavior and themajority of patients present atadvanced stage disease (57,6%),including lymph node invasion

sarcoma this is hard to achieve.Therefore radical nephrectomy stillremains the most important modali-ty of treatment (1, 3). Since mostpatients with apparently localizeddisease do have occult metastasis,additional polychemotherapy is usu-ally warranted. The standard chemo -therapeutic agents currently usedare vincristine, ifosfamide, doxoru-bicine, etoposide, adriamycine andifosfamide (1, 2). The role of radio-therapy is not clear, but it may beindicated in case of positive surgicalmargins or involvement of Gerota’sfascia (3). The prognosis of patients with

renal PNET/Ewing’s sarcoma is poor,with high local recurrence rates andonly a minority of patients experienc-ing long disease-free survival (1-4).

(25%), pulmonary metastases (20%)and liver metastases (14%) (1-5).One third of patients present withtumor thrombi in the renal vein orinferior vena cava at the time ofdiagnosis (1).The management principles of

renal PNET/Ewing’s sarcoma havebeen extrapolated from osseousEwing’s sarcoma, although thesequence of neoadjuvant chemo -therapy followed by surgery, whichis the standard of care in osseousEwing’s sarcoma, is usually not rele-vant in renal PNET/Ewing’s sarcomasince surgery is for the majority ofcases the initial and necessary stepto the diagnosis (2). The treatmentoptions should be further investigat-ed, but regarding the small numberof patients with renal PNET/Ewing’s

76 JBR–BTR, 2012, 95 (2)

Fig. 1. — Case 1: PNET/Ewing’s sarcoma of the right kidney in a 26-year-old male. In this late corticomedullary phase after contrastadministration (A,B) the upper pole mass in the right kidney shows enhancing solid components and extensive non-enhancingnecrotic and cystic areas. The tumor is ill-defined and partially surrounded by a small rim of normal renal cortex (arrow). There istumor thrombus in the right renal vein and inferior vena cava (C). In delayed phase (D) the renal calices and pelvis are compressedby the mass.

A

B

C

D


Conclusions

The CT-appearance of PNET/Ewing’s sarcoma of primary renalorigin is that of a large renal masswith heterogeneous contrastenhancement, necrotic or hemor-rhagic areas and occasional calcifi-cations. It is virtually indistinguish-able from other renal tumors such asrenal cell carcinoma. Nevertheless,in adolescents or young adults pre-senting with a large renal mass thediagnosis of PNET/Ewing’s sarcoma

Neuroectodermal Tumor: Rare, HighlyAggressive Differential Diagnosis inUrologic Malignancies. Urology,2006, 68: 257-262.

2. Mukkunda R., Venkitaraman R.,Thway K., Min T., Fisher C.,Horwich A., Judson I.: Primary AdultRenal Ewing’s Sarcoma: A Rare Entity.Sarcoma 2009, 504654. doi:10.1155/2009/504654.

3. Thyavihally Y.Y., Tongaonkar H.B.,Gupta S., Kurkure P.A., Amare P.,Muckaden M.A., Desai S.B.: PrimitiveNeuroectodermal Tumor of theKidney: A Single Institute Series of 16Patients. Urology, 2008, 71: 292-296.doi:10.1016/j.urology.2007.09.051.

4. Rappaport A., Oyen R.H.: RenalLymphoma and Renal Sarcoma. In:Quaia E. (ed). Radiological Imaging ofthe Kidney, 1st edn. Springer-Verlag,Berlin Heidelberg, 2011, pp 631-642.

5. Pomara G., Cappello F., Cuttano M.G.,Rappa F., Morelli G., Mancini P.,Selli C.: Primitive NeuroectodermalTumor (PNET) of the kidney: a casereport. BMC Cancer, 2004, 4: 3.

may be suggested and a preopera-tive fine needle aspiration or coreneedle biopsy can be taken into con-sideration. Radical nephrectomyremains the most important modali-ty of treatment, although neoadju-vant chemotherapy precedingnephrectomy might be a possibletreatment alternative.

References

1. Ellinger J., Bastian P.J., Hauser S.,Biermann K., Müller S.C.: Primitive

PNET/EWING’S SARCOMA OF THE KIDNEY — DE VISSCHERE et al 77

Fig. 2. — Case 2: PNET/Ewing’s sarcoma of the left kidney in a24-year-old female. The large upper pole tumor in the left kidneyshows heterogeneous contrast enhancement in arterial (A) andvenous (B) phase. Coronal reformatting (C) demonstrate thesharp demarcation of the tumor within kidney and adjacentstructures.

A

B

C


Case reports

Patients and initial management

Our first case is a 75-year old male with an important cardiac history (chronic atrial fibrillation with pre-ventive subcutaneous low molecular weight heparin (LMWH) injections and right heart failure) who was di-rected to the emergency department by his general physician because of massive hematochezia. Clinical eval-uation showed a non-tender abdo-men with a drop in blood pressure two hours after admission (blood pressure 73/46 mmHg). Blood tests confirmed the presence of LMWH as the activated partial thromboplastin time (aPTT) was prolonged (41.2 sec; 25.6-36.8 sec) and the international normalized ratio (INR) had a normal

endoscopically. Although the bleed-ing site was known from the endo-scopic evaluation the radiologist first wanted a CTA to get a look at the vascular anatomy.

Protocols

The patients were scanned using a 64-slice Aquilion scanner of Toshiba (Toshiba medical systems Europe, Zoetermeer, Netherlands). No special patient preparation was demanded other than intravenous placement of an 18 gauge catheter. Pre-contrast abdominal CT scan was performed prior to intravenous contrast admin-istration to exclude possible preex-isting radiodensities in the bowel lu-men. 100 ml of a non-ionic contrast agent (Xenetix©, Lobitridol 350 mg/ml, Guerbet, Roissy Charles de

value of 1.48. A total of 6 units of packed cells were administered. The approach of this acute LGIB started with a colonoscopy that revealed blood in the rectum and sigmoid but more proximal insertion of the endo-scope was impossible. The esopha-gogastroduodenoscopy (EGD) did not show any bleeding site. Since endoscopic evaluation was not able to localize the bleeding site and the bleeding did not stop spontaneous-ly, a computed tomography angiog-raphy (CTA) was requested.

In our second case a female pa-tient of 64 years old presented with a post-polypectomy bleeding in the distal third of the sigmoid. Endo-scopic coagulation and clipping stopped the bleeding but one hour later the patient presented with a re-bleeding that could not be stopped

JBR–BTR, 2013, 96: 78-80.

The CriTiCal role of CT angiography in The deTeCTion and Therapy of lower gasTro-inTesTinal bleedingM. Aertsen1, B. Termote1, G. Souverijns1, J. Vanrusselt1

lower gastro-intestinal bleeding (lgib) is defined as a bleeding site localised in the colon or anorectum. (1) in the past, the diagnosis of lgib has been a serious challenge for the radiology department because of its possible inter-mittent character, making it difficult to pinpoint the bleeding site. patients with a lgib will typically have undergone a long diagnostic work-up before they end up on the interventional radiology department. The development of multi-detector computed tomography (CT) has made radiological diagnosis of lgib easier. CT is not only able to localize the active bleeding site but may also demonstrate the vascular anatomy and the underlying cause, hereby directing further management and guiding therapeutic interventions, as will be illustrated in both of our cases.

Key-word: intestines, hemorrhage.

From: 1. Department of Radiology, Jessa Hospital, Hasselt.Address for correspondence: Dr M. Aertsen, M.D., Department of Radiology, Jessa Hospital, Stadsomvaart 11, B-3500 Hasselt, Belgium.E-mail: [email protected]

Fig. 1. — Coronal reconstructed maximum intensity projections of CTA images in arterial phase demonstrate the intraluminal contrast agent (arrow) due to bleeding from the medial colic artery, originating from the superior mesenteric artery.

A B C

aertsen-CS5-OK.indd 78 4/04/13 10:18

LOWER GASTRO-INTESTINAL BLEEDING — AERTSEN et al 79

used to trace the vessel of origin and direct the subsequent conventional angiography (CA).

The CA is performed by digital subtraction angiography technique (Philips MultiDiagnost Eleva, Philips Healthcare, Eindhoven, Netherlands) via a transfemoral Seldinger method. The technical factors were slightly adjusted to the patients’ habitus but generally followed standard values: pulse rate of 2 frames/s, 70 kVp and 100 mAs. Because the location of the bleeding as well as the vessel of origin were shown on the CTA, we immediately performed a selective catheterisation using a Simmons catheter (Terumo Europe, Leuven, Belgium). During selective angiogra-phy 10 mL of contrast agent was administered during each run (Hexabrix©, Ioxaglate 320 mg/ml, Guerbet, Roissy Charles de Gaule, France) at about 2 mL/s for both cases.

Diagnosis and therapy

The CTA of the first patient re-vealed the bleeding site in the medi-al third of the colon transversum (Fig. 1). Subsequently the patient was directly transported to the inter-ventional radiology department and conventional angiography was per-formed. The time interval between the CTA images and the first images of the CA was 35 minutes.

Selective catheterisation of the medial colic artery towards the colon transversum showed no bleeding al-though multiple runs were per-formed (Fig. 2).

At this point there were 2 possi-bilities, first, we could interrupt the intervention and monitor the patient until we suspected active rebleeding and repeat the intervention. Or, we could, after correlation with the im-ages of the CTA, selectively embolize the vessel of origin with gelfoam particles (Spongostan, Ethicon Incor-porated, Somerville, USA). Because we were positive the CTA demon-strated the bleeding site and the vas-cular anatomy, we chose the second option.

In the second case, the CTA dem-onstrated the known bleeding site as well as the vessel of origin, being a sigmoid artery. CA with selective catheterisation of the inferior mesen-teric artery was immediately per-formed; the time interval between the first images taken at CTA and the first run of CA images was 38 min-utes. Even after multiple runs and after catheterisation of other branch-es, the CA did not reveal the bleed-

contrast agent. Multiplanar recon-structions in the sagittal, coronal and axial plane were made of both fases. In the absence of orally administered contrast agent, the diagnosis of ac-tive LGIB was made by looking for the extra vasation of intravenous contrast agent into the bowel lumen. After the localisation of the bleeding site multiplanar reconstructions and maximum intensity projections were

Gaule, France) was injected at 4 mL/s. Two single breath hold scans were performed from above the dia-phragm to below the symphysis pu-bis. The arterial phase scan was trig-gered with the region of interest in the abdominal aorta just below the diaphragm and with a density of 150 HU above its pre-contrast density. The venous phase was scanned two minutes after start of the injection of

Fig. 2. — Two CA images of different runs, respectively showing injection of contrast in the superior mesenteric artery (A) and (B) the selective injection in the medial colic artery towards the middle third of the transverse colon, revealed no extravasation.

A B

A

C

B

DFig. 3. — A. CA image after injection of contrast in the inferior mesenterior artery

without identifiable bleeding site. B. Coronal CTA image in the arterial phase demon-strating the rectosigmoidal bleeding (arrow). C. Selective catheterisation of a sigmoid artery with injection of contrast material did not show the bleeding site. D. CA image after embolisation with contrast injection in the inferior mesenteric artery illustrating the diminished vasculature.


80 JBR–BTR, 2013, 96 (2)

tive impact on the evolution and the outcome of the patient and hence it should have a primary role in the management of LGIB.

references

1. Barnert J., Messman H.: Diagnosis and management of lower gastroin-testinal bleeding. Nat Rev Gastroen-terol Hepatol, 2009, 6: 637-646.

2. Longstreth G.F.: Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal haemor-rhage: a population-based study. Am J Gastroenterol, 1997, 92: 924-928.

3. Lieberman D.: Gastrointestinal bleed-ing: initial management. Gastroenter-ol Clin North Am, 1993, 22: 723-736.

4. Frattaroli F.M., Casciani E., Spoletini D.: Prospetive study com-paring multi-detector row CT and endoscopy in acute gastrointestinal bleeding. World J Surg, 2009, 33: 2209-2217.

5. Howarth D.M., Tang K., Lees W.: The clinical utility of nuclear medicine imaging for the detection of occult gastrointestinal haemorrhage. Nucl Med Commun, 2002, 23: 591-594.

6. Raju G.S., Gerson L., Das A., Lewis B.: American Gastroenterological Asso-ciation. American Gastro-enterologi-cal Association (AGA) Institute techni-cal review on obscure gastrointestinal bleeding. Gastroenterology, 2007, 133: 1697-1717.

7. Kuo W.T.: Transcatheter treatment for lower gastrointestinal hemorrhage. Tech Vasc Interv Radiol, 2004, 7: 143-150.

8. Van Dam J., Brugge W.R.: Endoscopy of the upper gastrointestinal tract. N Engl J Med, 1999, 341: 1738-1748.

9. Martí M., Artigas J.M., Garzón G., Alvarez-Sala R., Soto J.A.: Acute low-er intestinal bleeding: feasibility and diagnostic performance of CT angio-graphy. Radiology, 2012, 262: 109-116.

10. Geffroy Y., Rodallec M.H., Boulay- Coletta I., Jullès M.-C., Fullès M.-C., Ridereau-Zins C., et al.: Multidetector CT angiography in acute gastrointes-tinal bleeding: why, when, and how. Radiographics, 2011, 31: E35-46.

11. Ernst O., Bulois P., Saint-Drenant S., Leroy C., Paris J.-C., Sergent G.: Helical CT in acute lower gastrointes-tinal bleeding. Eur Radiol, 2003, 13: 114-117.

12. Sabharwal R., Vladica P., Chou R., Law P.W.: Helical CT in the diagnosis of acute lower gastrointestinal haem-orrhage. Eur J Radiol, 2006, 58: 273-279.

13. Graça B.M.B., Freire P.A., Brito J.B., Ilharco J.M., Carvalheiro V.M., Caseiro-Alves F.: Gastroenterologic and radiologic approach to obscure gastrointestinal bleeding: How, why and when? Radiographics, 2010, 30: 235-252.

emergency nuclear imaging is not everywhere and always available.

In contrast, CA is more suited for urgent situations and allows imme-diate therapeutic intervention (6). Disadvantages of this procedure include the risk of adverse reactions to intravenous administered contrast material and catheter induced complications as well as its detection rate of 0.5 ml/min (7). Additionally, false positives may occur in CA since there may be artefacts from peristal-sis and bowel gas movement (8).

CTA is a validated technique (9), commonly used in clinical prac-tice (10) and known for several years (11). The detection rate is 0.3ml/min, lower than CA and almost approaching the sensitivity of 99m-Tc RBC scintigraphy. Besides, it is minimally invasive, widely available and the development of multi-detec-tor CT has significantly reduced ac-quisition times.

Sabharwal et al. compared CA with CTA and proved that CTA has a higher sensitivity to detect active bleeding (12). However, CTA does not allow performing a simultaneous therapeutic intervention. Additional-ly, LGIB can be intermittent and this can influence the comparison of dif-ferent modalities for detection (2).

A major advantage of CTA is that besides its accuracy in detecting a bleeding site, it may also reveal the aetiology or the underlying patholo-gy and thus influence the subse-quent management (13). In addition to identifying the underlying cause it also illustrates the vascular anatomy and it allows rapid targeted emboli-zation without the need of perform-ing an extensive diagnostic angiog-raphy of all vascular territories (13).

In summary, although we know for sure there is a LGIB, CA is limited in demonstrating the bleeding site. As demonstrated in the literature CTA can play an important role in di-agnosis and subsequent therapy. The possible contradiction between CTA and CA may cause a dilemma, having to chose between interrupt-ing the interventional radiology pro-cedure and waiting for a rebleeding to continue in a critical patient, or continuing and embolizing the pre-sumed vessel of origin according to the CTA images. Our cases demon-strate the literature findings that CTA can guide subsequent embolization, even in the absence of acute bleed-ing during the angiographic proce-dure. CTA is known to have a posi-

ing site (Fig. 3). After correlation with the CTA images, selective emboliza-tion of the presumed vessel with polyvinyl alcohol (PVA) particles 500-710 μ (Cook Incorporated, Bloomington, USA) and gelfoam particles was executed.

Outcome

In both cases there was no clinical evidence of rebleeding after the se-lective embolization procedures. Our first patient was discharged from the intensive care and transferred to the cardiology department after 72 hours because his vital parameters were stable since the embolization.

The second patient with an em-bolised post-polypectomy bleeding was discharged from the hospital on the next day.

discussion

Lower gastro-intestinal bleeding (LGIB) is defined as a bleeding site localised in the colon or anorec-tum (1).

LGIB is most important in the elderly as its frequency increases with age (> 200 fold from 20 to 80 years) (2).

Currently, the standard diagnostic procedures in LGIB are colonoscopy, Technetium-99m (99m-Tc) labelled red blood cell (RBC) scintigraphy and CA, without one being clearly supe-rior to the others (3).

Frattaroli et al compared the diag-nostic accuracy of endoscopy and MDCT. He found that CTA revealed not only all bleeding sites that were visualised with colonoscopy but also the bleeding site in all patients that were negative in colonoscopy. Addi-tionally CTA revealed the aetiology of the bleeding in 88.2% of the cases, compared to 52.9% of the cases for endoscopy. There are several rea-sons why endoscopy was not able to demonstrate the bleeding site: ex-cessive blood in the colon, poor visi-bility due to insufficient colonic toilet and because the caecum could not be reached (4).

Even though 99m-Tc RBC scinti-graphy is the most sensitive method for detecting GIB with a detection rate of 0.1 ml/min and is aiming to identify intermittent bleeding, it has several disadvantages. First, it locali-ses the bleeding only to an area of the abdomen and the intestinal motility moves the intraluminal blood away. Second, it does not allow therapeutic intervention (5). Third,


Electrical injuries to the extremi-ties are a relatively uncommon formof trauma and may be responsiblefor a range of delayed neurologicmanifestations (1). As an increasingnumber of such injuries are exploredby MR imaging, potential abnormal-ities related to this condition arebeing discovered. We report a caseof high-voltage cerebral electricalinjury with delayed symptoms andwith imaging abnormalities. Only avery precise anamnesis could help inmaking the link between the imagingabnormalities and the injury.

Clinical case

A 42-year-old man came to theemergencies in June 2010 showing afirst crisis of seizure with right hemi-paresia and language disability last-ing for few minutes followed by apost-critic paresis. CT scanner of thebrain was normal (Fig. 1).He had no clinical and no surgical

history except for an occupationalincident in July 2006 when he expe-rienced an electrical shock whileworking in an elevator. The electricalcurrent got through his right hand,the patient collapsed and lost con-sciousness for few minutes. His righthand was slightly burned for a fewdays. No further worked up was performed.Four years after this electrical

incident, the first seizure occurred.Brain MR imaging was performedone month after the seizure anddemonstrated an increased T2 andFLAIR signal intensity in the left fronto-parietal white matter insidethe rolandic sulcus. There was aslight enhancement seen aroundand no mass effect (Fig. 2). On theT2*-weighted gradient echo (GE)

Discussion

Electric shock is a relativelyuncommon form of trauma and theseverity of the injury depends on thetype of current used and the appliedvoltage. High voltage shock isresponsible for persistent and severecomplication of electrocution (2).Low voltage electrical shocks are themost reported types of electro -cutions and most of the related com-plications are relatively minor andtransient (3). However, patients sur-viving high-voltage electrical injurymay show delayed sequelae (4) likeclonus, limb dystonia (5), parkinson-ism (7), or tremor. The mechanismsof these symptoms are unknownand the hypothesis of a direct dam-age to the nervous system or adelayed indirect effect such as denervation has been proffered (8).The abnormalities seen on the T2*weighted axial images in our patientsuggest that haemorrhage occurredon the cortical somatosensory areasof his left hemisphere. Functionalorganization of the primary motor

sequence, sensitive to the inhomo-geneity in static magnetic fields,multiples punctuate foci ofhypointensities were seen along thecortex of the precentral and the postcentral gyri of the left rolandic sulcus(Fig. 3). These foci were not sur-rounded by oedema and were notvisible on other sequences.A second brain MR imaging, per-

formed one week later in theabsence of contrast showed thesame foci of hypointensities alongthe left rolandic cortex on the T2*-weighted GE sequence. On this MRI,the T2 and FLAIR signal intensity inthe left fronto-parietal white matterinside the rolandic sulcus complete-ly disappeared without subsequentvolume loss within the left corti-cospinal tract (Fig. 4).The evolution leads us to con-

clude that the transient T2 signalabnormality in the white matter wasrelated to a post-critic oedema dueto the epileptic event that hadoccurred one month previously.The multiples punctuate foci of

hypointensities were considered assequelae related to the electricalshock underwent 4 years before.Thanks to detailed interrogation, ithas been evidenced that the patientwas presenting from time to time asthe incident itched in his right fingers.The localisation of the abnormali-

ties in the left somatosensory cortex,the signal loss on T2* sequence andthe clinical history lead us to suspectthat the patient’s imaging findingsrepresented a cortical sequela of acerebral electrocution injury and thatthe epileptic crisis was caused by thesequelae essentially because theclinical appearance of the epilepticcrisis oriented through a left corticalpathology.

JBR–BTR, 2013, 96: 81-83.

IMAGING OF EPILEPSY FOLLOWING ELECTRICAL INJURYC. Neugroschl1, S. Berrada2, J.-A. Elosegi3, C. Winant1

Electrical injury may result in brain injury with delayed symptoms and sequelae. We report a case of high-voltagecerebral electrical injury in a 42-year-old man through his right hand with delayed symptoms and with imagingabnormalities suggesting that haemorrhage had occurred on the cortical somatosensory areas of his left cerebralhemisphere. An appropriate patient’s clinical history should be obtained to correlate the lesions to the event as delaybetween the event and the symptoms can be very long.

Key-word: Epilepsy.

From: Department of 1. Neuroradiology, 2. Radiology, 3. Neurology CHUPMB, Mons.Address for correspondence: Dr C. Neugroschl, M.D., Department of Neuroradiology,CHU Ambroise Paré, 2 Boulevard Kennedy, B-7000 Mons, Belgium.E-mail: [email protected]

Fig. 1. — Axial CT without contrast atthe rolandic level shows no abnormality(no hemorrhage nor calcification).

neugroschl-_Opmaak 1 25/04/13 11:28 Pagina 81

82 JBR–BTR, 2013, 96 (2)

Fig. 2. — Axial T1-weighted (A), T2-weighted (B), diffusion weighted (C), FLAIR- (D, E) and T1 weighted with contrast (F) imagesshow an increased increased T2 and FLAIR signal intensity in the left fronto-parietal white matter inside the rolandic sulcus (B, D, E)and a slight enhancement (F, arrow).

FD E

CA B

Fig. 3. — Axial T2 gradient echo image shows hypointensities along the cortex of the precentral and the post central gyri of theleft rolandic sulcus.

CA B


and somatosensory cortex (SI) iswell established, with digit represen-tation along the postcentral gyrus.This somatotopic organization hasbeen detected with several tech-niques, including fMRI. Tactile stimu-lation of the hand is known to acti-vate the SI located in the cortex ofthe contralateral central sulcus (9). Inour case, the abnormalities areexactly located on the contralateralsomatosensory cortex of the righthand which was injured. This sug-gests a sensory input through thenervous circuit to the contralateralprimary motor and somatosensorycortex.Only few cases have been report-

ed with MR abnormalities (10) and toour knowledge, none had cortical

References

1. Cherington M.: Neurologic manifesta-tions of lightning strikes. Neurology,2003, 60: 182-185.

2. Wilbourn A.J.: Peripheral nerve disorders in electrical and lightninginjuries. Semin Neurol, 1995, 15: 241-255.

3. Fontanarosa P.B.: Electric shock andlightning strike. Ann Emerg Med,1993, 22 (2PT2): 378-387.

4. Adler C.H., Caviness J.N.: Dystoniasecondary to electrical injury: surfaceelectromyographic evaluation andimplications for the organicity of thecondition. J Neurol Sci, 1997, 148: 187-192.

5. Deveci M., Bozkurt M., Sengezer M.:Clonus: an unusual delayed neuro-logical complication in electricalburn injury. Burns, 2001, 27 (6): 647-651.

6. Jankovic J., Pardo R.: Segmentalmyoclonus. Clinical and pharmaco-logic study. Arch Neurol, 1986, 43:1025-1031.

7. Colosimo C., Kocen R.S., Powell M.,et al.: Torticollis after electrocution.Mov Disord, 1993, 8: 117-118.

8. Jankovic J.: Post-traumatic move-ment disorders: central and peri -pheral mechanisms. Neurology, 1994,44: 2006-2014.

9. Neugroschl C., Denolin V., Schuind F.,Van Holder C., David P., Balériaux D.,Metens T.: Functional MRI activationof somatosensory and motor corticesin a hand-grafted patient with earlyclinical sensorimotor recovery. EurRadiol, 2005, 15: 1806-1814. Epub2005 22.

10. Johansen C.K., et al.: Cerebralcortico spinal tract injury resultingfrom high voltage electrical shock.AJNR Am J Neuroradiol, 2008, 29:1142-1143.

hemorrhagic sequelae described onMRI. In our case, the correct diagno-sis was important as it correspondedto an occupational incident, there-fore, even 4 years after the event, thesequelae could be considered forinsurance.

Conclusion

Electrical injury may result inbrain injury with delayed symptomsand sequelae. With MRI, somelesions may be detected. Howeveran appropriate clinical historyshould always been performed inorder to correlate the lesions to theevent. This can be very importantespecially in the context of an occu-pational accident.

IMAGING OF EPILEPSY FOLLOWING ELECTRICAL INJURY — NEUGROSCHL et al 83

Fig. 4. —Axial FLAIR images show total disappearance of the parenchymal anomalies.

A B


Case report

A 45 year-old-male presented with history of off and on fever for the past 2 weeks, malaise and progres-sive abdominal distension for the past six months. His previous medi-cal history was otherwise normal.

On examination, patient was alert and oriented; there was no evidence of pallor or yellowish discoloration of eyes. Per abdomen examination revealed hepatomegaly with firm nodules palpable on it. Overlying skin was normal with no evidence of local rise of temperature. There was no palpable superficial lymphade-nopathy or splenomegaly. Haemato-logical and blood chemistry tests (RFT, ESR) were within normal lim-its. Surprisingly, liver enzymes were also within normal limit. Serology was negative for HIV and hepatitis B and C viruses.

He was referred to radiology sec-tion for Computed Tomography (CT) whole abdomen. CT showed multi-ple well defined, hypodense nodular masses distributed in both lobes of liver. After administration of con-trast, masses showed homogenous, mild enhancement (Fig. 1). There was evidence of displacement of vessels by masses in both lobes, which were distributed in subcapsu-lar location. No evidence of dilated biliary channels, vascular invasion or thrombosis was seen. Also, spleno-megaly and retroperitoneal lymph-adenopathy was notably absent. A list of space occupying lesions of liver including metastasis, haeman-gioma, and lymphoma was consid-ered in the differential diagnosis.

myeloproliferative disorder, bone marrow biopsy was also performed which did not showed any abnor-mality.

Final diagnosis of primary liver Non Hodgkin’s lymphoma was made and the patient underwent treatment which included cyclophosphamide, doxorubicin, vincristine and predni-sone (CHOP) regimen. Patient showed improvement of symptoms at 12 months follow up period, but presented again after 15 months of initial diagnosis with complains of paraplegia of acute onset. There was sensory loss up to T4 level, 0/5 weak-ness in B/L lower limbs, plantar were B/L flexors. He was immediately tak-en for MRI dorsal spine. MRI showed multiple altered signal intensity le-sions within the substance of cord at lower cervical and upper dorsal lev-els and vertebral bodies suggestive of secondary spread. He was given high dose methotrexate, but during the hospital stay patient developed respiratory complications and unfor-tunately could not be revived.

Alpha-feto protein (AFP) and carcino-embroyonic antigen (CEA) were also not elevated. Patient was advised bi-opsy to determine the nature of the lesions. FNA biopsy showed, mono-morphic population of atypical lym-phoid cells having hyperchromatic nuclei with fine opened up chroma-tin and scant cytoplasm (Fig. 2). Hist-pathology confirmed it to be large B-cell lymphoma. Further workup with CECT neck and chest did not re-vealed presence of mediastinal or cervical lymphadenopathy at any other site. Whole body fluorodeoxy-glucose positron emission tomogra-phy (FDG-PET) and Ga-scintigraphy were performed which did not show any other lesion. To confirm the

JBR–BTR, 2013, 96: 84-86.

PRIMARY LIVER LYMPHOMAS. Khalid1, S. Zaheer2, M. Khalid1, S. Zaheer3, M. Sheeraz Alam4

Lymphomatous involvement of liver is common in lymphoma, but primary non Hodgkin’s liver lymphoma is a rare entity. We present a case report of a middle aged male who was diagnosed with primary liver lymphoma after a long and exhaustive work up. Symptoms initially improved with chemotherapy but presented fifteen months later with central nervous system and vertebral dissemination. Primary liver lymphoma, even though rare should be kept in differentials of multiple space occupying lesions of liver with no evidence of vascular invasion, especially if there is no associated lymphadenopathy or spleen involvement.

Key-words: Liver neoplasms, diagnosis – Lymphoma, diagnosis.

From: 1. Department of Radiodiagnosis, 2. Department of Radiotherapy, 3. Department of Pathology, 4. Department of Medicine, Jawaharlal Nehru Medical College, AMU, Aligarh, India.Address for correspondence: Dr S. Khalid, M.D., Senior Resident, Department of Radio-diagnosis, Jawaharlal Nehru Medical College, AMU, Aligarh, UP, India – 202002. E-mail: [email protected]

Fig. 1. — Axial CECT of the abdomen in portal venous phase shows multiple well defined hypodense mildly enhancing nodules distributed in both lobes of liver displacing vessels with no evidence of vascular invasion or thrombosis and biliary dilatation. No splenomegaly nor lymphadenopathy is noted.

khalid-CS5-OK.indd 84 4/04/13 10:35

PRIMARY LIVER LYMPHOMA — KHALID et al 85

Discussion

Liver involvement by secondary Non Hodgkin’s lymphoma is relatively common. Primary liver lymphoma (PLL) is extremely rare. Among all extra nodal lymphomas, PLL consti-tutes < 1% of all cases (1,2).

Lei KI proposed the following cri-teria for the diagnosis of PLL: at the time of diagnosis, symptoms are mainly attributable to liver involve-ment, absence of clinically palpable lymphadenopathy and no radiologi-cal evidence of distant lymphade-nopathy, and peripheral blood smear shows no evidence of leukemic cells (2).

Due to its rare occurrence, aetiol-ogy is poorly understood. However, association between PLL and hepati-tis C has been reported (3, 4, 5). Higher incidence is seen in immuno-compromised patients (6). HBV and chronic hepatitis have also been im-plicated (7) but some disagree (8). PLL typically occurs in middle aged males as seen in our case. There is 2:1 male predominance reported (2, 9). Presentation is usually with com-plains of abdominal pain, distension, fever and weight loss (8).

On Ultrasonography (USG), PLL typically appears as multiple hypo-echoic masses in both lobes of liver. CT features are multiple, well defined hypodense lesions with no evidence of vascular or biliary channels inva-sion. On administration of contrast, mild homogenous or peripheral con-trast enhancement is seen. However, a significant number may not show any enhancement and can be detect-

cular (4, 8, 12) and other had been described.

PLL has been considered an ag-gressive disease with poor progno-sis (8). Emile J.F. et al. suggested that prognosis depends on whether the disease is nodular or there is dif-fuse liver infiltration (13). They con-cluded that diffuse liver infiltration has a poor prognosis while lympho-ma with nodular infiltration has a good prognosis with anthracycline based chemotherapy.

Treatment modalities include sur-gical resection, chemotherapy and radiotherapy alone or in combina-tion. Page RD et al. noted favourable results with combination chemother-apy (5). CHOP regime is the standard treatment for patients with diffuse large B cell lymphoma. Rituximab (monoclonal antibody targeting CD 20) augments survival when used with CHOP regime in elderly patients with diffuse large B-cell lymphoma without significant increase in toxic-ity (14). Our patient also responded

ed even on non- contrast scans (9). On MRI, they are moderately low in signal intensity on T1W sequence and mild to moderately hyperintense on T2W sequence and shows rim or no enhancement or contrast agent accumulation in the hepatobiliary phase (9-11). They are of high sig-nal intensity on diffusion-weighted imaging (DWI). However, these lesions demonstrate a very low ap-parent diffusion coefficient (11).

These lesions cannot be differenti-ated from lesions of lymphoma with secondary liver involvement. How-ever, lymphadenopathy and lesions in other organs/site helps to differen-tiates them. Liver is second only to regional lymph nodes as a site for metastatic disease. Metastasis also presents with multiple lesions in both lobes of liver, but enhancement pattern helps to differentiate them from lymphomatous deposits. The metastatic deposits may show hyper enhancement which is unlikely in lymphomatous lesions. Rim en-hancement may present a diagnostic difficulty. Lymphomatous deposits displace vessels whereas metastatic lesions invade them. Haemangioma is the most common benign lesion of liver, atypical hemangioma are hypoechoic on USG, but have a characteristic ‘centripetal fill in’ on the delayed post contrast scans which helps to confirm the diagno-sis.

On histology, the most common subtype of PLL is diffuse large B-cell lymphoma, as was seen in our case (2, 4). A few cases of small lymphocytic, T cell, anaplastic, folli-

Fig. 2. — Fine needle aspirate smear, showing monomorphic population of atypical lymphoid cells having hyperchromatic nuclei with fine opened up chromatin & scant cytoplasm consis-tent with diffuse large B-cell lymphoma (H&E, 40×).

Fig. 3. — Sagittal MR T2W images show multiple hyperintense lesions in the cord at lower cervical and upper dorsal levels and vertebral bodies suggesting secondary spread.


86 JBR–BTR, 2013, 96 (2)

well to CHOP regime with significant resolution of symptoms until he presented with again with acute onset paraplegia. He was given methotrexate for relapse but patient expired due to aspiration.

Teaching point

There are no specific radiological features which can confirm the diag-nosis but diffusion weighted MRI and contrast pattern may suggest the diagnosis. PLL should be con-sidered in the differential diagnosis of multiple well defined space occu-pying nodular lesions in liver with no evidence of vascular invasion or associated lymphadenopathy. Final confirmation comes from histopath-ological examination.

References

1. Freeman C., Berg J.W., Cutler S.J.: Occurrence and prognosis of extra-nodal lymphomas. Cancer, 1972, 29: 252-260.

9. Maher M.M., McDermott S.R., Fenlon H.M., et al.: Imaging of prima-ry non-Hodgkin’s lymphoma of the liver. Clin Radiol, 2001, 56: 295-301.

10. Steller E.J., van Leeuwen M.S., van Hillegersberg R., et al.: Primary lym-phoma of the liver – A complex diagnosis . World J Radiol, 2012, 28, 4: 53-57.

11. Kaneko K., Nishie A., Arima F., et al.: A case of diffuse type of primary he-patic lymphoma mimicking diffuse hepatocellular carcinoma. Ann Nucl Med, 2011, 25: 303-307.

12. Gomyo H., Kagami Y., Kato H., et al.: Primary hepatic follicular lymphoma : a case report and discussion of chemotherapy and favorable out-comes. J Clin Exp Hematop, 2007, 47: 73-77.

13. Emile J.F., Azoulay D., Gornet J.M., et al.: Primary non-Hodgkins’ lympho-mas of the liver with nodular and dif-fuse patterns have different progno-sis. Ann Oncol, 2001, 12: 1005-1010.

14. Coiffier B., Lepage E., Briere J., et al.: Chop chemotherapy plus rituximab compared with chop alone in elderly patients with dif fuse large-B-cell lym-phoma. N Engl J Med, 2002, 346: 235-242.

2. Lei K.I.: Primary non-Hodgkin’s lym-phoma of the liver. Leuk Lymphoma, 1998, 29: 293-299.

3. Bronowicki J.P., Bineau C., Feugier P., et al.: Primary lymphoma of the liver : clinical-pathological features and relationship with HCV infection in French patients. Hepatology, 2003, 37: 781-787.

4. Page R.D., Romangura J.E., Osborne B., et al.: Primary hepatic lymphoma. Favourable outcome after combination chemotherapy. Cancer, 2001, 92: 2023-2029.

5. Agmon-Levin N., Berger I., Shtalrid M., et al.: Primary hepatic lymphoma: a case report and review of the literature. Age Ageing, 2004, 33: 637-640.

6. Avlonitis V.S., Linos D.: Primary he-patic lymphoma: a review. Eur J Surg, 1999, 165: 725-729.

7. Ohsawa M., Aozasa K., Horiuchi K., et al.: Malignant lymphoma of the liver. Report of five cases and review of the literature. Dig Dis Sci, 1992, 37: 1105-9.

8. Lei K.I.K., Chow J.H.S., Johnson P.J.: Aggressive primary hepatic lympho-ma in Chinese patients. Presentation, pathologic features and outcome. Cancer, 1995, 76: 1336-1343.


Case report

A 73 year old man with a history of multiple myeloma and pulmonary embolism presents at the emergen-cy department with progressive dyspnea. A CT-angiography of the pulmonary arteries showed no pul-monary embolism or other relevant thoracal disease.

The next two weeks dyspnea in-creased and wheezing arose. Hence the man was examined by the oto-rhinolaryngologist. A laryngoscopy demonstrated a subglottic stenosis with an estimated lumen diameter of 50%. Subsequently, a CT study of the neck was done which showed a bulging mass arising from the cricoid cartilage resulting in a significant subglottic stenosis (Fig. 1 A, B (white arrows). The mass is horseshoe-shaped with a free anterior border and a cranial-caudal length of 2 cm. The mass has a slightly hyperdense solid consistence with shell-like cal-cifications in its periphery. There is no aggressive growth in the adjacent structures. No lymphadenopathies were seen in the examined region.

Additionally, a number of osteo-lytic bone lesions are visible in verte-bral bodies (Fig. 1C (white arrows), in the right clavicle (Fig. 1A, black ar-row) and in the sternal bone (Fig. 1C (white arrow)).

As the patient was known with multiple myeloma, treated by chemo therapy from 2009 till 2011, a cricoid localisation of multiple myeloma was hypothesized.

Given that a differentiation be-tween a cricoid location of multiple myeloma versus primary subglottic

Non-squamous cell malignancies of the larynx, hypopharynx and cer-vical esophagus are extremely rare. These include sarcomas, lymphoma and malignant minor salivary gland tumors. Squamous and non-squa-mous cell malignancies invade the cricoid cartilage secondary.

The mass in this patient appeared to involve only the cricoid. Thus a cartilaginous tumor, namely a chon-drosarcoma or chondroma, should be considered. These typically pres-ent as an expansile mass within the cartilage with intact mucosal surfac-es, containing arc or ring-like calcifi-cations. Laryngeal chondroma or chondrosarcoma cannot be distin-guished based on their imaging fea-tures. Most chondrosarcoma are low grade with good prognosis, however outcome worsens in patients with myxoid or dedifferentiated chondro-sarcoma.

Metastatic disease in the larynx by distant malignancies is very rare (2). Most frequently the primary tumor in these cases is cutaneous melano-ma or renal carcinoma. Sporadic cases originating from lung and co-lon adenocarcinoma have also been documented. Contrary to squamous cell carcinoma, metastatic disease tends to leave the mucosa intact.

This patient was known with mul-tiple myeloma. Therefore an extra-medullary plasmacytoma (EMP) in-volving the thyroid cartilage should also be considered. EMP of the cri-coid cartilage is a very rare entity with less than 10 cases described in literature (3, 4). After osseous meta-plasia with formation of a central marrow space, plasmacytoma may originate within the cricoid marrow, or disseminated plasma cells may be seeded and grow in the marrow space.

Multiple myeloma is next to non-Hodgkin lymphoma the most common hematological malignancy

malignancy invading the cricoid car-tilage was necessary for adequate therapy, a tracheoscopy with needle biopsy of the mass was performed. Histopathology and cytology showed groups of plasma cells consistent with multiple myeloma.

Treatment consisted of radio-therapy and peroral steroids.

A follow-up CT study 6 months af-ter therapy, showed a considerable volume decrease of the mass lesion (Fig. 2, white arrows), with decrease of the subglottic stenosis. The patients’ dyspnea and wheezing vanished.

Discussion

A subglottic mass in elder males leads to a rather broad differential diagnosis (1). First of all, a squamous cell carcinoma should be considered. If the lesion seems to originate from a laryngeal cartilage structure, a chrondrosarcoma or chondroma is at the top of the diagnostic list. With a history of multiple myeloma, an extramedullary plasmacytoma af-fecting the cricoid cartilage should also be included within this list. All mentioned pathologies occur mostly in older male patients.

The most common origin of a sub-glottic mass narrowing the airway lumen is squamous cell carcinoma. Especially in older males with chron-ic tobacco and alcohol use, it is the most likely diagnosis. Cricoid carti-lage alterations include lysis and sclerosis. Contrary to our case, this may be accompanied by infiltration of the glottic and extralaryngeal soft tissues.

JBR–BTR, 2013, 96: 87-88.

multiple myeloma iNVolViNG tHe CRiCoiD CaRtilaGeB. Floré1, R. Hermans1

We present the case of a man with dyspnea due to a mass in the cricoid cartilage that turns out to be an extramedullary plasmocytoma. although the patient has a history of multiple myeloma, the disease only rarely affects the cricoid cartilage. other subglottic lesions possibly involving the cricoid cartilage are squamous cell carcinoma, chondroma, chondrosarcoma and metastasis. the imaging characteristics suggesting extramedullary plasmocytoma arising from the cricoid consist of thinning and expansion of the cartilage laminae without mucosal lesions nor soft tissue mass adjacent to the cricoid cartilage. the patient was successfully treated with radiation therapy and peroral steroids.

Keyword: plasmacytoma.

From: 1. Department of Radiology, University Hospitals Leuven, Leuven, Belgium.Address for correspondence: Prof Dr R. Hermans, M.D., Herestraat 49, B-3000 Leuven, Belgium. E-mail: [email protected]

floré-hermans-CS5-OK.indd 87 25/04/13 11:31

88 JBR–BTR, 2013, 96 (2)

(10%). Incidence rates are higher in men and increase with age, in par-ticular between age 65 and 70. When there is involvement of cricoid cartilage by multiple myeloma, the mucosa of the subglottic regions usually remain intact, without evidence of tumor extension into the airway. The thinning and expansion of the cartilage laminae, and the lack of a soft tissue mass adjacent to the thyroid cartilage, suggest that the mass originated within the cricoid itself.

Radiation therapy is a standard local treatment for multiple myelo-ma (4), as done in this case. The effects of radiation therapy are cumulative to systemic therapy with steroids, chemotherapy or bone marrow transplantation.

References

1. Hermans R. (ed.): Head and Neck Cancer Imaging, 2nd ed. Springer-Verlag, 2012, pp. 58-91.

2. Nicolai P., et al.: Metastatic Neo-plasms to the Larynx: Report of Three Cases. The Laryngoscope, 1996,106: 851-855.

3. Straetmans J., Stokroos R.: Extra-medullaryplasmacytomas in the head and neck region. Eur Arch Otorhino-laryngol, 2008, 265: 1417-1423.

4. Shimada T., et al.: Multiple myeloma involving the thyroid cartilage. Auris Nasus Larynx, 2007, 34: 277-279.

Fig. 2. — Follow-up CT study 6 months after treatment. The white arrows show a considerable volume decrease of the mass, with decrease of the subglottic stenosis.

Fig. 1. — A: White arrows show bulging mass in cricoid car-tilage resulting in a significant subglottic stenosis. Black arrow shows osteolytic bone lesion in right clavicle. B: White arrows show bulging mass originating from the cricoid resulting in a significant subglottic stenosis. The cricoid is still bordered by a thin, calcified layer. C: The white arrows on this sagittal refor-matting in bone window show multiple osteolytic bone lesions in different vertebrae and the manubrium sterni.

A

B

C

floré-hermans-CS5-OK.indd 88 25/04/13 11:31

Pancreas serous cystadenoma: typicalimaging aspect of a rare tumor

T. Kirchgesner1, W. Bou Sleiman1, X. Hamoir1, D. Salovic1, J. Kirsch1

Abdominal ultrasonography performed in a 54-year-old womansuffering from dyspepsia revealed a large pancreatic mass (Fig. A).CT showed an 8 cm rounded shape pancreatic head mass, slightly lobulated, hypodense but of non pure hydric density at its edge (15-20 UH) with a stellar-shaped calcified center (Fig. B). After iodineinjection, multiple thin septa were visible forming multiple smalllodges non-exceeding 2 cm diameter. Pancreatic head or bodywere not atrophic and main pancreatic duct size was < 3 mm.

Comment

This imaging aspect is pathognomonic of polycystic serous cys-tadenoma (SC). From 80 to 90% of SC are observed in women withan average age of 52 years. Less than half of the tumors are symp-tomatic and then diagnosis is incidental in more than half of thecases. The tumors can be located in head, body or tail of the pan-creas, but cephalic location is the most frequent (> 50%). Contrarilyto intraductal papillary mucinous neoplasms, SC does not commu-nicate with the pancreatic ducts. Pancreatic SC may present 3 dif-ferent morphological patterns. The most typical aspect is the poly-cystic pattern (70%). In that case the tumor is made by multiplecysts measuring less than 2 cm of diameter. The cysts are separat-ed by fibrous septa, which can converge into a central scar thatmay calcify. Less than 20% of SC show the honeycomb pattern con-sisting in multiple subcentimeter cysts that cannot be individuallydistinguished by CT or MRI. Finally, oligocystic pattern is the morerare subtype (10%) with few large cysts with a diameter over 2 cm.

The so-called «solid» variant of serous cystadenoma is extremely rare and actually corresponds to the honeycombpattern composed of microcysts. In ultrasonography SC is typically a hypo-echoic round-shape mass made by multi-ple hypo-echoic smaller cysts. Usually, if central scar is present it appears as hyper-echoic lesion. In addition thedoppler study can detect the septa vascularization and of pancreatic main duct dilatation are not observed. Typicalaspect in CT is superposable to the ultrasonographic aspect. Without contrast, the mass looks homogeneouslyhypoattenuating with density higher than water (10-40 HU) except the central calcifications if they exist. After iodineinjection septa show high enhancement individualizing cysts and central fibrous scar. Tumor edges are slightly lobu-lated and better seen after iodine injection. Typical MRI aspect is an agglomeration of small cysts without communi-cation with the main pancreatic duct. Cysts are hypo-intense in T1-weighted images and hyper-intense in T2-weightedimages, while central scar shows relative hyper-intensity in T1 and hypo-intensity in T2 weighted images. The centralscar is hypo-intense on every acquisition when calcified. After Gadolinium injection a late enhancement of the fibrouscentral scar and septa may be observed. SC is a slow growing tumor. Complications of tumors more than 10 cm (giantSC) may be rupture, obstructive chronic pancreatitis and compression/invasion of adjacent structures. Neoplasticdedifferentiation (cystadenocarcinoma) has been reported but is exceptional contrarily to mucinous cystadenoma.Asymptomatic patients are followed with cross-sectional imaging, while surgical resection is indicated only in symp-tomatic patients or in suspected cystadenocarcinoma. Therefore radiological studies are an essential step to recog-nize the typical aspect of the SC and guide the therapeutic algorithm. Radiologist implication is important in bothdiagnostic and pre-operative assessment especially to describe the tumor vascular relations when surgery is fore-seen.

Reference

Jin-Young Choi et al. Typical and Atypical Manifestations of Serous Cystadenoma of the Pancreas: Imaging Findings with Pathologic Correlation. AJR,2009, 193: 136-142.

JBR–BTR, 2013, 96: 89.


1. CHWAPI, Site Notre Dame, Service de radiologie, Avenue Delmée 9,7500 Tournai, Belgium.

A

B

image-kirchgesner-_Opmaak 1 23/04/13 13:06 Pagina 1

JBR–BTR, 2013, 96: 90.

Traumatic urinary bladder rupture: the usefulnessof CT cystography

P. Montigny, J. Pringot, M-F. Billemont, P. Matthys1

A 38-year-old male presented at the emergency unit with acute abdominal painand massive hematuria after a fall in the stairs of his home. At physical examination,tenderness was found in the hypogastric area and in both right and left iliac regions.The first radiological investigation performed was ultrasonography (Fig. A). Free liq-uid was found in the Morisson pouch, in the perihepatic-space and in the perisplenicfossa. The bladder contained blood clots and there was no liquid in the Douglaspouch. Active bleeding was not excluded. Unenhanced and contrast-enhanced CT ofthe abdomen in arterial, venous and late phase was performed and large amount ofintraperitoneal liquid was confirmed but without evident cause (Fig. B). There wereno visceral injuries neither skeletal lesion nor vascular lesion. 60 minutes later, anadditional cystography phase was performed and revealed a rupture in the superioraspect of the bladder with intraperitoneal spilling of contrast (Fig. C and D).

Consequently, the patient was admitted for surgical repair of the bladder defect.

Comment

In blunt abdominal trauma, rupture of the urinary bladder is an uncommoninjury. Intra peritoneal bladder rupture (10-20% of cases) occurs typically in patientwith already distended bladder. According to the literature, intraperitoneal bladderrupture constituted the third most frequent cause following bowel and mesenteryinjury of symptomatic intra-abdominal free fluid after blunt abdominal trauma.Iatrogenic and spontaneous causes include pelvic surgery, suprapubic or Foleycatheter placement, bladder biopsy, ureteral stent manipulations, radiation therapy,and infection. Conventional cystography has long been considered the gold stan-dard in evaluating patient with suspected traumatic bladder lesion. According toVaccaro et al (1) CT cystography represents an alternative and may be routinelyused in trauma patients with pelvic fracture as well as patients with hematuria oreven in patients with severe pelvic trauma with no known pelvic fractures.

Vaccaro et al. made a comprehensive review paper of CT cystographic findingsin bladder injury and established a comprehensive classification (Table I).

Intraperitoneal bladder ruptures and combined intraperitoneal and extraperi-toneal ruptures require laparotomy with surgical repair of the bladder defect.Contusions and interstitial injuries are managed conservatively with Foley catheter-ization. Most extraperitoneal ruptures may be treated with catheter drainage of thebladder (1). The detection of bladder rupture as well as its accurate classification isessential for optimal management of the patient and can be achieve by CT ondelayed cystographic images.

Reference

1. Vaccaro J.P., Brody J.M.: CT cystography in the evaluation of major bladder trauma. RadioGraphics, 2000, 20: 1373-1381.


1. Department of Medical Imaging, Clinique Sainte-Elisabeth, Bruxelles, Belgium.

A

B

C

D

I Bladder contusion Incomplete or partial tear of the bladder mucosa. Findings at conventional and CT cysto -graphy are normal.

II Intraperitoneal rupture CT cystography demonstrates intraperitoneal contrast material around bowel loops,between mesenteric folds, and in the paracolic gutters.

III Interstitial bladder injury Intramural or partial-thickness laceration with intact serosa. CT cystography may demon-strate intramural contrast material without extravasation.

IVa Simple extraperitonealrupture

Extravasation of contrast material confined to the perivesical space.

IVb Complexe extraperitonealrupture

The contrast material extends beyond the perivesical space and may dissect into a varietyof fascial planes and spaces.

V Combined bladder injury CT cystography usually demonstrates extravasation patterns that are typical for both typesof injury.

Note: There are reported cases of surgically proved combined ruptures in which only one component of bladder injury wasdemonstrated at cystography.

image-montigny-_Opmaak 1 23/04/13 13:07 Pagina 1

Bilateral exostoses of the internal auditory canal

L. Dewachter1, F. Govaere1, I. Crevits1, R. De Man1

A 54-year-old female patient presented to her physician with a 3-year-old history of bilateral tinnitus and hearing loss. She also complained of paresthesiain the periauricular area. There were no episodes of imbalance or vertigo.Otologic history revealed that she had experienced a left serous otitis media

in 2008 and multiple episodes of otitis media as a child. The head and neck exam-ination yielded normal findings. Otologic examination revealed an atelectatictympanic membrane on the left side. Pure tone audiometry displayed a mildmixed hearing loss on both sides.CT and MRI scan were performed. Temporal bone CT scan (Fig. A) showed

bilateral prominent broad based bony growths of the anterior openings of theinternal auditory canal (IAC) resulting in a stenosis of the IAC on the right side(Fig. A1) and a narrowing of the IAC on the left side (Fig. A2).T1-weighted MRI (Fig. B) showed a hypo-intens lesion in the anterior opening

of the right IAC in contact with the statoacoustic nerve. A similar smaller lesionwas seen on the left side.The lesions showed a very low signal intensity on the 3D T2-weighted DRIVE

sequence (Fig. C) which could be compatibel with bone or calcification. This wasconfirmed on the MDCT.Based on these imaging findings, the diagnosis of bilateral IAC exostoses was

made.Because of the mild hearing loss the patient was treated conservatively and

clinical follow-up was recommended.

Comment

Exostoses, as well as osteomas are benign slow-growing bony lesions of theauditory canal. They are common in the external auditory canal but are rare inthe internal auditory canal. The cause remains unclear. Reported etiological factors are trauma, infection,

inflammation, developmental and genetic abnormalities.In most cases exostoses and osteomas remain asymptomatic but they may

cause symptoms due to a local compressive effect. Depending on their exactlocation and size they can manifest as hearing loss, vertigo or tinnitus.Since a biopsy specimen of the IAC cannot easily be obtained, the radiograph-

ic appearance is important in differentiating between different bony lesions.Exostoses are smooth-bordered, broad-based bony lesions growing into the

IAC. They are often multiple and bilateral whereas osteomas are solitary, stalkedlesions. Osteomas may also be differentiated from exostoses by the radiograph-ic appearance of bone marrow.On histologic specimen on osteoma displays fibrovascular channels within

the bone.Exostoses and osteomas are slow growing lesions and can remain stable for

many years. Treatment depends on the severity of the symptoms. Regular clini-cal follow-up and regular CT monitoring is recommended for asymptomaticlesions whereas surgical excision and decompression is the treatment of choicein patients with severe progressive symptoms.

Reference

1. Nguyen L., Baik F., Doherty J., Harris J., Nguyen Q.: Exostoses and Osteomas of theInternal Auditory Canal. Laryngoscope, 2010, 120: S215.

JBR–BTR, 2013, 96: 91.


1. Department of Radiology, Heilig-Hart ziekenhuis, Roeselare, Belgium.

A1

A2

B

C

image-dewachter-_Opmaak 1 25/04/13 11:34 Pagina 1

Transient restricted diffusion in thesplenium of the corpus callosumafter brain surgery

M. Beltran-Marin, N. Sadeghi1

We present the case of a 16-year-old male with 4th sur-gical intervention of a frontal oligodendroglioma grade IIbecause of metabolic and morphologic progression. Oneday after surgery he developed headache and low-gradefever lasting for 2 weeks. No neurological deficit wasobserved and biology showed no inflammatory syn-drome or metabolic disorder. Early postoperative MRI of the brain shows, in the

central portion of the splenium of the corpus callosum(CC), an ovoid area of homogeneous restricted diffusion,seen as a round homogeneous hyperintensity on diffu-sion-weighted imaging (DWI) (Fig. A) with decreasedADC values (Fig. B). This lesion is hyperintense on T2-weighted images and on fluid attenuated inversionrecovery (FLAIR) images, and slightly hypointense on T1-weighted images and shows no enhancement after con-trast agent administration (not shown).Follow-up MRI, after one month, shows complete

resolution of the signal anomaly of the splenium of theCC on DWI (Fig. C) and its corresponding ADC map(Fig. D).Isolated and focal reversible restricted diffusion in the

central area of the splenium of the CC is a particular phenomenon occurring in patients with viral encephalitis, meta-bolic disorders and status epilepticus or antiepileptic drugs withdraw.In ours case, the presence of low-grade fever and the absence of metabolic or epileptic related disorder suggests

encephalitis/encephalopathy as the most probable cause of this entity.

Comment

DWI is useful for evaluating cytotoxic edema due to excitotoxic brain injury, a common final pathway for variousneurologic diseases. When excitotoxic injury with less energy failure happens, it seems to cause a cytotoxic edemaof astrocytes and myelin sheaths, which protect neurons, and it seems to be transient and therefore, resolves on fol-low-up MR imaging. This mechanism is seen in epilepsy (status epilepticus or abrupt withdrawal of antiepilepticdrugs), toxic-metabolic disorders (hypernatremia and hypoglycemia) or in viral encephalitis/encephalopathy(Influenza virus, rotavirus, herpes-virus, adenovirus…).Regardless of the cause, clinically it may present with headache, fever, and seizures or may be silent. Callosal

disconnection syndrome is not associated.The specific location in the central splenium of the CC may be explained by the presence of a large number of

glutamate receptors and high enzymatic activity in this location. Based on the imaging of isolated, central area of restricted diffusion in the splenium of the CC on DW imaging a

history of epilepsy or metabolic disorder or infectious syndrome should be evaluated and treated and a follow up MRexamination should be proposed to confirm diagnosis based on the reversibility of the signal abnormality.Isolated focal reversible restricted diffusion in the splenium of the corpus callosum may be related to infection, meta-bolic disorders or epileptic conditions causing excitotoxic injury to astrocytes. Knowledge of MRI imaging findingsand the spectrum of diseases and conditions might prevent unnecessary invasive examinations and treatments.

Reference

1. Mortitani T., Smoker W.R.K., et al.: Diffusion-Weighted Imaging of Acute Excitotoxic Brain Injury. AJNR Am J Neuroradiol, 2005,26: 216-228.

JBR–BTR, 2013, 96: 92.


Department of Radiology, Erasme Hospital, Brussels, Belgium.

A B

C D

image-beltran-_Opmaak 1 23/04/13 13:09 Pagina 1

Appendicular intussusception with lym-phoid hyperplasia

Ph. Everarts1, E. Vanderveken2, M.O. Peny3, B. De Bont4

A 4-year-old boy is sent to paediatric consultation for night-recurring abdominal pain of 3 weeks duration.Clinical examination reveals a moderate pain to deep palpation

of the right iliac fossa. The rest of the clinical examination is unre-markable.Ultrasound (US) shows a slightly swollen 7 mm transverse

diameter appendix, electively sensitive. Swelling is the result ofhypoechogenic submucosal layer thickening, attributed to lym-phoid hyperplasia of the appendicular walls (Fig. A, black arrows).In addition, the mean portion of the appendix appears intussus-cepted in its distal portion (Fig. A, white arrows) and made protru-sion in the cecum, generating a target image (Fig. B). The proximalportion of the appendix is nodular and the end portion is normal(Fig. A). The ileocecal valve is well individualized and is normal.Blood biology proves to be normal. US performed 10 days later

finds the same aspect.Due to the persistence of symptoms, surgery by laparoscopy is

performed.The surgeon confirms intussusception but feared the presence

of anappendiceal tumor on the basis of the swollen and appendixnodular aspect.Histological analysis finds important lymphoid hyperplasia of

the appendiceal wall. No tumor process is found (Fig. C). Operatingsuites are uneventful and painful symptoms disappeared com-pletely.

Comment

Intussusception of appendix (IA) in children remains a very rarecondition, with an incidence estimated at 0.01% in children, andoccurring most often in the first decade of male children preferen-tially. The clinical presentation is highly variable and non-specific,combining abdominal pain and nauseas.In recent years, US diagnosis has been more common in the

pediatric population but remains hazardous and diagnosis by CT,endoscopy or barium enema is still describedt. The main reason isconfusion with the diagnosis of ileocecal intussusception and inmost reported cases, an attempt to reducing of ileocecal intussus-ception by enema before surgery is mentioned.The causes of IA can be multiple and are mostly described in

adults. The appendix is an organ rich in lymphoid tissue which canbe in hyperplasia. Appendicular lymphoid hyperplasia is wellknown but observation with US in combination with an IA hasnever been reported.We hypothesize that lymphoid hyperplasia has been the cause

for intussusception at the start of contractions of the cecum.Surgery is recommended to amend pain and especially to avoid

secondary colonic intussusception, which is described as a compli-cation of the IA.

In conclusion, this case illustrates the need for careful analysisof the ileo-caecal junction in diagnosis of ileocecal or appendiceal

intussusception. It also demonstrates for the first time the US appearance of appendiceal intussusception with lymphoid hyperplasia.

Reference

1. Koumanidou C., Vakaki M., Theofanopoulou M., et al.: Appendiceal and appendiceal-ileocolic intussusception: sonographic andradiographic evaluation. Pediatr Radiol, 2001, 31: 180-183.

JBR–BTR, 2013, 96: 93.


Department of 1. Radiology, 2. Pediatric Surgery, 3. Pathology, 4. Pediatry,CH Jolimont-Lobbes, Haine St Paul, Belgium.

A

B

C

image-everarts-_Opmaak 1 25/04/13 11:35 Pagina 1

Agenesis of the infrarenal inferiorvena cava

M. Devooghdt, N. Favoreel, B. van Holsbeeck,J. Marrannes, E. Laridon1

A 71-year-old man presented to the emergencyroom with complaints of progressive dyspnoe andpain in both lower extremities. His medical historyconsisted of multiple idiopathic deep vein thrombo-sis, familial deafness and cholecystolithiasis. Clinicalexamination revealed large varicose veins in bothlower extremities. A following electrocardiogram,echocardiography and radio graphy of the thoraxwere normal (not shown). D-dimeren had risen forwhich an angio CT of the thorax was performed. Thisshowed no pulmonary embolism (not shown). Avenous duplex of the lower extremities revealedinsufficiency of both the superficial and deep venoussystem (not shown). An abdominal CT with intra-venous contrast injection showed absence of theinfrarenal inferior vena cava (Fig. A), absence of thecommon iliac veins, enlarged ascending lumbar veins(Fig. B) and prominent anterior paravertebral collater-al veins (Fig. C) which lead to a prominent azygosvein (Fig. C). A complex venous collateral circulationwas found infrarenally (Fig. A) as well as in theabdominal wall (Fig. D). The suprarenal IVC was nor-mal (Fig. E), formed by confluence of the renal veins.Multiple calcifications in the enlarged internal andexternal iliac veins confirm a history of deep veinthrombosis (Fig. F).

Comment

The normal inferior vena cava is composedof four segments during embryogenesis: hepatic,suprarenal, renal and infrarenal. The hepatic segmentis derived from the right omphalomesenteric vein.The suprarenal segment is formed by the anastomo-

sis of the right subcardinal vein and the right omphalomesenteric vein. The renal segment is derived from the anas-tomosis of the right subcardinal and the right supracardinal vein. The infrarenal segment is derived from the rightsupracardinal vein. The azygos and hemiazygos vein are respectively formed from the right and left supracardinalvein, whereas the common iliac veins are derived from the posterior cardinal veins. IVC anomalies are the result ofan abnormal regression or persistence of these embryonic veins. Huntington and McLure proposed a classificationsystem and suggested 14 theoretical variations of the IVC of which 11 have been observed to this day. The prevalenceof agenesis of the IVC in the general population is thought to be 0.2%-1% (1). These patients are reported to have ahigher risk of lower-extremity venous insufficiency and deep vein thrombosis, characteristically with a more proximallocation, a younger age of onset and often bilateral involvement (1). IVC agenesis incidence in young people withlower limb deep vein thrombosis is estimated up to 5% (1). In our case the absence of the infrarenal IVC and the com-mon iliac veins with preservation of the suprarenal segment suggests failure of development of the posterior cardi-nal and supracardinal veins. However some authors consider such an embryonic event unlikely, and suggest perina-tal IVC thrombosis as etiology. The radiological importance of this anomaly is to avoid misdiagnosis of these vesselsas retroperitoneal lympha deno pathies and to report it in preoperative assessment.

Reference

1. Pop S., Opincaru I.: Anomalies of the inferior vena cava in patients with deep venous thrombosis. Pictorial essay. MedicalUltrasonography, 2012, 14: 53-59.

JBR–BTR, 2013, 96: 94.


1. Dpt of Radiology, UZ Leuven, Leuven, Belgium.

image-devooghdt-_Opmaak 1 23/04/13 13:10 Pagina 1

Hemoptysis in a 39-year-old smoker

I. Willekens, B. Ilsen, M. de Maeseneer, F. Vandenbroucke, J. de Mey1

A 39-year old man, a smoker without significant medical history, presented with vague chest pain, cough, and hemoptysis. His symptoms had started 2 weeks earlier. Radiography showed an area of decreased lucency (ground glass appearance) in the right lower lobe. CT scan confirms the presence of a triangular area of inhomogeneous parenchymatous increased attenuation mainly of ground glass with inlying bronchocoeles and tree-in-bud appear-ance compatible with an intrapulmonary sequestration. The arterial supply is derived from the lower thoracic aorta. The venous drainage is to the left atrium.

The hemoptysis is a result of a supratherapeutic International Normalized Ratio (INR) on Sintrom intake for atrial fibrillation (AF). Treatment of seques-tration consisted of a thoracoscopic lobectomy.

Comment

Pulmonary sequestration is a relatively rare anomaly comprising 0.15-6.4% of all congenital pulmonary malformations. An area of dysplastic and non-functioning lung parenchyma is present without a normal connection to the tracheobronchial tree and the pulmonary arteries. It receives its vascular supply from a systemic artery. It is anatomically classified as intralobar or extralobar.

Intralobar pulmonary sequestration is located within the visceral pleura and is surrounded by normal lung, whereas extralobar pulmonary sequestra-tion is separated from the lung by a pleural envelope. The venous drainage of intralobar pulmonary sequestration is generally through the pulmonary veins, whereas the extralobar variant usually has a systemic venous return. Intralobar sequestration, the most common form of pulmonary sequestra-tion, is most commonly localized in the lower lobes.

Patients may present with an incidental pulmonary lesion on imaging and otherwise remain asymptomatic. More commonly however, they may manifest varying types of pulmonary conditions such as pleural effusions or recurrent pneumonia. A few articles have reported more severe complications such as aspergillosis and even fatal hemoptysis. Although the aetiology of the hemoptysis is uncertain, it is thought to be related to high-pressure blood flow in the sequestered lung from the anomalous systemic arteries.

Imaging studies are important in the diagnostic process with the modality dependent upon patient age and also in the differential diagnosis. Chest radio graphy may reveal a homogenous lesion in the lung base (left side > right side) in uncomplicated intralobar sequestration, although complicated sequestration may present as a cystic lesion with air-fluid levels. In the adult, chest CT scan is most helpful, and will provide information about the vascular anatomy, crucial for operative treatment. Previously, catheter angiography was performed to diagnose sequestration and demonstrate its blood supply. However, presently helical CT angiography offers a less invasive way to demonstrate the abnormalities. Visualization of the anomalous arteries and veins is important to make the correct diagnosis of pulmonary sequestration and differentiating it from other lung abnormalities. The capability of CT angiography to simultaneously image the arterial supply, venous drainage, and parenchymal changes in a single examination makes it the imaging modality of choice.

The main treatment for pulmonary sequestration should be surgical resection with a ligation of an aberrant artery because of recurrent pulmonary infection and the unfavorable cardiac consequences caused by the existing aorto-pulmonary shunt.

Reference

1. Savic B., Birtel F.J., Tholen W., Funke H.D., Knoche R.: Lung sequestration: report of seven cases and review of 540 published cases. Thorax, 1979, 34: 96-101.

JBR–BTR, 2013, 96: 95.


1. Department of Radiology, UZ Brussel, Jette, Belgium.

A

B

C

D

image-willekens-CS5-OK.indd 1 23/04/13 13:11

Unusual case of “airway hyperreactivity” in a child with an incomplete double aortic arch with atresia of the left aortic arch

M. Aertsen, E Bijnens1

A 10-year-old girl had an obstructive breathing pattern with recurrent episodes of wheezing and stridor since infancy, identified and treated as hyperreactivity of the airways with little improvement. Clinical examination revealed a protosystolic ejection murmur (graded 2/6). Subsequent echo-cardiography revealed a dominant right aortic arch and an atretic left arch.

Cardiac computed tomography was performed and confirmed the domi-nant right aortic arch (Fig. A) with mirror-image branching. Additionally there was a diverticulum of Kommerell (Fig. A, B, and D arrows A) and a small per-sisting ductus arteriosus (Fig. B, arrow B). There was a discrepancy between the level of the ductus arteriosus and the tracheal narrowing, suggesting the presence of a fibrous cord.

Only one third of the patients with a vascular tracheobronchial compres-sion will demonstrate significant symptoms and thus the majority remains asymptomatic although a number of them are currently diagnosed with atypical asthma.

According to the classification of Shuford and Sybers there is a spectrum of congenital anomalies from the single right aortic arch to the double aortic arch. Firstly, differentiation between a single right aortic arch with mirror-image branching from a double aortic arch with an atretic left arch (Fig. D) is important because there is an important correlation of a single right aortic arch with congenital heart diseases. Secondly, because the fibrous cord in patients with an atretic left aortic arch has to be searched and transected by the surgeon to relief the tracheobronchial compression.

Schlesinger et al described some objective characteristics in favour of the diagnosis of an incomplete double aortic arch with atresia of the distal left arch. First, there is a symmetric appearance of the subclavian and common carotid artery originating from the right and incomplete left aortic arch. Next, the incomplete left aortic arch is positioned more posteriorly in comparison with the innominate artery in the right aortic arch, however this is to some extent subjective. Finally there is a diverticulum on the descending aorta when there is an incomplete left aortic arch.

Multidetector computed tomography (MDCT) and magnetic resonance imaging (MRI) are the modalities of choice and the advantage of MDCT over MRI is its superior spatial resolution and the shorter acquisition time, in contrast MRI has the advantage of a higher intrinsic contrast resolution and its superiority in cardiac anatomy and physiologic evaluation. Both techni-ques do not allow to directly visualizing obliterated vascular segments and do not evaluate dynamic compression of the airway.

In conclusion we state that it is important to consider anatomical variants causing a vascular ring in children having atypical respiratory complaints and recurrent respiratory infections despite adequate treatment.

References

1. Marmon L.M., Bye M.R., Haas J.M., et. al.: Vascular rings and slings: long term follow-up of pulmonary function. J Paediatr Surg, 1984, 19: 683-690.

2. Kussman B.D., Geva T., McGowan F.X.: Cardiovascular causes of airway compres-sion. Paediatr Anaesth, 2004, 14: 60-74.

3. Shuford W.H., Sybers R.G.: The aortic arch and its malformations. Charles C. Thomas Publisher, Springfield, Illinois, 1974.

4. Schlesinger A.E., Krishnamurthy R., Sena L.M., et al.: Incomplete double aortic arch with atresia of the distal left arch: Distinctive image appearance. Am J Roentgenol, 2004, 184: 1634-1639.

JBR–BTR, 2013, 96: 96.


1. Medische Beeldvorming, Jessa Ziekenhuis, Hasselt, Belgium.

A

B

C

D

RCCA

RSA

LCCA

LSA

Atretic L arch

Aortic diverticulumL ductus

image-aertsen-CS5-OK.indd 1 25/04/13 16:15

JBR–BTR, 2013, 96: 97-100.

ANNUAL GENERAL ASSEMBLY OF THE ROYAL BELGIAN SOCIETY OF RADIOLOGY (RBRS), Tervuren, 26.01.2013

Presidential address

Dear colleagues, Dear friends,

I would like to thank you for being so numerous to attend this Congress of the “Royal Belgian Radiological Society” which will, this time, be devoted to interventional radiology.

Yet, in a few minutes, we will have a short break to honour Professor Philippe Grenier who will become a honorary member of our society. He will speak from a diagnostic point

of view. However, let’s not forget we are at first radiologists making a diag nosis.

It is with great pleasure that I have noticed that the unit of Prof. Grenier, and many more others, are called “Unit of diagnostic and interventional radiology” at “la Pitié Salpêtrière”.

My idea, while preparing this congress , was rather quickly defined, as I asked each sector of the RBRS to give a talk about a specialised subject in its field.

Each section of the RBRS is indeed a part of the vertebral column of the RBRS ; each section is moreover very active.

In this slide, you can read an exhaustive list of all the medical treatments in interventional radiology I have made. It is not only about vascular treatments as non vascular ones make up more than the half of the treatments in question.

I will of course not read that list : you just have to notice I have made a list of 137 treatments or group of treatments, Every year, new ones are created.

The interventional radiology has established its pedigree throughout the years, since the beginning by

Charles Dotter who described the first angioplasty in 1964. Meanwhile, we have come a long way : the guiding systems have become more sophisticated and the equipment companies have on their side developed incredible tools. The collaboration with these companies is excellent and I thank them for their presence today.

As the RBRS is going to be revised and updated soon – I will have a word about it at the end of the program – we can already consider renaming the “Royal Belgian Radiological Society” Diagnostic & Interventional. Like its national Belgian Journal.

Another pioneer of interventional radiology in our country is Professor Julien Struyven, whom I hand over to.

Before listening to him, let me quote one of our masters in Interventional Radiology, Professor Francis Joffre, who said :

“A radiologist who does not perform interventional treatments is a onelegged man”

JeanFrançois De Wispelaere,President RBRS 2012

2012 Honorary Membership Nominees: Prof. Ph Grenier and Prof. J. Struyven

Pr Ph Grenier (left) receiving the Honorary Membership diploma from President J.F. De Wispelaere.

During the general assembly, President De Wispelaere eulogized the two nominees as Honorary Members if the Royal Belgian Radiological Society in 2013: Professor Philippe Grenier from Paris. and Prof. Julien Struyven from Brussels.

Dear Colleagues,

We will not honour Professor Jacques Pringot today, though we had chosen him to become a member of honour of the RBSR. Because of a health problem, he has decided,

Naamloos-1 97 25/04/13 13:24

98 JBR–BTR, 2013, 96 (2)

although he is among us, to turn down the invitation and to postpone the ceremony and his talk will take place during our next congress in November.

I straightaway ask the president of our next congress Bob Hermans, to praise Jacques Pringot, who is a mainstay of the RBSR , as he has been for many years now, the editor of the JBRBTR, which is well listed in the radiological literature.

He has also had an incredible career which we will relate in November.

Is it necessary to introduce Professor Philippe Grenier who has been a role model in thoracic radiology ?

The articles and books he wrote about that subject were of a major help during my training course.

Philippe A. Grenier is full Professor of Radiology at the University Pierre & Marie Curie, Chairman of the Department of Radiology and Head of the Medical Board at PitiéSalpêtrière Hospital, Paris, France.

Professor P.Grenier received his medical degree in 1972 and began his career at Beaujon Hospital, Medical School Xavier Bichat, where he was appointed Professor of radiology From there, he went to the Medical School of Bobigny, as professor of radiology in 1988, before accepting his present position as professor of radiology at Pierre & Marie Curie University. Since 1990, he has been chairman of the department of diagnostic radiology at PitiéSalpêtrière Hospital in Paris, and has served as Head of the Medical Board of the hospital since 2007 when he was elected. He was also appointed VicePresident of the University from 1998 to 2001.

A pioneer in the diagnosis of chronic airway disease and diffuse infiltrative lung disease using highresolution CT, Pr Grenier is still contributing to the evaluation of chest disease with multislice CT and MR. Our colleague is a respected expert in chest imaging and respiratory disease, author or coauthor of about 215 peerreviewed articles, 70 book chapters and publisher of 5 books, .

Member of the editorial boards of European Radiology, Journal of Thoracic Imaging and Academic Radiology, Pr Grenier has reviewed for several national and international scientific journals on medical imaging and respiratory diseases. He has given invited lectures in 170 international scientific meetings or universities (with today’s one, 171). He has also obtained 12 grants for research and several awards for scientific

exhibitions and outstanding scientific research from international societies.

Actively involved in the organization of the European Congress of Radiology from the beginning, he was president of ECR 2002 and chaired successively the Committee for Subspecialties and the Committee for Education of the European Association of Radiology. He received the gold medal of European Congress and Association of Radiology in 2007.

Dr Grenier went one step further and became president in 2003 of the prestigious Fleischner Society,(after the name of its founder Felix Fleischner, probably Dr Grenier’s mentor) an international multidisciplinary group dedicated to chest disease, in which he was elected a member more than 20 years ago. He was a founding member of the European Society of Thoracic Imaging, the general secretary of this society for 8 years, and president in 2008. He also served as chairman of the RSNA International Advisory Committee from 2010 to 2012. He received Honorary Membership from the RSNA and Honorary Fellowship from the Royal College of Radiologists. Afterwards, he also received Honorary Membership from the Swedish, Japanese, Austrian, Italian, Argentinian and French Canadian Societies of Radiology.

This is the reason why it is a great honour for me to confer on him the title of Honorary Membership from the RBSR.

J.F. De Wispelaere,President RBRS 2012

Dear Colleagues, Ladies, Gentlemen,

Let me start first by saying, from the bottom of my heart, all my warm thanks to my friend and colleague Jean François De Wispelaere for inviting me during this official ceremony to praise Professor Struyven who has been my master.

Julien Struyven was born in November 1937 and as a real Belgian citizen and according to his bilingual educational background, he belongs to the two communities of our Country.

He graduated in 1965 as a doctor of the ULB Brussels Free University. His interventional orientation, after a short detour in surgery, brought him eventually on the right track, (I mean) Radiology.

He was recognized as a radiologist in 1969 but he had been long before a precursor of cardiovascular imaging in Belgium, since he started to make angiographies in 1966. After a training in the US, he performed the first coronarography done in Belgium in 1969.

Pioneer of different techniques he performed several first surgeries in Belgium: the first embolisation in 1974, the first dilatation in 1979 and the first coronary dilatation in 1980.

After his work at Saint Pierre and Brugman Brussels hospitals, he took the head of the radiology department of the newly created Erasmus Hospital of the Free Brussels University.

For several years, he gave a rare energy and a flawless enthusiasm which allowed the radiology department to expand together with the hospital, moving from 30 up to 900 beds. He acquired an indisputable

Pr J. Struyven eulogized by Dr Chr. Delcour.

Naamloos-1 98 25/04/13 13:24

ANNUAL GENERAL ASSEMBLY – TERVUREN, 26.01.2013 99

President-Elect address

As you know, we are currently working on a reorganization of the different radiological societies. This projects aims at a more efficient communication and interaction between radiologists and other stakeholders in the Belgian social security, which is important to safeguard and improve our professional position.

Until this project is finalized, the Royal Belgian Radiological Society will continue to work as a scientific society, in close collaboration with the NURUNR and the concilium radiologicum. Apart from protecting our professional interests, similar attention needs to be given to training, education and scientific work in radiology. The RBRS is doing impor

tant work in this regard, not in the least via the different scientific sections of the society. Education and fostering of scientific work will remain an important purpose, also within a unified society structure.

As the new 2013 president, I have the honor to organize the next annual symposium. I would like to take the occasion to announce this symposium, which will take place on November 16th 2013, in Leuven. The main topic of this symposium will be head and neck imaging.

Prof. Dr. Robert Hermans,President RBRS 2013Dear colleagues,

It is a great honor to serve as your president for the year 2013.

scientific reputation testified by the many publications originating from its department.

In 1984 he was appointed Ordinary Professor in radiology in the ULB and he launched a school to which I am proud to belong.

Professor Struyven is also the author and coauthor of more than 250 articles listed in Medline, and numerous books chapters. He also has been a great communicator, having given more than 500 lectures and being an invited orator for more than150 times.

Besides a brilliant academic career, he has been a formidable entrepreneur, managing the radiology development in Belgium and being an active member of our Society as Chairman and Secretary General during several years. He is still today member of the Executive Committee and is in charge of the web site.

He has been a key interlocutor in various official Bodies having played a role in the Belgian radiology development: member of the CTMTGR of the INAMIRIZIV, member of the Su

perior Health Committee, member of the Quality Promotion National Committee, chairman of the Radiology Accreditation Commission, founder and chairman of the Consilium Radiologicum and chairman of the Imaging College.

His international career is brilliant.Professor Struyven is an honorific

member of various radiology societies all over the world.

The CIRSE, Cardio Vascular and Interventional Radiological Society of Europe, would not be what it is presently without the contribution of Julien Struyven who has been at the origin of its creation made through the merging of two separate societies: the European College of Angiography and the European Society of Cardiovascular Radiology.

In 1990 he organised in Brussels the annual meeting of the CIRSE and later on became its Chairman leaving his mark.

On his impulse the CIRSE developed itself in a very impressive way with an exponential increase of the number of its members. It also got

organised in an exemplary way becoming a representative European body in the field of interventional radiology and building a very high level European teaching structure.

In addition to Professor Struyven’s numerous academic merits that I just tried to summarize, he is also very endearing, profoundly human and at the service of others.

Endowed with a good sense of humour he is a great knowledgeable modern art lover with a genuine passion.

I definitely could not finish his portrait without thanking him personally because I would never have been what I became, professionally as well as personally, if I had not the opportunity and the privilege to know him.

On behalf of all the present participants, it is an honour for me to thank Professor Julien Struyven for his exceptional contribution to the development of our Speciality. I ask you to applaud him warmly.

Christian Delcour

Naamloos-1 99 25/04/13 13:24

100 JBR–BTR, 2013, 96 (2)

medical imaging including nuclear medecine, technologists and nuclear federal agency of control.

This response of Mrs Onkelinx to the claims of radiological is encouraging and we will not fail to keep you informed of the evolution.

What will become of the RBRS, we are currently in the last straight line of merging with the National Union of the Radiologists (UNRNUR) and Consilium Radiologicum?

You thus see that the future is not so dark for interventional radiology and radiology in general, but that there is still much work to do.

There is a need for volunteers but especially for the renewal of these volunteers by motivated young people, because one cannot make only scientific radiology. Our beefsteak also should be defended. The Belgian society of Radiology must thus become the newsgroup and the think tank for the future of Belgian radiology.

JeanFrançois De Wispelaere,President RBRS 2012

It is thus a completely unfair situation that we have denounced for a long time,and which was clearly expressed in a note given to the cabinet of Laurette Onkelinx last year. The idea would be to finance the room of interventional radiology like an operating room, setting up equality of surgeons and radiologists.

Our French friends go further in the organization of interventional radiology or at least in a proposal : the services offered in IR could be divided into two or three groups and the financing in proportion to the services offered. That supposes obviously policy options, because one cannot do all by all and correctly. That must also pass by a specific recognition of a training in interventional radiology. But there one is still far from the account! Nevertheless this idea must make its way and must be held in the spirit during the discussions.

I transmitted to you not later that yesterday an answer of the Minister for health Mrs Laurette Onkelinx, to a well justified anger on behalf of group BELMIP. BELMIP stands for Medical Belgium Imaging Platform exit of the old “Marchal group”. BELMIP gathers all living strength in

We have now arrived at the end of the scientific part of this symposium. This walk through interventional radiology was extremely enriching and brings the proof so necessary that interventional radiology interests all the fields.

On the initiative of Christian Delcour, several among us collaborated in the drafting of a memo intended for the competent jurisdictions concerning the problems of the acts in interventional radiology and overall for its financing.

Why interventional radiology is pointing in the services of radiology? Quite simply because it costs money, whereas the other subspecialities of radiology are correctly refunded. The principal element which explains why interventional radiology does not even bring in money costs some is its system of financing.

To pay necessary equipment and staff the radiologist must more or less refund 70% of honorary with the current system of financing, whereas an identical room installed to the surgical district is financed differently: the surgeon having to reassign only 10 to 20% (great maximum) of his fees.

Closing address

Naamloos-1 100 25/04/13 13:24

Transthoracic biopsy of lung lesions: an updateJ. Coolen, W. De Wever, J. Bogaert, J. Verschakelen1

Since the first reports of needle biopsy of the lung in the late 1800s, improving technologies in needle design (fine needle aspiration (FNA) and coaxial (CORE) biopsy) and ra-diologic equipment (Scopy, Comput-er Tomography, CT-Fluoroscopy (CTF), C-arm Cone-Beam CT, Ultra-Sonography and Magnetic Reso-nance Imaging) have helped secure the place of tissue biopsies of suspi-cious pulmonary lesions under ra-diologic visual control.

In general, percutaneous tissue sampling of a pulmonary, pleural or mediastinal lesion is performed when the diagnosis cannot be estab-lished by bronchoscopic techniques, or when histological diagnosis will modify staging of the disease or when therapeutic strategy will be in-fluenced. Relative contraindications are severe bullous emphysema at the puncture site, uncorrectable co-agulopathy, severe pulmonary hy-pertension, highly vascular masses or unilateral lung.

There are multiple factors affect-ing the diagnostic accuracy of this procedure. Besides correct needle position, lesion size and puncture technique/modality, also operator experience and presence of the pa-thologist on site are important fac-tors.

For pleural based lesions we sometimes use a US-guided proce-dure, but for the most commonly performed transthoracic biopsy pro-cedures, we choose for CTF-guided CORE biopsies. This real-time meth-od shows the exact needle trajectory during needle advancement, but the major drawback are dose related problems.

The most common complications are pneumothorax and haemor-rhage. The predictor for risk of pneu-mothorax is lesion depth. Other fac-tors are needle size, puncture angle, patient age, increased number of

in industrialized nations, affecting al-most exclusively the elderly popula-tion. Approximately 2-3% of the pop-ulation over the age of 75 has severe aortic valve stenosis, a progressive disease than when symptomatic is associated with a high degree of mortality.

Elective surgical aortic valve replacement is considered the most effective treatment for advanced disease, significantly improving symptoms and survival compared to those who refused or couldn’t have surgery.

Unfortunately, not all patients are eligible for surgery. Several studies have identified various subgroups of patients who have a substantially el-evated risk for operative complica-tions or death. As such, some series have reported that up to 32% of pa-tients with severe aortic valve steno-sis can’t have surgical aortic valve replacement for a variety of reasons. Therefore, a less invasive approach is needed for this subgroup of pa-tients in order to offer a possible definite treatment.

In recent years, specific aortic valve prostheses have been devel-oped that can be transported to the aortic root using a non-surgical en-dovascular or percutaneous trans-apical approach. Once in place, these bioprosthetic valves function-ally replace the native valve by dis-placing it to the aortic root wall. Giv-en their less invasive nature these procedures are less demanding on patients and can therefore be ap-plied in the specified non-surgical subgroup. This procedure is named trancatheter aortic valve replace-ment or implantation (TAVR, TAVI) or percutaneous aortic valve replace-ment (PAVR). Recently published data from individual centers, large prospective studies, observational registries and multicenter random-ized, controlled trials have validated the efficacy of this procedure in pa-tients with severe aortic valve steno-sis, both in the high-risk surgical co-hort (PARTNER A) as in the subgroup deemed to be too high-risk for con-

passes through the pleura, presence of COPD. The risk of bleeding is also increased in centrally located lesions and decreases with increasing lesion size, but is usually self-limiting if platelets and prothrombin level are normal. Air embolism and seeding of the tract are very rare complica-tions.

The incidence of complications can be reduced by interlacing a streamlined procedure, where a checklist is helpful: including a cor-rect application form with indication of biopsy, pre-biopsy control of con-tra-indications, available informed consent indication patient coopera-tion, and delayed CXR chest after 4 hours before hospital discharge.

For the correct indications, trans-thoracic needle biopsy is a good pro-cedure when tissue is an issue. The choice of procedure technique (FNA versus CORE biopsy) and modality depends on variables such as cost and availability. Computer tomo-graphic fluoroscopy can be an ap-propriate technique for transthoracic procedures. Because this technique�s compliance with occupational limits of dose, the use of low dose proto-cols and possible hardware dose re-duction techniques (such as Hand-CARE©) are warranted. Measuring and evaluating scan doses gives knowledge and brings responsibility. Accuracy of correct sample can be augmented by evaluate previous ex-aminations; PET avid and diffusion weighted restricted zones are more suspicious for malignancy.

1. Department of Radiology, Group of Chest Radiology, University Hos-pital of Leuven, Belgium.

The value of CT in the pre- and post-procedural assessment of the aortic root in transcatheter aortic valve replacementR. Salgado1, O. Ghekiere2

Severe aortic valve stenosis is the most frequent valvular heart disease

JBR–BTR, 2013, 96: 101-103.

ABSTRACTS OF PAPERSpresented at the Annual Symposium of the SRBR - KBVR, on January 26, 2013SAMENVATTINGEN VAN DE UITEENZETTINGENvoorgesteld aan het Jaarlijks Symposium van de KBVR, op 26 januari 2013RESUMES DES COMMUNICATIONSprésentées lors du Symposium Annuel de la SRBR, le 26 janvier 2013

proc(lung cancer)2013(2).indd 101 30/04/13 09:17

102 JBR–BTR, 2013, 96 (2)

chial tumor (benign or malignant) and to detect any postinfectious or inflammatory focal bronchial steno-sis or broncholithiasis.

Thin collimation MDCT is regard-ed as the current gold standard im-aging technique for the diagnosis and extent assessment of bronchiec-tasis. It is superior to HRCT with 10-mm intervals and provides multipla-nar reformations that increase the detection rate of bronchiectasis, the readers’ confidence as to the distri-bution of bronchiectasis and im-prove agreement between observers as to the diagnosis of bronchiectasis. Reformations of images along the long axis of the airways, selected by using the swivel mode, and on which minIP is applied, help assess the ex-tent of bronchiectasis at the segmen-tal level and the number of genera-tions of bronchial divisions involved. The extent of decreased lung attenu-ation reflects the extent of oblitera-tive bronchiolitis associated with bronchiectasis and remains the strongest determinant of airflow ob-struction in these patients. Comple-mentary expiratory CT using low dose may be increase the perception of mosaic perfusion pattern. Focal areas of expiratory air trapping may be displayed on thick coronal and sagittal reformatted slabs with minIP making feasible a semi-quantitative evaluation of air trapping extent.

In patients with bronchiectasis, the use of maximum intensity pro-jection (MIP) is recommended in or-der to improve the detection of foci of infectious bronchiolitis recognized as tree in bud sign. MIP is also ap-preciated in case of non specific cen-trilobular nodular pattern in order to visualize linear branching opacities connected to these small nodules (tree in bud sign) leading to the diag-nosis of infectious bronchiolitis. MIP may also increase the sensitivity of MDCT in detecting non infectious in-flammatory bronchiolitis such as re-spiratory bronchiolitis in smokers or follicular bronchiolitis in collagen vascular disease.

In patients with COPD, the assess-ment of proximal airways is recom-mended as bronchial wall thicken-ing, bronchial diverticulas, cylindrical bronchiectasis and tracheobroncho-malacia are markers of clinical sever-ity of the disease.

As the interobserver variability in the assessment of bronchial wall thickening in patients with obstruc-tive lung disease is significant, spe-cific softwares have been developed for quantitative analysis of bronchial wall thickness. Using such softwares,

9. Piazza N., de Jaegere P., Schultz C., Becker A.E., Serruys P.W., Anderson R.H.: Anatomy of the aortic valvar complex and its implications for transcatheter implantation of the aor-tic valve. Circ Cardiovasc Interv, 2008, 1: 74-81.

10. Gurvitch R., Webb J.G., Yuan R., et al.: Aortic annulus diameter determi-nation by multidetector computed to-mography: reproducibility, applicabil-ity, and implications for transcatheter aortic valve implantation. JACC Car-diovasc Interv, 2011, 4: 1235-1245.

1. Department of Radiology, Ant-werp University Hospital, Edegem, 2. Department of Radiology, Cliniques CHC Saint Joseph, Liège, Belgium.

How to get the most out of visual-izing airways and lung disease with CT?Ph A. Grenier1

By using thin collimation and heli-cal volumetric acquisition over the entire lung during a single breath hold Multidetector Computed To-mography (MDCT) provides high-resolution volumetric data set, based on voxels of small volume having cubic or almost cubic dimensions. This offers the advantage of multi-planar reformations of a very high quality. Coronal oblique reforma-tions along the long axis of the tra-chea are well adapted for the assess-ment of proximal airways (trachea and mainstem bronchi). Volume av-eraging permits to select a slab of thickness adapted to include more proximal airways in the image, on which minimum intensity projection (minIP) may be applied to blurr the vessels. Virtual endoscopy consists in a three-dimensional (3D) internal rendering of airways providing a view in perspective of the inner sur-face of the airway. CT bronchogra-phy consists in a 3D external render-ing of the air content of the airways. These different post-processing techniques may be applied in combi-nation for a better assessment of tra-cheobronchial lesions. This is partic-ularly appreciated in case of airway lesion of complex anatomy or to as-sess tracheal stenosis (post-intuba-tion, malignant, inflammatory).

The detection of any endobron-chial abnormality is improved by the visualization of overlapped thin axial images in a dynamic mode, moving up and down through the volume, to check the lumen of all bronchi from their origin to their distal divisions. This allows not to miss an endobron-

ventional surgery (PARTNER B). These favorable outcomes with di-minished symptoms and prolonged survival, has lead to the success and increasingly widespread perfor-mance of this intervention.

Nevertheless, not every patient can receive such a device. Besides the clinical selection, certain techni-cal and anatomic criteria have to be met, and it is in this respect that non-invasive imaging techniques play a crucial role in the selection and fur-ther pre-operative work-up of pa-tients.

CT can offer valuable information regarding annulus size, in order to determine if the annulus size of the patients falls within the size range of available transcatheter valves. It also allows proper evaluation of the fem-oral and subclavian arteries for ac-cess evaluation. Finally, CT can ade-quately visualize the position of the implanted prosthetic valve and its expansion in the aortic root.

Bibliography

1. Bose A.K., Aitchison J.D., Dark J.H.: Aortic valve replacement in octoge-narians. J Cardiothorac Surg, 2007, 2: 33.

2. Smith C.R., Leon M.B., Mack M.J., et al.: Transcatheter versus surgical aor-tic-valve replacement in high-risk pa-tients. N Engl J Med, 2011, 364: 2187-2198.

3. Leon M.B., Smith C.R., Mack M., et al.: Transcatheter aortic-valve implanta-tion for aortic stenosis in patients who cannot undergo surgery. N Engl J Med, 2010, 363: 1597-1607.

4. Ussia G.P., Barbanti M., Petronio A.S., et al.: Transcatheter aortic valve im-plantation: 3-year outcomes of self-expanding CoreValve prosthesis. Eur Heart J, 2012.

5. Kodali S.K., Williams M.R., Smith C.R., et al.: Two-Year Outcomes after Transcatheter or Surgical Aortic-Valve Replacement. N Engl J Med, 2012.

6. Makkar R.R., Fontana G.P., Jilaihawi H., et al.: Transcatheter Aortic-Valve Replacement for Inoperable Severe Aortic Stenosis. N Engl J Med, 2012.

7. Leipsic J., Hague C.J., Gurvitch R., Ajlan A.M., Labounty T.M., Min J.K.: MDCT to Guide Transcatheter Aortic Valve Replacement and Mitral Valve Repair. Cardiol Clin, 2012, 30: 147-160.

8. Hamdan A., Guetta V., Konen E., et al.: Deformation dynamics and me-chanical properties of the aortic annu-lus by 4-dimensional computed to-mography: insights into the functional anatomy of the aortic valve complex and implications for transcatheter aortic valve therapy. J Am Coll Cardi-ol, 2012, 59: 119-127.


ABSTRACTS OF PAPERS 103

ment of diffuse lung disease. Radio-graphics, 2005, 25: 1639-1652.

2. Grenier P.A., Beigelman-Aubry C., Fetita C., et al.: New frontiers in CT im-aging of airway disease. Eur Radiol, 2002, 12: 1022-1044.

1. Department of Radiology, Hôpital Pitié-Salpêtrière, Université Pierre et Marie Curie, Paris, France.

Diagnosis and treatment of endole-aks after endovascular repair of thoracic and abdominal aortic an-eurysmsS. Heye

A common complication of endo-vascular repair of a thoracic or ab-dominal aortic aneurysm (TEVAR – EVAR) is an endoleak occurring in up to 30% of cases. Endoleak is defined as the persistence of blood flow out-side the lumen of the endoprosthe-sis, but within the aneurysm sac and can be classified into 5 categories, depending on the blood flow into the aneurysm sac. Typical features of the different types of endoleaks are dis-cussed as well as the imaging mo-dalities to detect and classify an en-doleak and the diverse (endovascular) treatment options.

for evaluation of disease progres-sion or improvement. MIPs increase the detection and the profusion as-sessment and characterization of nodular pattern and improve the as-sessment of the size and distribution of pulmonary vessels. In interstitial lung disease with fibrosis, minIPs improve the recognition of traction bronchiectasis and bronchiolectasis, ensure the distinction between trac-tion bronchiolectasis and honey-combing, and may detect airway dis-tortion before airway dilatation. It also increases the visualization of honeycombing, lung cysts, ground glass opacity, interlobular septal thickening and peribronchial infiltra-tion. The use of volumetric multide-tector HRCT however results in a greater radiation dose that does spaced axial imaging. On the other hand, radiation dose may be dramat-ically reduced without loss of signifi-cant information by using iterative reconstruction techniques, adapta-tion of acquisition and reconstruc-tion parameters, and postprocessing techniques.

References

1. Beigelman-Aubry C., Hill C., Guibal A., et al.: Multidetector row CT and post-processing techniques in the assess-

investigators have demonstrated that in COPD patients bronchial wall thickness and extent of emphysema are both the strongest determinants of FEV1 and are associated with COPD exacerbation frequency. In asthma, bronchial wall thickening correlates with pathologic measures of remodelling and with asthma se-verity and asthma control. In patients with bronchiectasis, the bronchial wall thickening on the baseline CT correlates with functional deteriora-tion overtime, and severe bronchial thickness is the most adverse prog-nostic determinant.

In diffuse infiltrative lung disease, high-resolution CT with 1-mm thick section obtained at 10-mm intervals has been widely accepted as the im-aging standard of reference for as-sessing diffuse lung disease. How-ever only approximately 10% of the lung parenchyma is scanned and characteristic foci of the disease may be missed. Volumetric and multide-tector HRCT offers several advantag-es: 1) complete imaging of the lungs and thorax, 2) viewing of contiguous slices for the purpose of better defin-ing lung abnormalities, 3) recon-struction of scan data in any plane and/or using MIPs or minIPs, and 4) precise level-by-level comparison of studies obtained at different times


JBR–BTR, 2013, 96: 104-105.

NEWS FROM THE UNIVERSITIES

8th SCIENTIFIC PRIZE EM. PROF. DR A.L. BAERTOp 4 december 2012 vond, in aanwezigheid van rector Prof. Dr. M. Waer, meerdere ere-rectoren en talrijke andere

hoogleraren o.m. van de KU Leuven, de U Antwerpen, de U Gent, de U Liège en de VU Brussel de inhuldiging plaats van het “Fonds em. Prof. Dr. A.L. Baert” in de rectorale salons van de Universiteitshallen.

Dit fonds wordt nu beheerd door het Leuvens Universiteitsfonds en zal de “Wetenschappelijke Prijs em. Prof. Dr. A.L. Baert”, opgericht in 1997, verderzetten.

De laureaten van deze Prijs zijn: Robert Hermans, Marc Lemmerling en Lieven Van Hoe (1998), Johan Van Goethem (2000), Michel De Maeseneer (2002), Steven Dymarkowski (2004), Mireille Van Goethem (2006), Geert Maleux (2008) en Chantal Van Ongeval (2010).

De doelstelling van het fonds blijft de ondersteuning en bevordering van wetenschappelijk onderzoek in de radiolo-gie. Daartoe zal er ook in de toekomst een tweejaarlijkse prijs toegekend worden aan een radioloog, opgeleid aan één van de vier Nederlandstalige universiteiten in België, op basis van een met goed gevolg verdedigde doctoraatsthesis.

Dit jaar is Bert De Foer de laureaat van de 8ste Prijs. Hij behaalde zijn diploma van doctor in de genees-, heel- en verloskunde aan de KU Leuven en in 1995 werd hij erkend als geneesheer-specialist in röntgendiagnose aan de KU Leuven (onder leiding van Prof. Dr. A.L. Baert). Daarna volgde hij nog een bijkomende opleiding magnetische resonan-tie aan de Universiteit Antwerpen (onder leiding van Prof. Dr. P. Parizel) en was hij als radiologie actief in het regionaal ziekenhuis Zeeuws-Vlaanderen in Terneuzen. Sedert 1997 is hij staflid radiologie in het Sint-Augustinusziekenhuis in Antwerpen. Hij is er ook verantwoordelijk voor de hoofd- en halsradiologie. In 2011 behaalde hij de graad van doctor in de Biomedische Wetenschappen aan de KU Leuven met een proefschrift getiteld: “The value of magnetic resonance imaging in the preoperative evaluation and the postoperative follow-up of middle ear cholesteatoma”.

De KU Leuven en de oprichters van het “Fonds em. Prof. Dr. A.L. Baert” willen de talrijke schenkers van harte danken voor hun gift, zonder de welke dit initiatief niet mogelijk zou geweest zijn. Dankzij de financiële steun van vele Vlaamse radiologen en oud-assistenten enerzijds en de sponsoring van meerdere ondernemingen anderzijds zal het fonds in de komende jaren de Vlaamse radiologie verder op het voorplan kunnen brengen door wetenschappelijk onderzoek te stimuleren.

Mocht u nog wensen een bijdrage te doen, kan u uw gift storten op de volgende rekening van de KU Leuven BE48 5583 9126 0027 met als mededeling OF0-KAP006-P3367

Namens de oprichters van het Fonds em. Prof. Dr. A. Baert,

Prof. Dr. Ph. DemaerelBeheerderFonds em. Prof. Dr. A. Baert

Em. Prof. Dr. A.L. Baert Prof.Dr. Ph. DemaerelVoorzitter van de Jury Secretaris van de Jury Dienst radiologie, UZ Leuven

ANNOUNCEMENT

De 9de Wetenschappelijke Prijs van het Fonds em. Professor Dr A.L. Baert zal uitgereikt worden in 2014. Kandidaten moeten hun werk samen met hun curriculum vitae indienen in 6 gedrukte exemplaren bij de secretaris en 1gedrukt exemplaar bij Prof. Dr. A.L. Baert, uiterlijk op 30 september 2014. Slechts werken die minder dan 2 jaar oud zijn op de datum van hun indiening kunnen in aanmerking genomen worden. Het werk moet opgesteld zijn in het Nederlands of in het Engels, met in beide gevallen, een uitgebreide samenvatting van minstens 15 bladzijden in het Nederlands (ca. 47 regels per blz.).

news (Baert)-2013(2)-OK.indd 104 25/04/13 13:30

ABSTRACT OF THE PAPER 105

Fig. 2. — Bert De Foer, laureaat van de 8ste Prijs em. Prof. Dr. A.L. Baert, ontvangt de Prijs uit handen van em. Prof. Dr. A.L. Baert.

Fig. 1. — Plechtige inhuldiging van het Fonds em. Professor dr. A.L. Baert: links: Philippe Demaerel, Voorzitter van het Departement Beeldvorming & Pathologie, KU Leuven, midden: Minne Casteels, Vice Rector Biomedischel Wetenschappen, KU Leuven, rechts: Albert L. Baert, em. Professor Radiologie, KU Leuven.

news (Baert)-2013(2)-OK.indd 105 25/04/13 13:30

The purpose of this thesis was to evaluate the role of Magnetic Reso-nance (MR) imaging, especially Dif-fusion-Weighted (DW) MR imaging in the preoperative evaluation of cholesteatoma patients and the post-operative follow-up of cholesteato-ma patients. Regarding the use of DW MR imaging, difference should be made between Echo Planar (EP) DW sequences and non-EP DW se-quences.

The conclusion of this first (EP DW) study phase is that the combi-nation of standard MR sequences before and after intravenous admin-istration of gadolinium and EP DW sequences appears to have the high-est sensitivity in detecting middle ear cholesteatoma and the size limit for detection of cholesteatoma using EP DW sequences is 5 mm. This makes EP DW sequences useless for the evaluation of the usually very small pre-second-look residual cho-lesteatoma in patients after CWU tympanoplasty and after PBOT (1). EP DW sequences can be used to evaluate patients prior to first-stage surgery taking into account that le-sions smaller than 5 mm will be missed and that empty or evacuated retraction pockets display no high signal on DW sequences (1). These conclusions have been confirmed in several other papers in peer-re-viewed journals (2, 3).

In the second study phase, the combined protocol was changed. The standard sequences have been adjusted to delayed gadolinium-en-hanced T1-weighted imaging, based upon the work of Marc Williams and Denis Ayache (4). This means that imaging is performed 45 minutes after the intravenous administration of gadolinium. Immediate scanning after intravenous administration of gadolinium might result in FP find-ings as scar tissue and granulation tissue take time to enhance.

The DW sequence has been changed from an EP DW sequence to

dehiscence (7, 8). However in patients with an un-

clear clinical history and a doubtful micro-otoscopy, MRI using non-EP DW sequences can be used as a screening tool to evaluate the pres-ence of cholesteatoma. In those cas-es, MRI –using non-EP DW sequenc-es- should be preferred as the primary imaging tool (7).

In case of an infected cholesteato-ma or a cholesteatoma with clinical suspicion of associated complica-tions MR imaging, using the combi-nation of non-EP DW sequence and delayed gadolinium-enhanced T1-weighted sequences, is required in order to evaluate the middle ear, in-ner ear and middle fossa.

In both last subgroups, CT scan is reserved for the immediate pre-oper-ative setting to evaluate all anatomi-cal detail (7).

The role of MR imaging and non-EP DW sequences more specifically has gained even more importance in the evaluation of patients prior to second-look evaluating the presence of residual cholesteatoma or in the evaluation of patients looking for re-current cholesteatoma (9). It is clear that EP DW sequences have been abandoned and that non-EP DW se-quences are to be preferred due to their higher imaging matrix, thinner slices and complete lack of suscepti-bility artefacts (5, 7, 9).

ADC maps also seem to have an advantage in differentiating choles-teatoma from post-operative tissue, scar tissue, inflammation and/or cholesterol granuloma as cholestea-toma is the only entity with a clear signal drop on ADC maps (10).

CT can no longer be used as the primary imaging tool of patients in a pre-second look setting. Moreover, second-look surgery should prefera-bly be replaced by MRI using non-EP DW sequences. CT scan should be reserved for the immediate pre-oper-ative evaluation of these patients and selection of second-look should be performed based upon MRI using non-EP DW sequences (6, 7).

By doing so, the number of unnec-essary second-look interventions can be reduced as well as the high number of useless CT scans prior to

a non-EP based DW sequence. The sequence we use is a single-shot tur-bo SE DW MR imaging sequence or half-Fourier acquisition single-shot turbo SE (HASTE) DW MR imaging sequence.

This sequence has a thinner slice thickness, a higher resolution and a complete lack of air-bone interface artefacts in the temporal bone result-ing in a possible capability of detect-ing smaller cholesteatoma (5).

Fifty-seven patients clinically sus-pected of having an acquired choles-teatoma and 63 patients prior to second-look surgery were included.

It was concluded that there was no statistical significant difference between the non-EP DW sequence alone and the combination of non-EP DW imaging sequence and delayed gadolinium-enhanced T1-weighted sequences.

MR imaging in patients suspected of having middle ear cholesteatoma can be applied by using only a non-EP DW imaging sequence, avoiding the need for further contrast agent administration. Also non-EP DW im-aging sequences have significantly higher sensitivity, specificity, PPV, and NPV than delayed gadolinium-enhanced T1-weighted sequences, and results are less dependent on the observer’s experience (6).

The imaging approach of middle ear cholesteatoma has changed sig-nificantly during the last decade (7).

Whereas at the onset, CT scan was regarded as the only valid imag-ing tool for the evaluation of middle ear cholesteatoma (8), MRI has con-quered its place in the evaluation of patients presenting with middle ear cholesteatoma (7).

In patients prior to first-stage sur-gery presenting with a clinically evi-dent cholesteatoma, CT scan has its place in the evaluation of ossicular erosion and tegmen integrity. It will also highlight temporal bone anato-my such as degree of aeration and position of facial nerve and possible

JBR–BTR, 2013, 96: 106-107.

THE VALUE OF MAGNETIC RESONANCE IMAGING IN THE PREOPERATIVE EVALUATION AND THE POSTOPERATIVE FOLLOW-UP OF MIDDLE EAR CHOLESTEATOMA1

B. De Foer2

1. Submitted and presented in fulfillment of the requirements for the degree of “Doctor in de Biomedische Wetenschappen on November 14, 2013. 2. Laureate of the Prize Em. Prof. Dr. A.L. Baert, Dept of Radioogy, Sint Augustinus Ziekenhuis, Antwerp.

abstracts baert laureate-OK.indd 106 25/04/13 16:16

ABSTRACT OF THE PAPER 107

8. Lemmerling M., De Foer B.: Imaging of cholesteatomatous and non-cho-lesteatomatous middle ear disease. In: Lemmerling M., Kollias S.S. (eds). Radiology of the Petrous bone. 2001, Springer Verlag, New York, pp 31-47.

9. De Foer B., Vercruysse J.P., Bernaerts A., Deckers F., Pouillon M., Somers T., Casselman J., Offeciers E.: Detection of postoperative residual cholesteatoma with non-echo-planar diffusion-weighted magnetic reso-nance imaging. Otol Neurotol, 2008, 29: 513-517.

10. Khemani S., Singh A., Lingam R.K., Kalan A.: Imaging of postoperative middle ear cholesteatoma. Clin Radi-ol, 2011 Apr 23 (Epub ahead of print).

with delayed contrast-enhanced MR-imaging: initial findings. Eur Radiol, 2003, 13: 169-174.

5. De Foer B., Vercruysse J.P., Pilet B., Michiels J., Vertriest R., Pouillon M., Somers T., Casselman J.W., Offeciers E.: Single-shot, turbo spin-echo, diffusion-weighted imaging versus spin-echo-planar, diffusion-weighted imaging in the detection of acquired middle ear cholesteatoma. Am J Neuroradiol, 2006, 27: 1480-1482.

6. De Foer B., Vercruysse J.P., Bernaerts A., Meersschaert J., Kenis C., Pouillon M., De Beuckeleer L., Michiels J., Bogaerts K., Deckers F., Somers T., Hermans R., Offeciers E., Casselman J.W.: Middle ear choles-teatoma: non-echo-planar diffusion-weighted MR imaging versus delayed gadolinium-enhanced T1-weighted MR imaging: value in detection. Radio logy, 2010, 255: 866-872.

7. De Foer B., Vercruysse J.P., Spaepen M., Somers T., Pouillon M., Offeciers E., Casselman J.W.: Diffu-sion-weighted magnetic resonance imaging of the temporal bone. Neuro-radiology, 2010, 52: 785-807.

second-look surgery, thus reducing patients irradiation significantly.

References

1. Vercruysse J.P., De Foer B., Pouillon M., Somers T., Casselman J., Offeciers E.: The value of diffusion-weighted MR imaging in the diagno-sis of primary acquired and residual cholesteatoma: a surgical verified study of 100 patients. Eur Radiol, 2006, 16: 1461-1467.

2. Jeunen G., Desloovere C., Hermans R., Vandecaveye V.: The value of magnetic resoncance imag-ing in the diagnosis of residual or re-current acquired cholesteatoma after canal wall-up mastoidectomy. Otol Neurotol, 2008, 29: 16-18.

3. Jindal M., Doshi J., Srivastav M., Wilcock D., Irving R., De R.: Diffusion-weighted magnetic resonance imag-ing in the management of cholestea-toma. Eur Arch Otorhinolaryngol, 2010, 267: 181-185.

4. Williams M.T., Ayache D., Alberti C., Héran F., Lafitte F., Elmaleh-Bergès M., Piekarski J.D.: Detection of postoperative residual cholesteatoma

Fig. 1. — Coronal MR imaging of an attical cholesteatoma in the left middle ear with surrounding inflammation in a 42-year-old man.

Turbo SE T2-weighted image shows a moderately intense nodular lesion (arrow) underneath the left temporal lobe in the left temporal bone. Note the surrounding soft tissues with high signal intensity in the mastoid and middle ear (arrowheads). B. De-layed gadolinium-enhanced SE T1-weighted image shows the unenhancing cholestea-toma (arrow) surrounded by enhancing inflammation in middle ear and mastoid (arrowheads). C. Single-shot turbo SE DW sequence image shows the cholesteatoma as a small hyperintense lesion in the signal void of the left temporal bone (arrow).

A

A

B

B

CC

Fig. 2. — A 35-year-old man evaluated 12 months after first-stage cholesteatoma surgery before second look surgery. Sec-ond-look surgery demonstrated postop-erative and inflammatory changes with-out any evidence of residual cholesteatoma.

A. Axial CT scan. A status after CWU mastoidectomy is noted. Complete opaci-fication of the postoperative cavity can be found (arrows). No differentiation of these soft tissues can be made. B. Coro-nal turbo SE DW sequence. No clear nodular hyperintense lesions can be observed excluding any residual choles-teatoma. Note the moderate intense signal of the inflammatory and postoper-ative changes in the cavity (arrows). C. Coronal delayed gadolinium-enhanced T1-weighted image. Enhancement of the inflammatory and postoperative changes in the cavity can be noted (arrows).

abstracts baert laureate-OK.indd 107 25/04/13 16:16

03-05.13MUSCULOSKELETAL ULTRASOUNDBrusselsBasic lectures and demonstrations followed by hands-on trainingInformation: [email protected]

31.05.13JOINT MEETING HEAD AND NECK(BELGIUM & THE NETHERLANDS)Maastricht, Hotel BeaumontInformation:[email protected]

21-22.03.13ATELIER DE COLONOSCOPIE VIRTUELLELeuvenInformation: [email protected],[email protected]

22.06.13STRATÉGIE ET DÉFIS EN IMAGERIEPÉDIATRIQUE ONCOLOGIQUEComment faire mieux avec moinsd’argent et de rayonsLiègeOrganization and information: Dr L. Rausin, [email protected]

12-13.09.13ATELIER DE COLONOSCOPIE VIRTUELLELiège, Clinique St JosephInformation: [email protected]

JBR–BTR, 2013, 96: 108.

FORTHCOMING COURSES AND MEETINGS

NATIONAL MEETINGS

Detailed and real time information is available on RBRS website at www.rbrs.org

09-12.05.133RD IDKD INTENSIVE COURSE IN HONGKONGDiseases of the Chest and HeartHong Kong, ChinaInformation: www.idkd.org

31.05.13JOINT MEETING HEAD AND NECK (BELGIUM & THE NETHERLANDS)Maastricht, Hotel BeaumontInformation:[email protected]

08.06.13JOURNEE DE RAIDOLOGIE HEPATOBILI-AIRE ET DIGESTIVEParis, CAP 15Theme: Pancréas, Foie et PéritoineInformation: http://radiologie-bicetre.e.monsite.com/

21-24.09.13ASIAN PACIFIC DIGESTIVE WEEK –WORLD CONGRESS OF GASTRO -ENTEROLOGYShangai, PRChinaInformation: www.gastro2013.org

RBRS – Chest Radiology10-12.10.13

RBRS – Head and Neck Radiology31.05.13

Miscellaneous03.05.13, 22.06.13, 12-13.09.13

INTERNATIONAL MEETINGS

22-Forthc. courses-96(2)_Opmaak 1 25/04/13 16:17 Pagina 1

The Belgian radiology journal wishes to thank Guerbet for their continuous support

The Belgian radiology journal wishes to thank GE for their continuous support

The Belgian radiology journal wishes to thank Philips for their continuous support

Contrast for life

GOLD SPONSOR

BRONZE SPONSOR

BRONZE SPONSOR

Editor: Professor J. PRINGOT, Koning Leopold III laan 20, B-3001 HEVERLEE

Membre de l’Union des Editeurs de la Presse Périodique

Lid van de Unie van de Uitgevers van de Periodieke Pers

Printed in Belgium by UNIVERSA PRESS, Honderdweg 24 - B-9230 WETTEREN

Avnet Comm. VAKouterveldstraat 20, 1831 DiegemTel. 02/709 93 13Fax 02/709 93 33 Mr. S. Stevens

Bracco Imaging Europe n.v./s.a.Belgian BranchAvenue Pasteurlaan 6, 1300 WavreTel. 010/68 63 76Fax 010/68 63 63Mrs. N. Maes

GE Medical Systems Kouterveldstraat 20, 1831 DiegemVictor Cuyckens – Zone Sales Manager BeLux

Guerbet n.v./s.a.Av. H. Dunantlaan 31, 1140 BrusselTel. 02/726 21 10 Fax 02/726 24 01Mrs. M. Van Bellinghen

Siemens n.v./s.a.Business ParkMarie Curie Square 30, 1070 Brussel/Bruxelles Tel. 02/536 45 70Fax 02/536 45 77 Mr. G. Descamps

Contact details of advertising firms

00b-JBR-Sponsoring_JBR-Adv.index-2003/6 26/04/13 10:30 Pagina 1

Large enough for even the smallest details. EIZO RadiForce™ RX840.To make the right decisions, you need a reliable image. That‘s why EIZO has developed the RX840 for radiological diagnostics. Thanks to its 36-inch screen and a resolution of up to 8 megapixels, the RX840 is capable of detecting even the smallest of details. The large diagnostic monitor displays full-sized images of fi ne structures in monochrome and color.

91 cm (36") LCD for diagnosis 8 megapixel resolution in monochrome and color Long-lasting LED backlights Integrated front sensor (IFS) for greyscale calibration 5-year guarantee, including brightness guarantee

For more information, please visit www.eizo.com

MUTTER • DU: XX.XX.13

eizME3019_AZ_RX480_ECR_A4_IC_eng_2ml.indd 1 18.01.13 14:52

Documents

JBR 2013-2