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Purpose: To investigate the usefulness of opposed-phase gradient-echo (GRE) technique in detecting occult posttraumatic bone injuries in the knee. Occult injuries account for pain and, if not properly treated, may progress to severe chondral and bone damage. An early diagnosis provided by MRI can help avoid interventional procedures., Material and Methods: We submitted to MRI of the knee 51 patients (32 men and 19 women) with negative plain radiographic findings and at least one traumatic bone injury at MRI. MR examinations were performed with a 0.5 T unit and included a conventional SE or GRE T1-weighted sequence and an opposed phase GRE sequence on the coronal or sagittal plane (2-3 minutes acquisition). To assess the lesion number and conspicuity, images were retrospectively reviewed by two readers. Injury conspicuity was graded as: 0 (poorly visible), 1 (visible), and 2 (well visible). Marrow-to-injury signal intensity ratio was calculated in 30 patients: a ROI was positioned in the site of highest signal intensity and adjacent bone marrow and the ratio analyzed with Student's "t"-test., Results: In-phase and out-of-phase images showed 71 injuries in 51 patients. Conventional (in-phase) imaging missed 6/71 lesions. Injury conspicuity on out-of-phase images was of grade 2 in 58 cases (81.6%) and of grade 1 in 13 cases (18.3%), versus 23 (32.3%) and 42 (59.1%), respectively, on conventional images. Injury conspicuity was graded as 0 in 6 cases (8.4%) on conventional images. Quantitative analysis of marrow-to-injury signal intensity ratio showed higher values for out-of-phase GRE than conventional images., Conclusion: Opposed-phase GRE are quick sequences available on all MR systems which appear superior to conventional T1-weighted images in detecting occult injuries in the knee. Injuries are more conspicuous because their signal intensity is lower due to the simultaneous presence of fat and water protons, which is typical of bone trauma, GRE sequences make a useful and rapid complement to T1-/T2-weighted fat saturation acquisitions in the study of the post-traumatic knee.

Purpose: Anterolateral fibrous impingement of the ankle is one of the causes of post-traumatic pain in the foot. We investigated the comparative accuracy of US and MRI in this condition., Material and Methods: Fourteen patients were submitted to arthroscopy, plain radiography, US and MRI of the foot. The patients, all sportsmen, had a clinical history of sprains; the major symptoms were pain, swelling and clicking on foot dorsiflexion., Results: US showed anterior talofibular ligament changes in all patients and mid-low-echogenicity synovial tissue filling the lateral malleolar gutter. MRI demonstrated a small mass of synovial tissue in the gutter in 8 patients, with mid-low signal intensity before Gd-DTPA and mid-low contrast enhancement after contrast administration and no abnormal findings in 6 patients. Arthroscopy showed a small firm mass of proliferative synovium in the lateral malleolar gutter in all patients., Conclusions: Fibrous impingement must be suspected in the sportsmen presenting typical symptoms after ankle trauma. US is poorly accurate in diagnosing this condition. MRI shows a small synovial mass in the lateral malleolar gutter in more than half the patients, but aspecific MR findings do not rule impingement our MR images must be acquired along the proper planes and with Gd-DTPA administration.

Purpose: In the cranial humeral end, osteochondral injuries localize in a circular crown including part of the humeral head and part of the major and minor tuberosities. Since this region is easy to depict with US, we investigated the potentials of this technique in detecting osteochondral injuries., Materials and Methods: Seventy-five osteochondral injuries found at 492 US examinations performed in 12 months with a 7.5 MHz linear probe were retrospectively reviewed. Clinical history taking was focused on the following: a) previous trauma or b) luxation-instability and c) if the patient was a sportsman devoted to activities requiring forced abduction-external rotation or adduction-internal rotation. Since the site of the head's humeral injury is an important clue for diagnosis, we subdivided the humeral circle into four ideal quadrants by two perpendicular lines with the main line passing through the bicipital groove. Then, each injury was ascribed to a quadrant. All patients were also submitted to radiography (at least two films) and to MRI; CT was performed in 12 patients. Ten patients underwent surgery., Results: We found 34 Hill-Sachs lesions, 15 traumas, 9 arthrotic lesions, 7 cases of anterointernal and 4 of posterosuperior impingement, 4 cases of infraspinatus enthesopathy and 2 erosions due to perihumeral calcifications. In our experience, US was an accurate tool in the identification of humeral head conditions, which were confirmed at CT and/or MRI in all patients (no false positives). As for the injury nature, US diagnosis was confirmed in all Hill-Sachs lesions (34/34 cases), traumas (15/15 cases) and 50% of the cases of posterosuperior impingement (2/4 cases). These conditions made up about 2/3 of the whole cases (51/75 cases). US failed to establish the injury nature in the 9 arthrotic lesions, 7 cases of anterointernal impingement, 4 cases of infraspinatus enthesopathy and 2 erosions due to perihumeral calcifications., Conclusions: US can be suggested as the method of choice in the study of the osteochondral lining of the humeral head.

Introduction: Till 20 years ago, physical examination of the breast was the fundamental procedure for the diagnosis of breast conditions, but mammography has now become the only examination to diagnose infraclinical carcinoma. High quality mammographic images enhance the radiologist's skill., Material and Methods: We performed 2713 mammograms in a year's work and then selected 456 patients with questionable or poor mammographic findings (craniocaudal or midlateral oblique views) for further studies. The additional examinations were performed either to show the whole gland or to clarify the following findings: hyperdensity/asymmetry, ill defined nodule/pseudonodule, stellate lesions, microcalcifications, superficial or cutaneous lesions, inflexed nipples. As additional studies, we acquired spot compression images with/without magnification, exaggerated craniocaudal and cleavage images, images with a skin marker, rolled and tangential images. Based on radiologic findings, 155 patients were submitted to US, 104 to FNAB (under US or stereotaxic guidance) and 67 to surgery., Results: The additional views proved useful in 83.2% of patients showing the whole parenchyma in 35.4%, ruling out suspected abnormalities in 28.8%, depicting and characterizing nodules and microcalcifications in 19% of patients., Conclusions: In our study, additional views played an important role in the correct execution of mammographic studies because they: showed the whole gland; permitted to rule out suspected pathologic conditions; confirmed and defined previous questionable lesions, thus allowing the radiologist to plan the proper diagnostic route.

We report on 31 cases of calcaneal fractures studied with CT according to the latest classification by the Italian Surgical Society of the Foot. Of the utmost importance is the radiologic assessment of the posterior facet and of the underlying bone, which make up the so-called talamus which bears most of the body weight. In our series, talamus fractures were the most frequent ones (26/31 cases): they are characterized by a main sagittal line, running obliquely and dividing the posterior surface and the bone into an anteromedial, or substentacular, fragment and a posterolateral, or tuberosity, fragment. According to fracture severity, the first differential criterion is the presence/absence of displacement and depression (type I fractures the latter, 6 cases in our series, and (types II and III the former, 20/26 cases in our series). Based on the degree of displacement and depression, fractures as classified as type II (10/26 cases) when only the lateral portion of the talamus is displaced and depressed, or as type III (10/26 cases) when the whole talamus is fragmented, displaced and depressed. Moreover, other worsening factors must be considered and B subgroups differentiated in types II and III fractures; these factors are: calcaneus-cuboid facet involvement, lateral wall fragmentation, posterior facet comminution, a small sustentacular fragment and a secondary frontal fracture interrupting the plantar cortex. Extra-talamic fractures, defined as such when isolated, rarely occur. Relative to the anterior apophysis, radiologic attention must be focused on fractures of the dorsal prominence, or beak, which are very often misdiagnosed. As regards the posterior tuberosity, its lateral dislocation must be studied because it may account for calcaneofibular impingement. CT exhibits excellent potentials, provided that slices are thin, acquired on the axial and coronal planes and that, as far as possible, sagittal reconstructions are used, the latter being very useful to depict talamic surface.

The increasing number of radiologic examinations performed on patients previously submitted to arthroscopic meniscectomy led us to analyze the types of lesion most frequently found in these patients and the prognostic factors related to meniscectomy. Thus, the radiographs, CT and MR examinations were reviewed of 34 symptomatic patients submitted to arthroscopy at least 1 year earlier and in whom symptoms had appeared no more than 3 months earlier, thus ruling out the symptoms related to surgical complications. Lesions were found in the menisci, in the meniscal stumps and in the articular ends. The lesions involving the menisci not submitted to previous arthroscopy were not studied in detail. As to meniscal stumps, CT and MRI exhibited the same diagnostic accuracy, in detecting lesion recurrence, in 50% of cases. In the remaining cases their results were similar, with some false negatives (CT) and some false positives (MRI). As to osteoarthritis, MRI proved superior in detecting the microscopic evidence of cartilage-bone erosions even though 20% of patients exhibited findings of such entity as to be visible at CT. As regards the macroscopic evidence of articular ends deformity, CT and MRI yielded the same results. To define the prognostic factors of meniscectomy, all patient was asked to define their activity level after meniscectomy, that is before the onset or recurrence of symptoms. A detailed questionnaire was used to this purpose, using the Tapper-Hoover rating scale, expressly developed to derive a functional knee score after meniscectomy. The results indicate that the functional knee score (related to prognosis) was lower in patients older than 40, in meniscectomy performed in older age, in long intervals between trauma and meniscectomy, after complex and horizontal-cleavage lesions and, finally, in sedentary activity.

Combination of fat suppression techniques with intravenous paramagnetic contrast administration is usually performed using high-field MR systems. We combined a modified three-point Dixon technique for fat suppression with gadolinium-DTPA administration in the investigation of soft tissue neoplasms at 0.5 T. Nineteen patients with 21 neoplasms (14 primary malignant, 2 metastatic, 5 benign tumors) were examined. Examination protocol included unenhanced SE T1, PD and T2-weighted images. After the intravenous administration of gadolinium-DTPA (0.1 mmol/kg), a modified three-point Dixon technique provided three image sets, i.e., conventional T1-weighted SE images, fat-suppressed T1-weighted images and water-suppressed T1-weighted images. Two observers evaluated the lesions for conspicuity and size in three image groups: unenhanced T1-, PD and T2-weighted images, enhanced conventional T1-weighted images, enhanced T1-weighted images with fat suppression. Ten lesions showed greater conspicuity on enhanced fat-suppressed images than on unenhanced T1-, PD and T2- and enhanced conventional T1-weighted images. In 16 cases lesions were more conspicuous on enhanced water images than on conventional enhanced T1 images. Ten tumors exhibited a larger size (difference exceeding 20%) on enhanced fat-suppressed images. The combination of gadolinium with the modified Dixon technique improves the demonstration of soft tissue neoplasms at 0.5 T and allows lesion size to be measured more accurately.

CT and MR potentials were compared in 30 patients submitted to anterior cruciate ligament reconstruction using the patellar tendon. In each patient the clinical data were correlated with the following radiologic parameters: the course of the tibial and femoral tunnels, their intraarticular outlet sites and their shape, the shape of the intercondylar notch and of the medial wall of the lateral femoral condyle and, finally, the shape of the graft and of the synovia. The intraarticular outlet site of the tibial tunnel was studied on the sagittal or transverse planes. In the former case the distance from the anterior tibial edge was considered, together with its relationship to sagittal tibial depth. The intraarticular outlet site of the femoral tunnel which was studied on sagittal and coronal MR planes was determined at CT by calculating its distance, i.e., the number of scans, from the intercondylar notch and from the posterior edge of the femoral condyle. MRI yielded better results thanks to its multiplanarity, but CT proved superior in defining size and shape of the bone outlets, the presence of bone chips (sometimes responsible for synovial reaction), the shape of the intercondylar notch and of the medial wall of the lateral condyle. As regards graft visualization, both CT and MRI yielded satisfying results in most cases. Nevertheless, MR potentials appeared superior thanks to its capabilities in demonstrating the graft in its full length and in differentiating it from surrounding synovial reaction.

This study was aimed at evaluating CT diagnostic capabilities in detecting carcinoid tumors of the small bowel and comparing CT results with conventional radiographic findings. The CT diagnosis of carcinoid tumor was made in 6 cases based on CT findings. All patients had undergone conventional radiographs (transit or double-contrast studies of the small intestine) and 2 patients had undergone double-contrast barium enema of the colon. 500 ml of oral contrast medium were administered 2 hours, 1 hour and 15 minutes before CT scans, respectively. A hypotonic agent was injected i.v. immediately before the examination. Primary lesion extent, mesenteric involvement, extramesenteric lymph nodes and hepatic metastases were the investigated CT patterns. The first two variables were also assessed on plain radiographs. In all patients the diagnosis of enteric carcinoid tumor was confirmed at surgery or liver biopsy. CT proved to be useful in demonstrating the primary tumor in 5 cases, mesenteric involvement in all patients, liver metastases in 3, lymphadenopathy in none. CT yielded very accurate findings and thus allowed the diagnosis of carcinoid tumor to be made in all the 6 patients, while plain films resulted normal in 2 cases and aspecific in 4. In conclusion, CT, if adequately performed, proved the best technique to detect carcinoid tumors of the small bowel. Of course, further evidence is required.

MRI of the knee was performed in 30 patients who had been submitted to arthroscopically-guided reconstruction of the anterior cruciate ligament from patellar tendon. The autograft structure was investigated and MR results were correlated with clinical findings. Partial/total meniscectomy had been carried out in 21/30 cases. The patients were imaged at various postoperative intervals (3-24 months) by means of an 0.5-T magnet (GE MR Max Plus) in full knee extension and internal rotation. Sagittal and axial T1-weighted images (slice thickness: 3 mm) were combined with real-time reconstruction which better demonstrated the whole graft. T2-weighted coronal images (slice thickness: 5 mm) were also acquired. In each patient the following clinical variables were considered: anterior drawer sign, Lachman test, pivot shift, degree of leg extension, and finally functional recovery. The following MR variables were then considered: structure and alignment of bone tunnels, structure and signal intensity of the graft, degree of synovial inflammation, structure and signal intensity of the posterior cruciate ligament and finally structure of the menisci and/or meniscal residues. Symptoms-MR correlation suggests that the different outcome of surgical reconstruction may depend on the correct alignment of the tibial and femoral bone tunnels and on good meniscal condition. Bone tunnels must be located on the same plane, posterior and parallel to the slope of the intercondylar roof, since angulation causes the latter to impact the graft during knee extension, with inflammation and risk for rupture. As for menisci, tiny residues or total ablation overload tha graft, whose signal increases and whose synovia becomes inflamed. The latter pattern is always distinguished from that of the autograft, whose signal intensity seems not to change in time. In conclusion, MR proved an accurate and non-invasive technique to image this kind of postoperative knee, since metallic artifacts do not reach the joint space.

This study was aimed at assessing the clinical utility of conventional and color duplex-Doppler US in the diagnosis of thoracic outlet syndrome. Conventional US and Doppler examinations were performed in a prospective study. The results were correlated with angiographic findings. Thirteen patients affected with thoracic outlet syndrome were studied by means of both conventional US and spectral Doppler flow imaging. Five cases (5/13) had neurovascular symptoms in the right upper limbs, 7/13 in the left upper limbs and 1/13 in both upper limbs. An accessory cervical rib was demonstrated in 2/13 cases (associated with muscular hypertrophy in one case and bilateral in the other), by means of plain films of the spine. Conventional US depicted muscular hypertrophy in 7/13 cases--bilateral in one case and monolateral in 6/13 cases, with marked muscular asymmetry. In 5/13 cases, no bone/muscle anomalies were demonstrated. The patients with an accessory cervical rib and scalenus muscle hypertrophy were seen to exhibit two types of hemodynamic alterations in the subclavian artery--i.e., turbulence and changes in the systolic window with no increase in peak systolic velocity in 5/13 cases with mild stenosis, normal or reduced peak systolic velocity with changes in the reversed flow in 3/13 cases with mild/medium-grade stenosis, either during indifferent position or after dynamic tests. In 2/13 patients with no bone/muscle alterations, turbulence was demonstrated in the subclavian artery. However, in 3/13 cases Doppler US revealed no arterial flow abnormalities--3/13 false negatives relative to mild vascular compression. Selective arteriography demonstrated vascular alterations in the subclavian artery in all cases, with or without Doppler anomalies; while angiography was often positive during hyperabduction maneuvers color duplex Doppler demonstrated hemodynamic alterations at rest with indifferent position of the upper limb. In conclusion, conventional US allowed the evaluation of the thickness of both anterior and middle scalene muscles and of possible muscular asymmetries. Color duplex Doppler US demonstrated primary and secondary alterations in the subclavian artery or vein. Therefore, conventional US, duplex and color Doppler prove to be valuable non-invasive tools in the patients with neurovascular symptoms in the upper limbs and could allow the selection of the cases to submit to arteriography.

The authors report their experience with a comparative US study employing different-frequency probes (7.5, 10, 13 and 15 MHz) in Achilles tendon conditions. The study population included 49 patients, 37 of them athletes. All patients complained of the same symptoms: achillodynia in the middle third (group A, 29/49 cases), achillodynia in the lower end (group B, 16/49 cases), suspected partial rupture in the middle third (group C, 2/49 cases) and suspected distal rupture in the upper third (group D, 2/49 cases). In group A, the different frequencies yielded different results. 7.5 MHz frequencies yielded negative results in 13/29 patients, versus 3/29 with higher frequencies, which demonstrated peritenon inflammation in 10/29 cases. In the remaining 16 cases, where 7.5 MHz frequencies had shown tendon inflammation and degeneration, the higher frequencies confirmed the findings, even though their accuracy was greater. On the contrary, in the cases of distal achillodynia where pain was mainly due to inflammation of the retrocalcaneal bursa, the different frequencies yielded similar results, even though the higher ones proved more accurate in revealing tendon abnormalities--i.e., thickening, focal hypolucencies, spotty microcalcifications, irregularity of the bone lining. In group B, the different frequencies once again exhibited similar results showing a focal hypoechoic discontinuity which was correctly diagnosed on the basis of clinical history. Finally, as for group C, the lower frequencies gave better results because of the deeper location of the region of interest. In both cases a small blood collection was visible, between gastrocnemius and soleus, in the absence of clear-cut tendon lesions. No matter what the condition, the higher frequencies were extremely valuable since they allowed excellent demonstration of tendon anatomy. The tendon is enveloped by the peritenon, made of two macroscopically distinct sheaths the distinction of which is allowed by higher frequencies when a minimal amount of fluid is present. From the peritenon, the intratendon septa originate circumscribing spaces containing tendon fiber bundles. The vessels, which run longitudinally, are located within the confluence of the septa. On US images, the septa appear as thin hypoechoic stripes or small hyperechoic spots depending on the type of scan (longitudinal/axial). As to tendon fibers--i.e., tenocytes, collagen and elastic fibers--their pattern is homogeneous and hypoechoic since devoid of interfaces.

Laryngeal and mesopharyngeal cancers are usually diagnosed by means of endoscopy which, however, fails to demonstrate tumor spread to adjacent structures. Aim of the present work is to assess the role of US in the evaluation of these lesions, relative to the demonstration of both the primary tumor with its local spread and metastases. This could help choose the correct therapeutic approach and select the patients ineligible for surgery to treat with chemo-/radiotherapy. Twenty-seven patients underwent US: 9 had mesopharyngeal and 5 supraglottic cancers, 11 had glottic and 2 subglottic lesions. With the only exception of subglottic cancers, US always demonstrated the primary tumor and its spread to anterior and posterior perilaryngeal structures. Moreover, node involvement could be studied. US proved uninformative in demonstrating the posterolateral laryngeal walls, the subglottic area, the presence of deep lymph nodes and the retrocartilaginous structures when associated with calcifications of the thyroid cartilage. In summary, we believe that US can be useful as the first-step imaging modality to stage laryngeal and mesopharyngeal cancers and to follow the patients submitted to chemo-/radiotherapy.

Our experience is reported with the combined use of radiology and US in the study of 210 joints of hemophilic patients. The study was carried out considering that in hemophilia the classification of the grades of disease generally relies upon X-ray findings which, although reliable in the advanced stages of the disease, appear inadequate in the early stages. In fact, synovial hypertrophy, cartilage erosions and initial subchondral cysts are most often missed on X-ray films. In the examined cases, US was employed to evaluate: 1) the degree of synovial hypertrophy, 2) the status of the explorable cartilage, 3) the presence of effusions and 4) the status of bone linings--whenever erosions, even of minimal extent, were suspected, X-rays were always performed and the results employed as the reference standard. The examined joints did not exhibit the same grade of involvement: the knee, elbow and ankle had advanced arthropathy in 85% of cases, corresponding to > or = 7 according to Pettersson score. On the contrary, the shoulder and hip were found to be equally involved either by initial (Pettersson score: 0-6) or by advanced arthropathy (Pettersson score: > or = 7). Moreover, in nearly 10% of the cases, hemarthrosis was found which showed no correlation with the grade of joint involvement. Our results indicate that: 1) US appears very useful in the early stages of the disease when the X-ray picture is negative or poorly significant. The demonstration of early alterations is useful mainly in those cases in whom synoviectomy is considered (for prevention); the latter is useful only if performed before cartilage erosion appear; 2) US appears equally useful in hemarthrosis cases, especially in those of limited extent in which the clinical therapeutic management may be difficult; 3) US appears unnecessary in the cases of advanced arthropathy in which X-rays serve as the reference standard.

Twenty-nine small hepatocellular carcinomas (sHCCs) less than 5 cm in diameter were treated with percutaneous ethanol injection (PEI) under US guidance in 24 cirrhotic patients. The nodules were treated on an outpatient basis with 6-18 ethanol injections; the total amount of alcohol delivered to each lesion was 10-103 ml. Twenty-seven of the 29 HCCs (93.1%) showed no evidence viable neoplastic tissue at a dynamic CT scan combined with multiple fine-needle biopsies performed one month after the end of treatment; in 10 cases MR confirmed the presence of necrosis showing marked hypointensity of the lesions in T2-weighted images. None of the 27 necrotized sHCCs recurred locally during a 4-44 months' follow-up period (mean 18 months). Two lesions larger than 4 cm showed incomplete response to treatment. No complications occurred after a total number of 264 alcohol injections. The 1-year survival rate in the 16 patients with a follow-up longer than 12 months was 93.7%. PEI proved to be a safe and effective treatment for sHCCs. In particular, PEI can be viewed as a reliable alternative to surgery in the management of nodules less than 3 cm in diameter, considering the operative hazards and the high risk of new lesions occurring in resected livers.

The authors evaluated the US patterns of 50 prostatic carcinomas before and after radiation therapy, analyzing the correlation of US patterns with histologic (bioptic) findings and with treatment outcome. Before radiation therapy, 28 tumors were hypoechoic, 8 were isoechoic and 14 mixed. In 18 of 28 hypoechoic carcinomas, the lesion showed a progressive increase in echogenicity, becoming completely isoechoic 9-18 months after the end of treatment. In this group of patients the final response to treatment was complete in 17 cases and partial in 1; during the follow-up (24-90 months, mean 48 months) neither local recurrences nor distant metastases were observed. In 10 of 28 hypoechoic carcinomas, a hypoechoic area of variable size was still clearly recognizable within the lesion after a minimum period of 18 months since the end of treatment. Nine of these patients underwent histology and persistent carcinomas were found in 8 of them; one patient developed distant metastases. In the group of isoechoic and mixed carcinomas, no significant differences were observed in the US patterns relative to treatment outcome. Persistent prostatic carcinoma after radiation therapy seems not to affect its US pattern. If the tumor is hypoechoic before treatment, the persistence of a hypoechoic area within the lesion 18 months after the end of treatment must be regarded as a possible therapeutic failure and histologically verified. On the contrary, the evolution of the lesion toward isoechogenicity is usually related to a favorable outcome. If the tumor is isoechoic or mixed before treatment, a reliable US evaluation is not possible and the correct assessment of the response to treatment can only be made with multiple biopsies.