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Abstract Background Open arch surgery is technically demanding for the surgeon and surgically and biologically invasive for the patient, requiring a variably long period of hypothermic circulatory arrest. Case presentation Here we present a case of an elderly patient with chronic renal failure and multiple splanchnic artery disease successfully treated for a rupturing pseudoaneurysm of the aortic arch with a technique that we developed for particularly frail patients. The procedure includes: triple supra-aortic vessel perfusion; distal thoracic aorta antegrade perfusion; balloon endo-clamping of the descending aorta; and anastomosis of an off-the-shelf hybrid arch prosthesis in Ishimaru zone 0. These maneuvers allowed to maintain an extracorporeal circulation in the phase of distal anastomosis, instead of a period of circulatory arrest, employing just mild hypothermia: technical details are depicted and discussed also in comparison with other methods proposed in the literature. Conclusions Being able to take advantage of both open surgery advancements and endovascular methods is the key to cardiovascular surgery success today in front of complex pathologies of the aorta: increasing safety and reducing invasiveness of therapeutic options may progressively extend surgical candidacy to the frailest patients.

Background: The aim of this study is to define and determine the rate of acute non-A–non-B aortic dissections, and to evaluate CT angiography findings and possible complications, as well as to discuss management strategies and currently available therapy. Non-A non-B type of aortic dissection is still a grey area in the radiologist’s mind, such that it is not entirely clear what should be reported and completed in terms of this disease. Methods: A retrospective single-center study including 36 pre-treatment CT angiograms of consecutive patients (mean age: 61 years) between January 2012 and December 2022 with aortic dissection involving the aortic arch with/without the thoracic descending/abdominal aorta (type non-A non-B). Results: According to the dissection anatomy, we identified three modalities of spontaneous acute non-A–non-B anatomical configurations. Configuration 1 (n = 25) with descending-entry tear and retrograde arch extension (DTA entry). Configuration 2 (n = 4) with Arch entry tear and isolated arch involvement (Arch alone). Configuration 3 (n = 7) with Arch entry and anterograde descending (±abdominal) aorta involvement (Arch entry). CT angiogram findings, management, and treatment options are described. Conclusions: Acute non-A non-B dissection represents an infrequent occurrence of aortic arch dissection (with or without involvement of the descending aorta) that does not extend to the ascending aorta. The complete understanding of its natural progression, distinct CT angiography subtypes, optimal management, and treatment strategies remains incomplete. Within our series, patients frequently exhibit a complex clinical course, often necessitating a more assertive approach to treatment compared to type B dissections.

Background: Amyotrophic lateral sclerosis (ALS) is a neuromuscular progressive disorder characterized by limb and bulbar muscle wasting and weakness. A total of 30% of patients present a bulbar onset, while 70% have a spinal outbreak. Respiratory involvement represents one of the worst prognostic factors, and its early identification is fundamental for the early starting of non-invasive ventilation and for the stratification of patients. Due to the lack of biomarkers of early respiratory impairment, we aimed to evaluate the role of chest dynamic MRI in ALS patients. Methods: We enrolled 15 ALS patients and 11 healthy controls. We assessed the revised ALS functional rating scale, spirometry, and chest dynamic MRI. Data were analyzed by using the Mann–Whitney U test and Cox regression analysis. Results: We observed a statistically significant difference in both respiratory parameters and pulmonary measurements at MRI between ALS patients and healthy controls. Moreover, we found a close relationship between pulmonary measurements at MRI and respiratory parameters, which was statistically significant after multivariate analysis. A sub-group analysis including ALS patients without respiratory symptoms and with normal spirometry values revealed the superiority of chest dynamic MRI measurements in detecting signs of early respiratory impairment. Conclusions: Our data suggest the usefulness of chest dynamic MRI, a fast and economically affordable examination, in the evaluation of early respiratory impairment in ALS patients.

Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy divided into two types: light-chain (LA) and transthyretin (ATTR) CA. Cardiac magnetic resonance (CMR) has emerged as an important diagnostic tool in CA. While late gadolinium enhancement (LGE), T1 mapping and extracellular volume (ECV) have a consolidate role in the assessment of CA, T2 mapping has been less often evaluated. We aimed to test the value of T2 mapping in the evaluation of CA. This study recruited 70 patients with CA (51 ATTR, 19 AL). All the subjects underwent 1.5 T CMR with T1 and T2 mapping and cine and LGE imaging. Their QALE scores were evaluated. The myocardial T2 values were significantly (p < 0.001) increased in both types of CA compared to the controls. In the AL-CA group, increased T2 values were associated with a higher QALE score. The myocardial native T1 values and ECV were significantly (p < 0.001) higher in the CA patients than in the healthy subjects. Left ventricular (LV) mass, QALE score and ECV were higher in ATTR amyloidosis compared with AL amyloidosis, while the LV ejection fraction was lower (p < 0.001). These results support the concept of the presence of myocardial edema in CA. Therefore, a CMR evaluation including not only myocardial T1 imaging but also myocardial T2 imaging allows for more comprehensive tissue characterization in CA.

“Emergency” is a scenario that every medical professional must face since the first day of her/his career [...]

Advancing medical technology revolutionizes our ability to diagnose various disease processes. Conventional Single-Energy Computed Tomography (SECT) has multiple inherent limitations for providing definite diagnoses in certain clinical contexts. Dual-Energy Computed Tomography (DECT) has been in use since 2006 and has constantly evolved providing various applications to assist radiologists in reaching certain diagnoses SECT is rather unable to identify. DECT may also complement the role of SECT by supporting radiologists to confidently make diagnoses in certain clinically challenging scenarios. In this review article, we briefly describe the principles of X-ray attenuation. We detail principles for DECT and describe multiple systems associated with this technology. We describe various DECT techniques and algorithms including virtual monoenergetic imaging (VMI), virtual non-contrast (VNC) imaging, Iodine quantification techniques including Iodine overlay map (IOM), and two- and three-material decomposition algorithms that can be utilized to demonstrate a multitude of pathologies. Lastly, we provide our readers commentary on examples pertaining to the practical implementation of DECT’s diverse techniques in the Gastrointestinal, Genitourinary, Biliary, Musculoskeletal, and Neuroradiology systems.

Immune-checkpoint inhibitors have profoundly changed cancer treatment, improving the prognosis of many oncologic patients. However, despite the good efficacy of these drugs, their mechanism of action, which involves the activation of the immune system, can lead to immune-related adverse events, which may affect almost all organs. Pulmonary adverse events are relatively common, and potentially life-threatening complications may occur. The diagnosis is challenging due to the wide and non-specific spectrum of clinical and radiological manifestations. The role of the radiologist is to recognize and diagnose pulmonary immune-related adverse events, possibly even in the early stages, to estimate their extent and guide patients’ management.

Technology is making giant strides and is increasingly improving the diagnostic imaging of both frequent and rare acute and chronic diseases [...]

Hypersensitivity pneumonitis (HP) is a diffuse parenchymal lung disease (DLPD) characterized by complex interstitial lung damage with polymorphic and protean inflammatory aspects affecting lung tissue targets including small airways, the interstitium, alveolar compartments and vascular structures. HP shares clinical and often radiological features with other lung diseases in acute or chronic forms. In its natural temporal evolution, if specific therapy is not initiated promptly, HP leads to progressive fibrotic damage with reduced lung volumes and impaired gas exchange. The prevalence of HP varies considerably worldwide, influenced by factors like imprecise disease classification, diagnostic method limitations for obtaining a confident diagnosis, diagnostic limitations in the correct processing of high-resolution computed tomography (HRCT) radiological parameters, unreliable medical history, diverse geographical conditions, heterogeneous agricultural and industrial practices and occasionally ineffective individual protections regarding occupational exposures and host risk factors. The aim of this review is to present an accurate and detailed 360-degree analysis of HP considering HRCT patterns and the role of the broncho-alveolar lavage (BAL), without neglecting biopsy and anatomopathological aspects and future technological developments that could make the diagnosis of this disease less challenging.

Background: Small renal masses (SRMs) are defined as contrast-enhanced renal lesions less than or equal to 4 cm in maximal diameter, which can be compatible with stage T1a renal cell carcinomas (RCCs). Currently, 50–61% of all renal tumors are found incidentally. Methods: The characteristics of the lesion influence the choice of the type of management, which include several methods SRM of management, including nephrectomy, partial nephrectomy, ablation, observation, and also stereotactic body radiotherapy. Typical imaging methods available for differentiating benign from malignant renal lesions include ultrasound (US), contrast-enhanced ultrasound (CEUS), computed tomography (CT), and magnetic resonance imaging (MRI). Results: Although ultrasound is the first imaging technique used to detect small renal lesions, it has several limitations. CT is the main and most widely used imaging technique for SRM characterization. The main advantages of MRI compared to CT are the better contrast resolution and tissue characterization, the use of functional imaging sequences, the possibility of performing the examination in patients allergic to iodine-containing contrast medium, and the absence of exposure to ionizing radiation. For a correct evaluation during imaging follow-up, it is necessary to use a reliable method for the assessment of renal lesions, represented by the Bosniak classification system. This classification was initially developed based on contrast-enhanced CT imaging findings, and the 2019 revision proposed the inclusion of MRI features; however, the latest classification has not yet received widespread validation. Conclusions: The use of radiomics in the evaluation of renal masses is an emerging and increasingly central field with several applications such as characterizing renal masses, distinguishing RCC subtypes, monitoring response to targeted therapeutic agents, and prognosis in a metastatic context.

Endometrial cancer (EC) is intricately linked to obesity and diabetes, which are widespread risk factors. Medical imaging, especially magnetic resonance imaging (MRI), plays a major role in EC assessment, particularly for disease staging. However, the diagnostic performance of MRI exhibits variability in the detection of clinically relevant prognostic factors (e.g., deep myometrial invasion and metastatic lymph nodes assessment). To address these challenges and enhance the value of MRI, radiomics and artificial intelligence (AI) algorithms emerge as promising tools with a potential to impact EC risk assessment, treatment planning, and prognosis prediction. These advanced post-processing techniques allow us to quantitatively analyse medical images, providing novel insights into cancer characteristics beyond conventional qualitative image evaluation. However, despite the growing interest and research efforts, the integration of radiomics and AI to EC management is still far from clinical practice and represents a possible perspective rather than an actual reality. This review focuses on the state of radiomics and AI in EC MRI, emphasizing risk stratification and prognostic factor prediction, aiming to illuminate potential advancements and address existing challenges in the field.

Acinetobacter baumannii (Ab) is an opportunistic Gram-negative pathogen intrinsically resistant to many antimicrobials. The aim of this retrospective study was to describe the imaging features on chest X-ray (CXR) and computed tomography (CT) scans in hospitalized patients with multidrug-resistant (MDR) Ab pneumonia. CXR and CT findings were graded on a three-point scale: 1 represents normal attenuation, 2 represents ground-glass attenuation, and 3 represents consolidation. For each lung zone, with a total of six lung zones in each patient, the extent of disease was graded using a five-point scale: 0, no involvement; 1, involving 25% of the zone; 2, 25–50%; 3, 50–75%; and 4, involving >75% of the zone. Points from all zones were added for a final total cumulative score ranging from 0 to 72. Among 94 patients who tested positive for MDR Ab and underwent CXR (males 52.9%, females 47.1%; mean age 64.2 years; range 1–90 years), 68 patients underwent both CXR and chest CT examinations. The percentage of patients with a positive CT score was significantly higher than that obtained on CXR (67.65% > 35.94%, p-value = 0.00258). CT score (21.88 ± 15.77) was significantly (p-value = 0.0014) higher than CXR score (15.06 ± 18.29). CXR and CT revealed prevalent bilateral abnormal findings mainly located in the inferior and middle zones of the lungs. They primarily consisted of peripheral ground-glass opacities and consolidations which predominated on CXR and CT, respectively.

The spleen, often referred to as the “forgotten organ”, plays numerous important roles in various diseases. Recently, there has been an increased interest in the application of radiomics in different areas of medical imaging. This systematic review aims to assess the current state of the art and evaluate the methodological quality of radiomics applications in spleen imaging. A systematic search was conducted on PubMed, Scopus, and Web of Science. All the studies were analyzed, and several characteristics, such as year of publication, research objectives, and number of patients, were collected. The methodological quality was evaluated using the radiomics quality score (RQS). Fourteen articles were ultimately included in this review. The majority of these articles were published in non-radiological journals (78%), utilized computed tomography (CT) for extracting radiomic features (71%), and involved not only the spleen but also other organs for feature extraction (71%). Overall, the included papers achieved an average RQS total score of 9.71 ± 6.37, corresponding to an RQS percentage of 27.77 ± 16.04. In conclusion, radiomics applications in spleen imaging demonstrate promising results in various clinical scenarios. However, despite all the included papers reporting positive outcomes, there is a lack of consistency in the methodological approaches employed.

Awareness of gender differences in cardiovascular disease (CVD) has increased: both the different impact of traditional cardiovascular risk factors on women and the existence of sex-specific risk factors have been demonstrated. Therefore, it is essential to recognize typical aspects of ischemic heart disease (IHD) in women, who usually show a lower prevalence of obstructive coronary artery disease (CAD) as a cause of acute coronary syndrome (ACS). It is also important to know how to recognize pathologies that can cause acute chest pain with a higher incidence in women, such as spontaneous coronary artery dissection (SCAD) and myocardial infarction with non-obstructive coronary arteries (MINOCA). Coronary computed tomography angiography (CCTA) and cardiac magnetic resonance imaging (CMR) gained a pivotal role in the context of cardiac emergencies. Thus, the aim of our review is to investigate the most frequent scenarios in women with acute chest pain and how advanced cardiac imaging can help in the management and diagnosis of ACS.

Non-traumatic thoracic aorta emergencies are associated with significant morbidity and mortality. Diseases of the intimomedial layers (aortic dissection and variants) have been grouped under the common term of acute aortic syndrome because they are life-threatening conditions clinically indistinguishable on presentation. Patients with aortic dissection may present with a wide variety of symptoms secondary to the pattern of dissection and end organ malperfusion. Other conditions may be seen in patients with acute symptoms, including ruptured and unstable thoracic aortic aneurysm, iatrogenic or infective pseudoaneurysms, aortic fistula, acute aortic thrombus/occlusive disease, and vasculitis. Imaging plays a pivotal role in the patient’s management and care. In the emergency room, chest X-ray is the initial imaging test offering a screening evaluation for alternative common differential diagnoses and a preliminary assessment of the mediastinal dimensions. State-of-the-art multidetector computed tomography angiography (CTA) provides a widely available, rapid, replicable, noninvasive diagnostic imaging with sensitivity approaching 100%. It is an impressive tool in decision-making process with a deep impact on treatment including endovascular or open surgical or conservative treatment. Radiologists must be familiar with the spectrum of these entities to help triage patients appropriately and efficiently. Understanding the imaging findings and proper measurement techniques allow the radiologist to suggest the most appropriate next management step.

Diffuse lung disorders (DLDs) and interstitial lung diseases (ILDs) are pathological conditions affecting the lung parenchyma and interstitial network. There are approximately 200 different entities within this category. Radiologists play an increasingly important role in diagnosing and monitoring ILDs, as they can provide non-invasive, rapid, and repeatable assessments using high-resolution computed tomography (HRCT). HRCT offers a detailed view of the lung parenchyma, resembling a low-magnification anatomical preparation from a histological perspective. The intrinsic contrast provided by air in HRCT enables the identification of even the subtlest morphological changes in the lung tissue. By interpreting the findings observed on HRCT, radiologists can make a differential diagnosis and provide a pattern diagnosis in collaboration with the clinical and functional data. The use of quantitative software and artificial intelligence (AI) further enhances the analysis of ILDs, providing an objective and comprehensive evaluation. The integration of “meta-data” such as demographics, laboratory, genomic, metabolomic, and proteomic data through AI could lead to a more comprehensive clinical and instrumental profiling beyond the human eye’s capabilities.

A severe mismatch between the supply and demand of oxygen is the common sequela of all types of shock, which present a mortality of up to 80%. Various organs play a protective role in shock and contribute to whole-body homeostasis. The ever-increasing number of multidetector CT examinations in severely ill and sometimes unstable patients leads to more frequently encountered findings leading to imminent death, together called “hypovolemic shock complex”. Features on CT include dense opacification of the right heart and major systemic veins, venous layering of contrast material and blood, densely opacified parenchyma in the right hepatic lobe, decreased enhancement of the abdominal organ, a dense pulmonary artery, contrast pooling in dependent lungs, and contrast stasis in pulmonary veins. These findings are biomarkers and prognostic indicators of paramount importance which stratify risk and improve patient outcomes. In this review, we illustrate the various CT patterns in shock and review the spectrum and prognostic significance of thoraco-abdominal vascular and visceral alarming signs of impending death with the intention of increasing awareness among radiologists and radiographers to prepare for immediate resuscitation when required.

In recent decades, cardiac computed tomography (CT) has emerged as a powerful non-invasive tool for risk stratification, as well as the detection and characterization of coronary artery disease (CAD), which remains the main cause of morbidity and mortality in the world. Advances in technology have favored the increasing use of cardiac CT by allowing better performance with lower radiation doses. Coronary artery calcium, as assessed by non-contrast CT, is considered to be the best marker of subclinical atherosclerosis, and its use is recommended for the refinement of risk assessment in low-to-intermediate risk individuals. In addition, coronary CT angiography (CCTA) has become a gate-keeper to invasive coronary angiography (ICA) and revascularization in patients with acute chest pain by allowing the assessment not only of the extent of lumen stenosis, but also of its hemodynamic significance if combined with the measurement of fractional flow reserve or perfusion imaging. Moreover, CCTA provides a unique incremental value over functional testing and ICA by imaging the vessel wall, thus allowing the assessment of plaque burden, composition, and instability features, in addition to perivascular adipose tissue attenuation, which is a marker of vascular inflammation. There exists the potential to identify the non-obstructive lesions at high risk of progression to plaque rupture by combining all of these measures.

Immunotherapy in the form of ICIs has revolutionized advanced NSCLC treatment algorithms, with ICI-containing combination treatments being the latest addition to approved regimens. However, PD-L1 still represents the only routinely assessed and validated biomarker apart from genetic drivers testing, impairing our capacity to personalize and guide treatment. Therefore, this paper aims to analyze the most promising emerging predictive biomarkers that could help us in the near future to select patients more effectively.

Obstruction of the superior vena cava represents an under-recognized cause of chylothorax in the adult population. Our case report describes the successful conservative management of chylothorax due to bilateral superior vena cava obstruction in an adult patient with complex congenital heart disease. (Level of Difficulty: Beginner.)

Lipomas are the most common form of benign soft tissue tumors in humans, occurring infrequently in visceral organs. Pulmonary lipomas are seen rarely and can occur such as an endobronchial (80%) or peripheral parenchymal (20%) lesion. Less than 10 cases of lung peripheral lipoma are described in literature, none cavitated. We report the clinical case of a 51-year-old emphysematous smoker man with a peripheral intrapulmonary middle-lobe cavitating lipoma, revealed during a routine chest X-ray for emphysema, subsequently confirmed by high-resolution computed tomography (HRCT) and positron emission tomography (PET)–CT. Some hypotheses are made about the origin of cavitation. Biopsy and surgery were not done due to the fully benign nodular features at imaging. The nodule was unchanged till 2 years, last follow-up with low-dose HRCT. It is probably useful to choose a conservative approach with a follow-up, if there is a high suspicion of benignity.

Transcatheter leadless pacemaker dislodgment is a rare and potentially fatal complication of leadless device implantation. We present the first case of multidetector computed to-mography images of leadless pacemaker migration and embolization in the pulmonary middle lobe artery. The patient was managed by percutaneous retrieval of the dislodged device and re-implantation in the appropriate position.

Spontaneous ruptured aneurysm involving an aberrant subclavian artery with a right-sided aortic arch and Kommerell’s diverticulumis a rare life-threatening condition that can be treated successfully if promptly identified. Multidetector Computed Tomography angiography is the first line imaging modality of thoracic vascular anomalies diagnosis. We report the case of a 74-year-old man suffering from this emergency ondition with mediastinal hematoma mostly extending to the left-side extrapleural cavity. The patient underwent successful emergency thoracic endovascular aortic repair and an Amplatzer vascular plug was placed into the first segment of the ALSA. Post-procedural imaging showed complete exclusion of the aneurysm. Emergency endovascular repair can be effective in such cases.

Herein, we report the case of a 60-year-old man, a smoker with a history of arterial hypertension and diabetes mellitus. After computed tomography (CT) for an episode of hemoptysis, the patient underwent elective thoracic endovascular aortic repair (TEVAR) because of a degenerative aneurysm of the descending thoracic aorta. The area of perianeurysmal pulmonary atelectasis reported on the CT scan was not considered. Three months later, he developed an aortopulmonary fistula without endoleaks. Although TEVAR is a relatively safe procedure, no detail should be overlooked in the preoperative evaluation in order to avoid life-threatening complications. Further, the effectiveness and modality of prolonged antibiotic prophylaxis and/or preoperative respiratory physiotherapy should be assessed in such cases.