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Lung ultrasound (LUS) scanning is useful to diagnose and assess the severity of pulmonary lesions during COVID-19-related ARDS (CoARDS). A conventional LUS score is proposed to measure the loss of aeration during CoARDS. However, this score was validated during the pre-COVID-19 era in patients with ARDS in the ICU and does not consider the differences with CoARDS. An alternative LUS method is based on grading the percentage of extension of the typical signs of COVID-19 pneumonia on the lung surface (LUSext).Is LUSext feasible in patients with COVID-19 at the onset of disease, and does it correlate with the volumetric measure of severity of COVID-19 pneumonia lesions at CT scan (CTvol)?This observational study enrolled a convenience sampling of patients in the ED with confirmed COVID-19 whose condition demonstrated pneumonia at bedside LUS and CT scan. LUSext was visually quantified. All CT scan studies were analyzed retrospectively by a specifically designed software to calculate the CTvol. The correlation between LUSext and CTvol, and the correlations of each score with PaoWe analyzed data from 179 patients. Feasibility of LUSext was 100%. Time to perform LUS scan was 5 ± 1.5 mins. LUSext and CTvol were correlated positively (R = 0.67; P .0001). Both LUSext and CTvol showed negative correlation with PaoLUSext is a valid measure of the severity of the lesions when compared with the CT scan. Not only are LUSext and CTvol correlated, but they also have similar inverse correlation with the severity of respiratory failure. LUSext is a practical and simple bedside measure of the severity of pneumonia in CoARDS, whose clinical and prognostic impact need to be investigated further.

Background The necessity to identify and isolate COVID-19 patients to avoid intrahospital cross infections is particularly felt as a challenge. Clinically occult SARS-CoV-2 infection among patients admitted to the hospital is always considered a risk during the pandemic. The aim of our study is to describe the application of CT scan to reveal unexpected COVID-19 in patients needing hospital admission. Method In our emergency department, we prospectively enrolled adult patients needing hospital admission, without symptoms suspected of COVID-19, and showing negative reverse transcriptase-polymerase chain reaction (RT-PCR) swab test. CT scan was performed to diagnose clinically occult COVID-19 pneumonia. All the exams were read and discussed retrospectively by two expert radiologists and assigned to one of 4 exclusive diagnoses: typical (typCT), indeterminate (indCT), atypical (atyCT), negative (negCT). The clinical characteristics and final diagnoses were described and compared with the results of CT scans. Results From May 25 to August 18, 2020, we prospectively enrolled 197 patients. They showed 122 negCT, 52 atyCT, 22 indCT, and 1 typCT. Based on the CT imaging, the prevalence of suspected clinically occult COVID-19 pneumonia was 11.6% (23 patients). None had confirmation of SARS-CoV-2 infection after the hospital stay. Nineteen patients had negative serial RT-PCR while in 4 cases, the infection was excluded by clinical follow-up or appearance of positivity of RT-PCR after months. Conclusion Our descriptive analysis confirms that CT scan cannot be considered a valid tool to screen clinically occult COVID-19, when the asymptomatic patients need hospitalization for other conditions. Application of personnel protections and distancing among patients remains the best strategies to limit the possibility of intrahospital cross-infections.

Mortality risk in COVID-19 patients is determined by several factors. The aim of our study was to adopt an integrated approach based on clinical, laboratory and chest x-ray (CXR) findings collected at the patient’s admission to Emergency Room (ER) to identify prognostic factors. Retrospective study on 346 consecutive patients admitted to the ER of two North-Western Italy hospitals between March 9 and April 10, 2020 with clinical suspicion of COVID-19 confirmed by reverse transcriptase-polymerase reaction chain test (RT-PCR), CXR performed within 24 h (analyzed with two different scores) and recorded prognosis. Clinical and laboratory data were collected. Statistical analysis on the features of 83 in-hospital dead vs 263 recovered patients was performed with univariate (uBLR), multivariate binary logistic regression (mBLR) and ROC curve analysis. uBLR identified significant differences for several variables, most of them intertwined by multiple correlations. mBLR recognized as significant independent predictors for in-hospital mortality age > 75 years, C-reactive protein (CRP) > 60 mg/L, PaO2/FiO2 ratio (P/F) 7. Among the patients with at least two predictors, the in-hospital mortality rate was 58% against 6% for others [p p

Abstract. The application of point-of-care lung ultrasound (LUS) in the first diagnosis and management of Corona Virus Disease 2019 (COVID-19) has gained a great interest during a pandemic that is undermining even the most advanced health systems. LUS demonstrated high sensitivity in the visualization of the interstitial signs of the typical pneumonia complicating the infection. However, although this disease gives typical lung alterations, the same LUS signs observed in COVID-19 pneumonia can be detected in other common pulmonary conditions. While being non-specific when considered separately, the analysis of the distribution of the sonographic typical signs allows the assignment of 4 LUS patterns of probability for COVID-19 pneumonia when the whole chest is examined and attention is paid to the presence of other atypical signs. Moreover, the combination of LUS likelihood with the clinical phenotype at presentation increases the accuracy. This mini-review will analyze the LUS signs of COVID-19 pneumonia and how they can be combined in patterns of probability in the first approach to suspected cases.

Hyperhydration is characterized by increased quantity and altered distribution of body fluids. Fluid overload is frequently found in critically ill patients with acute kidney injury (AKI) and in heart failure patients and is associated with adverse outcomes. Although physical examination is still the first choice for the assessment of the hydration state, it is imprecise and often unreliable. Nowadays novel techniques are employed, sometimes together, in a comprehensive assessment strategy previously proposed as the “5B” approach: body weight changes, blood volume online monitoring, bioimpedance spectroscopy (BIS), B-natriuretic peptide, and body ultrasound (US), which includes inferior vena cava (IVC) diameter measure and lung US (LUS). The modern LUS has extended its field of clinical application from cardiology and intensive care setting to hemodialysis patients since the clinical evaluation alone has proven to be rather imprecise in estimating the correct “dry weight.” B-line detection by LUS has recently been confirmed to be superior in sensitivity to clinical signs of fluid overload such as lung crackles and peripheral edema. Furthermore, LUS has shown a greater predictive power for hydration-related cardiovascular morbidity and mortality than NYHA score or echocardiography. Based on evidence, LUS can be considered a valid diagnostic and prognostic tool for pulmonary congestion measurement in both extracorporeal and peritoneal dialysis patients.

Background: Solitary fibrous tumor of the pleura (SFTP) arising from the mediastinal pleura may be confused with primary mediastinal tumors. We studied the computerized tomographic (CT) findings of patients with SFTP that could suggest a diagnosis of SFTP. Materials and Methods: At our hospital from January 1995 to June 2012, 39 patients with histologically confirmed SFTP were surgically treated; seven of them abutting the mediastinal pleura. The study group included seven patients aged between 53 and 81 years. Baseline CT scans were retrospectively reviewed to identify radiological findings suggestive of SFTP including: (1) smooth and sharply delineated contours; (2) obtuse, acute, or tapering angles between the lesion and the mediastinum depending on the size; (3) homogeneous soft-tissue attenuation; (4) “geographic pattern” due to the contemporary presence of large vessels, necrosis, and calcifications; (5) displacement of the lung parenchyma; (6) presence of a cleavage plane; and (7) absence of lymphadenopathy or pleural methastasis. Results: All tumors formed acute angles with the pleura. Six out of the seven presented smoothly tapering margins, three had a “geographic pattern” of attenuation and displaced the anterior junction line; one showed an outside junction line development. Four cases had a clear pleural origin. Conclusions: The possibility of SFTP should be taken into account when a mass abuts the mediastinum projecting inside the thoracic cavity in the presence of an intense and “geographical pattern” of enhancement without lymphoadenopathy or pleural metastasis. These findings assume greater significance in the presence of discrepancy between the size of the lesion and the clinical presentation.

The pleura may be affected by primary or metastatic tumor spread of either intrathoracic or extrathoracic neoplasms. Primary pleural tumors are rare, representing approximately 10% of all pleural neoplasms. Malignant lesions are more common than benign ones. Malignant pleural mesothelioma (MPM) and solitary fibrous tumor of the pleura (SFTP) represent the two most common primary tumors. Primary neoplasms also include lymphoma, epithelioid hemangioendothelioma, synovial sarcoma, and other rarer entities.

Diverticular disease is a common disorder and its incidence increases with ageing. Pathophysiology is multifactorial. Lifestyle, including smoking, alcohol intake, decreased dietary fibres and lack of physical activity, plays a predominant role. Genetics seems also to contribute specifically for right-sided diverticular disease (RSD). The majority of the patients with diverticular disease are asymptomatic. Diverticulitis is the inflammation of the diverticula usually presenting with abdominal pain associated to nausea, vomiting, rectal bleeding, diarrhoea and fever. When the inflammation process affects the diverticula in the ascending colon, the condition represents a clinical challenge as it can be easily misdiagnosed with other acute abdominal emergencies. We reported a case of a 70-year-old female who presented to our Emergency Department (ED) with right upper quadrant pain and an initial clinical suspicion of cholecystitis. Ultrasound (US) and Computed Tomography (CT) demonstrated an anatomical variation of the sigmoid colon diverticulitis. This clinical report demonstrates that ultrasound plays a relevant part as first-step approach to the acute abdominal conditions and its accuracy increases together with other diagnostic tools such as Computer Tomography.

Pulmonary tuberculosis (TB) is nowadays one of the most common causes of infectious disease-related morbility and mortality worldwide. The differential diagnosis between TB and some others conditions is an emerging problem, particularly challenging when TB imaging mimicks sarcoidosis, lymphoproliferative disorders and pulmonary neoplasms. In these cases, the correct diagnoses can be made with certainty only with trans-bronchial or CT guided biopsy.

This atlas is designed as an easy-to-use reference guide that identifi es and illustrates the key patterns of diffuse lung diseases observed on high-resolution computed tomography (HRCT). This atlas documents in great detail each pattern’s signs with close Rad-Path correlations. This book also allows a rapid view of HRCT characteristics and appearances of the individual diseases grouped on the basis of their prevalent radiological pattern.

Malignant pleural mesothelioma is the most frequent primary neoplasm of the pleura and its incidence is still increasing. This tumor has a strong association with exposure to occupational or environmental asbestos, often after a long latent period of 30-40 years. Plain chest radiography (CXR) is usually the first-line radiologic examination, but the radiographic findings are nonspecific due to its limited contrast resolution and they need to be complemented by other imaging modalities such as computed tomography (CT), magnetic resonance Imaging (MRI), Positron emission tomography–computed tomography (PET-CT) and ultrasound (US). The aim of this paper is to describe the imaging features of this malignancy, underlining the peculiarity of CXR, CT, MRI, PET-CT and US and also focusing on diagnostic workup, based on the literature evidence and according to our experience. (www.actabiomedica.it)

This study describes the diffuse neoplastic conditions that may affect pleural membranes. These include mesothelioma, the most important and common malignancy of pleural origin, and metastatic involvement by carcinomas, lymphomas and thymomas. On the basis of diagnostic imaging, we identify the distinctive features of pleural involvement by each of these conditions and provide elements enabling accurate differential diagnosis. Finally, we discuss the best diagnostic approach in the case of suspected primary or secondary neoplastic involvement of pleural membranes.

Purposes Bedside lung ultrasound (LUS) is useful in detecting radio-occult pleural-pulmonary lesions. The aim of our study is to compare the value of LUS with other conventional routine diagnostic tools in the emergency department (ED) evaluation of patients with pleuritic pain and silent chest radiography (CXR). Methods Ninety patients consecutively admitted to the ED with pleuritic pain and normal CXR were retrospectively (n = 49) and prospectively (n = 41) studied. All patients were blindly examined by LUS and submitted to clinical examination and blood samples. The ability of blood tests and symptoms to predict any radio-occult pleural-pulmonary condition confirmed by conclusive image techniques and follow-up was evaluated and compared with LUS. Results In 57 cases, the final diagnosis was chest wall pain. The other 33 patients were diagnosed with a pleural-pulmonary condition (22 pneumonia, 2 pleuritis, 7 pulmonary embolism, 1 lung cancer, 1 pneumothorax). Lung ultrasound showed a sensitivity of 96.97% (95% confidence interval [CI], 84.68%-99.46%) and a specificity of 96.49% (95% CI, 88.08%-99.03%) in predicting radio-occult pleural-pulmonary lesions and significantly higher area under the curve (AUC) of receiver operating characteristic analysis (AUC, 0.967; 95% CI, 0.929-1.00) than d -dimer (AUC, 0.815; 95% CI, 0.720-0.911) and white blood cell count (AUC, 0.778; 95% CI, 0.678-0.858). None of the other routine tests considered or a combination between them better predicted the final diagnosis. Conclusions Chest radiography and blood tests may be inadequate in the diagnostic process of pleuritic pain. In case of silent CXR, LUS is critical for identifying patients with pleural-pulmonary radio-occult conditions at bedside and cannot be safely replaced by other conventional methods.

Purposes B-lines are vertical echogenic artifacts seen on lung ultrasound that allow bedside diagnosis of pulmonary edema. The BLUE protocol, published by Lichtenstein and Mezière, suggests that cardiogenic pulmonary edema is sufficiently ruled out in the ICU setting when B-lines are not predominant in the anterior chest (the B-profile). Our analysis sought to evaluate the sensitivity of the B-profile for ruling out pulmonary edema in the ED patient population. Methods The ultrasound lung scans of patients with confirmed official diagnoses of acute decompensated heart failure (ADHF) from two ED databases were retrospectively analyzed. 170 acutely dyspneic patients had complete studies (130 from one database and 40 from the other). The scans were reviewed using the B-profile definition for ruling out pulmonary edema and comparing that to an alternate scanning protocol that includes ultrasound evaluation of the lateral and anterior chest. Results Of the 170 ED patients with ADHF diagnoses, the B-profile missed 16.5% (n = 28) for a sensitivity of 83.5% (95% CI 77–89%). These 28 patients did not show anterior bilateral B-lines that fit the criteria for positive under the BLUE protocol. Moreover, 25% (7/28) of these missed patients had only lateral B-lines on their lung scans and B-lines would have been detected only by including scans of the lateral zones. Conclusions Limiting the sonographic lung examination to the anterior chest areas only will miss cases of ADHF in the dyspneic ED patients. The BLUE protocol (B-profile) may need to be modified to include examination of the lateral chest as necessary for ED patients with ADHF.

Tracheal rupture is an uncommon and potentially lifethreatening complication of endotracheal intubation. We present a case of intrathoracic tracheal rupture in a female patient who required emergent endotracheal intubation for acute respiratory distress related to chronic obstructive pulmonary disease exacerbation. Possible contributing factors to tracheal injury included overinflation of the tube cuff, chronic obstructive pulmonary disease, and chronic steroid use. The patient underwent surgical repair without complication. Postoperatively, the tube cuff was placed far distally, close to the carina, and mechanical ventilation was performed using low tidal volume and PEEP in order to avoid high ventilatory pressures.

Malignant fibrous histiocytoma (MFH) is a pleomorphic sarcoma, occurring most frequently in the deep soft tissues of the extremities, and it is most frequently seen in elderly patients. A primary MFH of the diaphragm is very rare, and to the best of our knowledge, a multi-phased spiral CT appearance of this tumour has not been previously reported. In this report, we describe the clinical and multi-phase CT features of a primary MFH of the diaphragm.

The role of computed tomography (CT) in the diagnosis of the solitary pulmonary nodule (SPN) is constantly expanding. CT helps to detect a growing number of increasingly small lesions, but, as with chest radiography, the primary goal in the evaluation of small pulmonary nodules is to exclude malignancy. Despite the availability of numerous, variously invasive, diagnostic tests, diagnostic accuracy tends to decline as the size of the nodule decreases. The role of the radiologist is therefore to help the clinician determine the most appropriate management strategy by using all available modalities [CT, magnetic resonance (MR) imaging, positron emission tomography (PET)] and evaluating the patient's clinical history and the imaging features leading to a diagnosis of benignity or malignancy. Imaging features include nodule size, margins, calcifications and fatty component, internal features (cavitations, pseudocavitations, air bronchogram, halo sign), as well as advanced techniques for characterisation (growth rate, contrast enhancement) and management (computer-aided diagnosis, Bayesian analysis, neural networks). The aim of this paper is to summarise the approach to pulmonary nodules from the point of view of the radiologist, oncologist and thoracic surgeon.

The evaluation of pleuritic pain in the emergency department (ED) presents a considerable challenge for the attending physician. Chest radiography (CXR) is a basic test, but its sensitivity is low, and often more sophisticated imaging techniques are needed. Our aim is to assess the diagnostic value of bedside B-mode lung ultrasound (LUS) in the visualization of radio-occult pulmonary lesions. Forty-nine patients complaining of pleuritic pain with negative CXR were prospectively studied by LUS. Detection of at least one of the following sonographic signs in the painful thoracic area was considered diagnostic: (i) the absence of pleural sliding; (ii) the focal alveolar-interstitial syndrome (AIS), defined by multiple artifacts B-line; (iii) the peripheral alveolar consolidation (PAC), defined by hypoechoic subpleural images; and (iv) the pleural disruption with thickening and irregularity of the line, with or without localized effusion. The final diagnoses were confirmed by spiral CT scanning (n = 12) and follow-up (n = 37). Final diagnoses were chest wall pain (n = 30), pleuropneumonia (n = 14), pulmonary embolism (n = 4), lung metastasis (n = 1). In 18 patients of the group with pulmonary conditions, LUS showed signs of pleurisy. They were PAC (n = 12), AIS (n = 17), pleural disruption (n = 17). If any sign is considered, the sensitivity of LUS in the diagnosis of radio-occult lesions was 94.7%, specificity was 96.7%, positive and negative predictive values were 94.7% and 96.7%, respectively, and accuracy was 95.9%. In patients with pleuritic pain of unknown cause, real-time LUS enables the diagnosis of radio-occult lung and pleural lesions.

Purposes: Multiple artifacts B lines (B+) at transthoracic lung ultrasound have been proposed as a sonographic sign of pulmonary congestion. Our aim is to assess B+ clearance after medical treatment in acute decompensated heart failure (ADHF) and to compare the usefulness of sonography with other traditional tools in monitoring resolution of pulmonary congestion. Methods: Eighty-one patients with a diagnosis of ADHF were submitted to lung ultrasound and chest radiography at admission, and 70 of them underwent the same procedures as control group after 4.2 ± 1.7 days of medical treatment. The ultrasound examination was performed with 11 scans on as many anterolateral thoracic areas (6 on the right side and 5 on the left side). Then, we calculated a sonographic score counting the B+ scans and compared it with radiologic score for extravascular lung water, clinical, and plasma brain natriuretic peptide improvement. Main Results: All patients showed B+ pattern at admission and significant clearing after treatment, with median number of 8 positive scans (range, 3-9 scans) vs 0 (range, 0-7 scans) (P b.05). Our sonographic score showed positive linear correlation with radiologic score (r = 0.62; P b .05), clinical score (r = 0.87; P b .01), and brain natriuretic peptide levels (r = 0.44; P b .05). Δ Sonographic score correlated with Δ clinical (r = 0.55; P b .05) and radiologic (r = 0.28; P b .05) scores. Conclusions: B line pattern mostly clears after adequate medical treatment of ADHF and represents an easy-to-use alternative bedside diagnostic tool for clinically monitoring pulmonary congestion in patients with ADHF.

This study was undertaken to identify the radiographic and computed tomography patterns allowing a diagnosis of bronchogenic cyst.We retrospectively reviewed chest radiographs and CT scans of 21 adults (ten men and 11 women, age range 18-74 years) with a histologically confirmed diagnosis of bronchogenic cyst.Sixteen cysts were located in the mediastinum and five in the lungs. On chest radiography, mediastinal cysts appeared as sharply marginated rounded areas of increased opacity; intrapulmonary cysts also exhibited an air-fluid interface. CT confirmed these morphological features in all cases. In addition, analysis of attenuation values allowed the subdivision of mediastinal cysts into three groups: fluid density (four cases), air density (two cases) and soft-tissue density (ten cases).All bronchogenic cysts were visualised on chest radiography, but the findings were nonspecific and required further characterisation by CT. The CT findings proved to be diagnostic when cystic attenuation values were evident. When soft-tissue attenuation values were demonstrated, a confident diagnosis was not possible, and other solid lesions had to be considered. In such cases, magnetic resonance imaging may be helpful to ascertain the cystic nature of the lesions.

This review discusses the usefulness of bedside lung ultrasound in the diagnostic distinction between different causes of acute dyspnea in the emergency setting, particularly focusing on differential diagnosis of pulmonary edema and exacerbation of chronic obstructive pulmonary disease (COPD). This is possible using a simple unit and easy-to-acquire technique performed by radiologists and clinicians. Major advantages include bedside availability, absence of radiation, high feasibility and reproducibility, and cost efficiency. The technique is based on analysis of sonographic artifacts instead of direct visualization of pulmonary structures. Artifacts are because of interactions between water-rich structures and air and are called "comet tails" or B lines. When such artifacts are widely detected on anterolateral transthoracic lung scans, we diagnose diffuse alveolar-interstitial syndrome, which is often a sign of acute pulmonary edema. This condition rules out exacerbation of COPD as the main cause of an acute dyspnea.

The aim of this paper is to provide an effective and comprehensive summary of the main inflammatory pleural diseases, providing the radiologist an overview of key points in CXR, CT and US, and their main aspects in the differential diagnosis. The diffuse benign pleural diseases are frequently found during the first-level radiological diagnostic approach, but they are often difficult to classify because of their poor characterization. Pleural effusion or thickening can have a benign or malignant cause and use of the appropriate imaging techniques is crucial to a correct diagnosis. The clinical features of pleural disease are often nonspecific and may require complex imaging and histology for diagnosis. The integration of informations derived from different methods (CXR, CT and US) is extremely important to an appropriate diagnosis.

In the post-operative course of the interventions of lung resection for primary tumor, complications of different nature and severity can arise, recognizing different pathogenetic mechanisms and differing according to the type of resection performed and to the time elapsed after surgery. The low diagnostic accuracy of chest radiography requires a thorough knowledge of the radiologist about all radiographic findings, both normal and pathological, which can be found in the immediate post-operative period (within 30 days after surgery). This article aims to describe the incidence, the clinical features and the radiological aspects of immediate complications following pulmonary resections, with specific reference to those in which the diagnostic imaging provides a fundamental contribution.

Diffuse comet-tail artifacts at lung ultrasound are due to thickened interlobular septa and extravascular lung water. This condition is typical of the alveolar-interstitial syndrome due to pulmonary edema, diffuse parenchymal lung disease or ARDS. Aim of our study is to assess the potential of bedside lung ultrasound to diagnose the alveolar-interstitial syndrome in patients admitted to our emergency medicine unit. The ultrasonic feature of multiple and diffuse comet-tail artifacts was investigated during 5 months, in 121 consecutive patients admitted to our unit. Each patient was studied bedside in a supine position, by 8 antero-lateral pulmonary intercostal scans. Ultrasonic results were compared with chest radiograph and clinical outcome. Lung ultrasound showed a sensitivity of 84% and a specificity of 98% in diagnosing the radiologic alveolar-interstitial syndrome. Corresponding figures in the identification of a disease involving lung interstitium were 83% and 96%. These preliminary data show that the study of comet-tail artifacts at lung ultrasound is a method reasonably accurate for diagnosing the alveolar-interstitial syndrome at bedside. This conclusion opens the hypothesis of the usefullness of bedside lung ultrasound in the evaluation of dyspnoeic patients in the emergency setting.

The mediastinum is divided into compartments (anterior, middle, posterior) on the basis of lateral chest radiographs. Several anatomical and radiological classifications of the mediastinum are reported in the literature. Most mediastinal abnormalities are initially suspected following chest radiography; the need for further investigation and the most appropriate imaging modality are largely dictated by the tentative diagnosis made on this examination. Although routine chest radiography initiates the evaluation of mediastinal disorders, it is rarely diagnostic: notable exceptions are teeth or bones within a mass, which are diagnostic of a teratoma; air/fluid levels suggest an oesophageal origin, hernia, cyst, or abscess. Chest radiography is followed by spiral computed tomography (sCT). However, even sCT with contrast material is occasionally diagnostic (a confident diagnosis can be made of some lesions such as mature teratoma and mediastinal goiter) but is usually sufficient for preoperative evaluation before mediastinotomy or mediastinoscopy: it is instrumental in planning further diagnostic workup. In certain cases, magnetic resonance imaging (MRI) may be complementary to sCT, but its use is not considered routine. Besides, although the anterior mediastinum is suitable for sonographic examination, the diagnostic value of ultrasonography has not been fully exploited. Thyroid scanning with radioactive iodine is useful in identifying and evaluating masses of suspected thyroid origin. The role of fluorodeoxyglucose positron emission tomography (FDG-PET) in mediastinal diseases continues to be evaluated: it has potential for differentiating between benign and malignant disease and is expected to play a more extensive role in the imaging of mediastinal neoplasms in the future. In this paper, the radiological features of masses located in the anterior mediastinum are discussed, with particular reference to radiographic and CT patterns useful to the clinician's everyday practice.

Tuberculosis has still an important impact on public health because it is an important cause of death, particularly in developing countries. On the other hand recent studies have shown that tuberculosis is again becoming concentrated in big cities of Western Europe, especially among immigrants, drug addicts, poor people, and the homeless, despite progress in reducing national rates of the disease. Diagnostic imaging is challenging for radiologists because signs of tuberculosis may easily mimic other diseases such as neoplasms or sarcoidosis. Clinical signs and symptoms in affected adults can be non-specific and a high level of pre-test clinical suspicion based on history is fundamental in the diagnostic work-up. Impact of tuberculosis in the world is extremely important considering the high incidence estimated during 2011 that was 8.7 million cases. This article gives a review of imaging patterns of chest tuberculosis as may be detected on conventional radiography and computerized tomography (CT). The main aim is to improve radiologist’s familiarity with the spectrum of imaging features of this disease and facilitate timely diagnosis. Furthermore, we consider the emerging role of alternative methods of imaging, such as magnetic resonance imaging (MRI), that can be helpful and highly accurate for a better definition of some signs of tuberculosis.

Key Clinical Message While acute arterial occlusion causes life-threatening ischemia and organ damage requiring urgent revascularization, the incidental identification of arterial occlusions in asymptomatic patients represents a therapeutic dilemma in clinicians. Does chronic asymptomatic artery occlusion require specific treatment?

Our aim is to present the case report of a woman affected by tracheal granular cell tumor analysed by multiphasic contrast-enhanced multidetector CT. The tumor presents as polypoid lesion (diameter 13 mm), with smooth and well-defined margins, elevated contrast enhancement in arterial phase, and a modest release of contrast in venous phase. This pattern is quite different from the other tracheal tumours. We have performed a comprehensive review of literature to assess all cases of granular cell tumors of the trachea; only 40 cases are reported. Of these, no one focused on the contrast enhancement aspect, so our work is the first showing a specific pattern in multidetector computed tomography (MDCT) of the tracheal granular cell tumour and may help in differential diagnosis.

Hydrostatic pulmonary edema is as an abnormal increase in extravascular water secondary to elevated pressure in the pulmonary circulation, due to congestive heart failure or intravascular volume overload. Diagnosis of hydrostatic pulmonary edema is usually based on clinical signs associated to conventional radiography findings. Interpretation of radiologic signs of cardiogenic pulmonary edema are often questionable and subject. For a bedside prompt evaluation, lung ultrasound (LUS) may assess pulmonary congestion through the evaluation of vertical reverberation artifacts, known as B-lines. These artifacts are related to multiple minimal acoustic interfaces between small water-rich structures and alveolar air, as it happens in case of thickened interlobular septa due to increase of extravascular lung water. The number, diffusion and intensity of B lines correlates with both the radiologic and invasive estimate of extravascular lung water. The integration of conventional chest radiograph with LUS can be very helpful to obtain the correct diagnosis. Computed tomography (CT) is of limited use in the work up of cardiogenic pulmonary edema, due to its high cost, little use in the emergencies and radiation exposure. However, a deep knowledge of CT signs of pulmonary edema is crucial when other similar pulmonary conditions may occasionally be in the differential diagnosis.

Introduction To prospectively evaluate the frequency and spectrum of incidental findings (IF) in a 5-year lung cancer screening program with low-dose spiral computed tomography (CT) and to estimate the additional costs of their imaging workup incurred from subsequent radiologic follow-up evaluation. Materials and Methods A total of 519 asymptomatic volunteers were enrolled. All IFs were reported and were considered clinically relevant if they required further evaluations or with clinical implications if they required more than one additional diagnostic test for characterization or medical and/or surgical intervention. Results IFs were commonly found (59.2%, 307/519 participants at baseline and 5.3% per year at 5-year follow-up [123 participants of 2341 LDsCT exams performed during follow-up], with an overall rate of 26.3%). IFs were categorized as previously unknown clinically relevant in 52 (10.0%) individuals at baseline. Of these, 36 (6.9%) individuals had IFs with clinical implications (10 clinically relevant, of which 6 had clinical implications, detected during the subsequent 5-year follow-up). The most common recommendations were for additional imaging of the thyroid and kidneys. Additional imaging was mainly performed by ultrasound (43/68 [63.2%]). Subsequent surgical intervention resulted from these findings in 7 (1.5%) subjects. Six malignancies were diagnosed (rate, 0.2% per year). Costs of subsequent radiologic follow-up studies were calculated as €4644.56 [U.S. $6575.04] at baseline and €1052.30 [U.S. $1489.69] at 5-year follow-up (average added costs per participant €8.95 [U.S. $12.67] and €2.25 [U.S. $3.19], respectively). Conclusions Low-dose spiral CT commonly detects IFs. Some of these require further investigations to assess their clinical relevance. Although such IFs add little clinical benefit to the screening intervention, moderate incremental costs are incurred based on additional radiologic procedures generated during short-term follow-up, given the potential for positive effects on patient care.

Chronic heart failure is a complex clinical syndrome often characterised by recurrent episodes of acute decompensation. This is acknowledged as a major public health problem, leading to a steadily increasing number of hospitalisations in developed countries. In decompensated heart failure, the redistribution of fluids into the pulmonary vascular bed leads to respiratory failure, a common cause of presentation to the emergency department. The ability to diagnose, quantify and monitor pulmonary congestion is particularly important in managing the disease. Lung ultrasound (US) is a relatively new method that has gained a growing acceptance as a bedside diagnostic tool to assess pulmonary interstitial fluid and alveolar oedema. The latest developments in lung US are not because of technological advance but are based on new applications and discovering the meanings of specific sonographic artefacts designated as B-lines. Real-time sonography of the lung targeted to detection of B-lines allows bedside diagnosis of respiratory failure due to impairment of cardiac function, as well as quantification and monitoring of pulmonary interstitial fluid. Lung US saves time and cost, provides immediate information to the clinician and relies on very easy-to-acquire and highly reproducible data.

A 70-year-old woman was hospitalized for dyspnea and chest pain. After radiological examinations and bronchoscopy, she was diagnosed with a stage IVsmall-cell carcinoma of the lung.