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Prostatic artery embolization (PAE) consists of blocking the arteries supplying the prostate to treat benign prostate hypertrophia (BPH). Its effectiveness on both urinary symptoms and flowmetric parameters has now been amply demonstrated by around a hundred studies, including several randomized trials. The main advantage of this procedure is the very low rate of urinary and sexual sequelae, including ejaculatory, with an excellent tolerance profile. The arterial anatomy is a key element for the realization of PAE. Its knowledge makes it possible to anticipate obstacles and prevent potential complications related to nontarget embolization. Nontarget embolization can occur with a small intraprostatic shunt or reflux and has no consequences except some local inflammation symptoms that resolve in a couple of days. Nevertheless, some situations with large arterial shunts arising from the prostatic artery must be recognized (accessory rectal, bladder, or pudendal branches), and must imperatively be protected before embolization, at the risk of exposing oneself to otherwise ischemic complications that are more severe, such as bladder necrosis and skin or mucosal necrosis. This article offers a step-by-step review of the various anatomical and technical key points to ensure technical and clinical success, while avoiding the occurrence of adverse events.

Objective Myocardial involvement may occur during systemic sclerosis (SSc) and can lead to impaired myocardial contraction and/or arrhythmia. Cardiac magnetic resonance imaging (MRI) is used for noninvasive characterization of the myocardium. The aim of this study was to evaluate the utility of cardiac MRI with intravoxel incoherent motion (IVIM) diffusion-weighted imaging (DWI) and longitudinal relaxation time (T1) sequence mapping for assessment of myocardial microvascular and interstitium impairment in SSc. Methods In this single-center prospective cohort study, 40 consecutive patients with SSc and 20 healthy controls were assessed by cardiac MRI with IVIM DWI and T1 mapping sequences on a 3T scanning system. Images were analyzed independently by 2 assessors, and Bland-Altman plots were used to assess interreader concordance and reproducibility. Characteristics of the patients were compared according to quartiles of T1 and perfusion fraction (f-coefficient) values, using exact Cochran-Ermitage trend tests for qualitative variables and analysis of variance for quantitative variables. Kaplan-Meier cardiac events-free survival curves were plotted and compared with a log-rank test for trend. Results T1 values were higher in SSc patients than in healthy controls, and were higher in the diffuse cutaneous SSc (dcSSc) subset (P = 0.02). Higher T1 values were associated with the immunologic pattern seen in patients with the dcSSc form (P = 0.0001), a higher modified Rodnan skin thickness score (MRSS) (P = 0.003), and a higher frequency of interstitial lung disease (P = 0.03). Moreover, higher T1 values were correlated with higher MRSS scores (r = +0.32, P = 0.04) and reduced forced vital capacity (r = -0.34, P = 0.048), and tended to be correlated with reduced total lung capacity (r = -0.30, P = 0.07). Lower f-coefficient values, as a measure of decreased tissue perfusion, were associated with less frequent use of vasodilators (P = 0.02 for angiotensin-converting enzyme inhibitors and P = 0.06 for calcium-channel blockers) and more frequent use of glucocorticoids (P = 0.02). The f-coefficients were inversely correlated with the T1 values (r = -0.31, P = 0.02). Furthermore, higher T1 values were associated with higher incidence of cardiac events (log-rank test for trend P = 0.03). Conclusion Increased T1 values, potentially suggesting microscopic fibrosis, were observed more frequently in patients with dcSSc, and higher T1 values were associated with interstitial lung disease and more frequent cardiac events during follow-up. The results of this study show that cardiac MRI with T1 mapping sequences and IVIM DWI may be useful in assessing myocardial involvement in patients with SSc.

Summary Background Cardiac sarcoidosis (CS) is a severe localization, observed mostly in cardiology departments. Despite appropriate cardiological treatment, CS is a potentially life-threatening condition, and accounts for 13–85% of sarcoidosis-related deaths. Aims This retrospective study aimed to give an overview of CS in a non-cardiac unit, to analyse the effect of first-line immunosuppressive treatment on outcome and survival and to evaluate factors associated with relapses. Methods From 534 cases of sarcoidosis, we selected 59 patients with CS according to “2006 international criteria”. We performed an in-depth analysis regarding symptoms, physical signs and cardiac investigation results. Patients were followed for a median period of 60 months. Results The median age at cardiac signs was 42 years. Echocardiography abnormalities, isotopic defects and abnormal magnetic resonance imaging findings were observed in 81%, 84% and 92% of patients, respectively. First-line treatment included steroids alone in 24 patients and steroids plus immunosuppressive therapy in 35 patients. Forty-seven (80%) patients recovered; 12 stabilized or worsened. The recovery rate was 75% in the steroids alone group versus 83% in the steroids plus immunosuppressive therapy group. Five (9%) patients died during follow-up, with two deaths attributed to CS. The overall 1- and 5-year survival rates were 98% and 92%, respectively. Conclusion Our series of patients with CS who received steroids alone or combined with immunosuppressive therapy had a good prognosis, with an overall 5-year survival rate of 92%. The recovery rate was 85%, with no significant difference between patients treated with steroids alone or plus immunosuppressive therapy.

To measure azygos, portal and aortic flow by two-dimensional cine phase-contrast magnetic resonance imaging (2D-cine PC MRI), and to compare the MRI values to hepatic venous pressure gradient (HVPG) measurements, in patients with cirrhosis. Sixty-nine patients with cirrhosis were prospectively included. All patients underwent HVPG measurements, upper gastrointestinal endoscopy and 2D-cine PC MRI measurements of azygos, portal and aortic blood flow. Univariate and multivariate regression analyses were used to evaluate the correlation between the blood flow and HVPG. The performance of 2D-cine PC MRI to diagnose severe portal hypertension (HVPG ≥ 16 mmHg) was determined by receiver operating characteristic curve (ROC) analysis, and area under the curves (AUC) were compared. Azygos and aortic flow values were associated with HVPG in univariate linear regression model. Azygos flow (p

Systemic sclerosis per se should not be considered as an a priori contraindication for a pre-transplantation assessment in patients with advanced interstitial lung disease and/or pulmonary hypertension. For lung or heart-lung transplantation, a multidisciplinary approach, adapting the pre-transplant assessment to systemic sclerosis and optimizing systemic sclerosis patient management before, during and after surgery should improved the short- and long-term prognosis. Indications and contraindications for transplantation have to be adapted to the specificities of systemic sclerosis. A special focus on the digestive tract involvement and its thorough evaluation are mandatory before transplantation in systemic sclerosis. As the esophagus is almost always involved, isolated gastro-oesophageal reflux disease, pH metry and/or manometry abnormalities should not be a systematic per se contraindication for pre-transplantation assessment. Corticosteroids may be harmful in systemic sclerosis as they are associated with acute renal crisis. A low dose corticosteroids protocol for immunosuppression is therefore advisable in systemic sclerosis.

L’apport de l’IRM cardiaque dans l’approche multimodalite moderne des cardiomyopathies est devenu incontournable.La sequence apportant la plus grande plus-value diagnostique est la sequence de rehaussement tardif myocardique.Les caracteristiques des prises de contraste observees sur cette sequence apportent une orientation etiologique ainsi que des donnees pronostiques que peu d’autres techniques peuvent fournir.

Aims Identification of the cause of out-of-hospital cardiac arrest (OHCA) is of paramount importance. We investigated the ability of our imaging strategy to provide an early etiological diagnosis of OHCA and the influence of this strategy on ICU survival. Methods Retrospective review of a prospectively acquired ICU database (01/2000–12/2010) including all OHCA patients without obvious extracardiac cause, for which an early diagnosis research was conducted (coronary angiography and/or brain and chest CT scan) within 24h after resuscitation. These procedures could be performed separately or be combined, according to a decision algorithm. Results Of the 1274 patients admitted after OHCA during this 10-year period, the imaging strategy was applied in 896 patients. Patients who benefited from coronary angiography and/or CT scan were admitted to our ICU after a median delay of 180 [130–220]min after resuscitation. Seven hundred and forty-five coronary angiographies were performed, of which 452 (61%) identified at least one significant coronary lesion deemed responsible for the OHCA. CT-scan was performed in 355 patients and provided a diagnosis in 72 patients (20%), mainly stroke ( n =38) and pulmonary embolism ( n =19). Overall, this strategy allowed early diagnosis in 524 patients (59%). ICU survival was significantly higher for patients with a diagnosis identified by coronary angiography as compared with CT-scan (43% vs 10%, p Conclusion The use of an early diagnosis protocol with immediate coronary angiography and/or CT scan provided the etiology of nearly two thirds of OHCA cases. In this large retrospective database, coronary angiography yielded a better diagnostic value than brain and/or chest CT-scan.

Objectives Specific cardiac involvement in granulomatosis with polyangiitis (GPA) is probably underestimated since many of these conditions are subclinical. The objective of this study was to assess the prevalence and patterns of cardiac abnormalities detected by cardiac MRI (CMRI) in patients with GPA. Methods Thirty-one consecutive patients with newly diagnosed or relapsing GPA underwent CMRI to assess morphological, functional, perfusion at rest and delayed enhancement abnormalities. Results At least one abnormality was observed on CMRI for 19 of 31 patients (61%). Four patients (13%) had an impaired left ventricle ejection fraction (LVEF). LV regional wall motion abnormalities were found in 11 patients (35%). Late gadolinium enhancement (LGE) was detected in 10 of 31 patients (32%). LGE was mostly nodular ( n = 9). Myocardial early contrast enhancement was detected in 5 of the 31 patients (16%), which was systematically associated with LGE in the same territory. CMRI detected pericarditis in eight patients (26%). GPA with

The purpose of this study is to describe an imaging method based on a CT technique, CT antegrade colonography, for the evaluation of low anastomosis and to evaluate the value of CT antegrade colonography before early ileostomy closure after proctectomy in low rectal endometriosis.One hundred ninety-five patients referred for low rectal endometriosis underwent proctectomy and were eligible for early ileostomy closure. All patients underwent standard antegrade fluoroscopy (n=77) or CT antegrade colonography (n=118) 8 days after surgery. The negative predictive values, positive predictive values, sensitivity, specificity, and likelihood ratio of standard antegrade fluoroscopy and CT antegrade colonography in detecting anastomotic leakage and abscesses were assessed. The reference standard for positive and negative examinations was based on clinical follow-up, imaging, surgical, or interventional procedure findings.Negative and positive predictive values for detecting anastomotic leakage were 100% (95% CI, 96.8-100%) and 100% (95% CI, 39.8-100%), respectively, for CT antegrade colonography and 98.6% (95% CI, 92.4-100%) and 100% (95% CI, 54.1-100%), respectively, for standard antegrade fluoroscopy. The negative and positive predictive values for detecting abscess were 100% (95% CI, 96.8-100%) and 100% (95% CI, 47.8-100%), respectively, for CT antegrade colonography and 97.3% (95% CI, 90.8-99.7%) and 100% (95% CI, 2.5-100%), respectively, for standard antegrade fluoroscopy.CT antegrade colonography may play a major role in the evaluation of low anastomosis protected by an ileostomy after proctectomy in low rectal endometriosis, leading to the development of a new strategy with early restoration of the intestinal continuity.

Resume Le placenta praevia se definit comme une insertion basse du placenta qui constitue une menace d’hemorragie du post-partum. Le placenta peut etre insere plus ou moins profondement dans le myometre, selon qu’il est accreta, increta ou percreta. Le diagnostic peut etre fortuit ou de plus en plus souvent prevu par l’echographie et l’imagerie par resonance magnetique. La prise en charge des anomalies d’insertion du placenta necessite des equipes entrainees ayant notamment la possibilite d’effectuer une transfusion massive. L’hysterectomie cede chaque fois que possible la place a des traitements conservateurs avec eventuellement embolisation. La rachianesthesie est possible pour les cesariennes electives en cas de placenta praevia de localisation posterieure, n’ayant pas saigne au cours du troisieme trimestre, en l’absence de cicatrices uterines multiples, et d’aspects echographiques suspects de placenta accreta. L’anesthesie generale est indiquee dans les contextes hemorragiques, urgents, pour les placentas anterieurs, en cas de cicatrices uterines ou de suspicion de placenta accreta ou percreta.

Our study results demonstrate the accuracy of MR imaging cine phase-contrast azygos blood flow measurement as a means of identifying high-risk hemorrhage esophageal varices in patients with chronic liver disease and portal hypertension.

Recently, pneumatosis intestinalis has been described in patients receiving bevacizumab, a monoclonal antibody to VEGF-A. Pneumatosis intestinalis is a condition characterized by subserosal and submucosal gas-filled cysts in the gastrointestinal tract. We report on pneumatosis intestinalis in patients receiving oral anti-VEGF agents. Patients shared the following characteristics: long-term (> 4 months) exposure to anti-VEGF agents, lack of other factors predisposing to pneumatosis intestinalis, and lack of recent surgical intervention. Taken together, these observations suggest that pneumatosis intestinalis is a probable class-effect of anti-VEGF agents.

SummaryHeart involvement, including primary myocardial involvement, is very common in systemic sclerosis. There is strong evidence that primary myocardial involvement is related to repeat focal ischaemic injury causing subsequent irreversible myocardial fibrosis. Clinically evident cardiac involvement is recognized to be a poor prognostic factor; thus preclinical identification is highly encouraged. The severity of heart involvement has been confirmed recently. Echocardiography, including pulsed tissue Doppler echocardiography, is the cornerstone of routine heart assessment. Myocardial perfusion may be assessed by single photon emission computed tomography. If available, cardiac magnetic resonance imaging should be considered as it allows simultaneous measurement of ventricular volumes and function and myocardial perfusion, and assessment of possible inflammation and/or fibrosis. Biological variables, such as B-type natriuretic peptides, are highly relevant, valuable markers of global heart involvement in systemic sclerosis and should be considered for screening of patients and/or research purposes.

Acute coronary syndrome, with an estimated prevalence of 300 000 cases annually in France, is one of the principal diagnostic and therapeutic emergencies in atheroma. In cases of atypical chest pain, with or without signs of severity, coronary, aortic and pulmonary CT should allow emergency specialists to rule out rapidly diagnoses of coronary disease, pulmonary embolism, aortic dissection or other chest conditions. Should acute coronary syndrome develop after immediate therapeutic management, a cardiac MRI will provide the cardiologist with the additional data necessary to assess the patient's prognosis--especially by assessing myocardial viability--and decide on subsequent management. In cases of acute coronary syndrome with normal coronary angiography, cardiac MRI can distinguish myocardial infarction from myocarditis or from Tako Tsubo syndrome.

Sinonasal CT must be studied with both soft tissue and bone algorithms. Sinonasal findings in Wegener's granulomatosis are mucosal thickening, subtotal opacification, air-fluid level, bony destruction (mainly of the nasal septum), and sclerosing osteitis. Orbital MRI helps to define the extent of the disease. Contiguous granulomatous infiltration of the orbit appears dark (hypointense signals) on both T2-weighted-and T1-weighted images, but is enhanced after gadolinium administration. Cerebral MRI findings include diffuse linear dural thickening, enhanced by injection, and local dural thickening contiguous with orbital, nasal and paranasal disease. The remote granulomatous lesions in brain parenchyma are the least common form of central nervous system lesion. The pituitary gland and infundibulum can also be involved in Wegener's granulomatosis. These imaging findings of Wegener's granulomatosis are nonspecific. They should be combined with clinical examination and c-ANCA tests to confirm the diagnosis.

Key points Churg-Strauss syndrome and Wegener granulomatosis are the two principal ANCA-associated vasculitides. Cardiac damage is frequent and prognosis poor. This damage is often subclinical initially and undetectable with standard cardiac imaging techniques (such as cardiac ultrasound or myocardial scintigraphy). Cardiac MRI permits early diagnosis of the different types of cardiac damage (myocarditis, pericarditis, and impaired myocardiac perfusion) that may occur during ANCA-associated vasculitis, even before the onset of symptoms. Early detection of this cardiac damage is crucial for it enables faster implementation of aggressive treatment, which may significantly improve disease prognosis. The widespread, even routine, practice of cardiac MRI in patients with ANCA-associated vasculitis thus seems justified, for this noninvasive examination provides essential diagnostic and prognostic information and helps guide therapeutic management.

Objective To determine the diagnostic and prognostic significance of cardiac magnetic resonance imaging (CMRI) in a cohort of patients with eosinophilic granulomatosis with polyangiitis (EGPA). Methods We conducted a monocentric retrospective study including 42 EGPA patients who had consecutively undergone CMRI at diagnosis or during follow-up, independently of signs of cardiac involvement. Results Forty-two patients (male 59.5%, mean age at diagnosis 46.5 years) were included. ANCA was positive in 26.2%, and median EGPA duration before the 1st CMRI screening was 5 months. Seventeen (40.5%) were diagnosed with cardiomyopathy, independently of CMRI findings. CMRI showed myocardial late gadolinium enhancement (LGE) in 82.4% patients with cardiomyopathy vs. 44% without cardiomyopathy (P = 0.024). Using LGE as the sole criterion, CMRI sensitivity and specificity for diagnosing cardiomyopathy were 82.4% and 56%, respectively. Among the 15 patients with cardiomyopathy who underwent additional CMRI during follow-up, CMRI-detected cardiac lesions had improved in 7 patients, while those of 8 patients worsened or stabilized despite treatment. These latter patients presented with significantly more cardiac events during follow-up (P = 0.026). No differences were found between non-cardiomyopathic patients with or without CMRI anomalies concerning EGPA cardiac manifestations and outcomes. Conclusion The diagnostic significance of myocardial LGE in EGPA patients remains uncertain and should not be the only criterion for cardiomyopathy diagnosis. For patients with no other signs of cardiomyopathy, CMRI-detected anomalies do not seem to adversely affect prognosis or outcome. For patients with cardiomyopathy, CMRI reassessment seems promising in detecting patients with a less favorable cardiac outcome.

Background Peripherally inserted central catheters (PICCs) are increasingly used in patients with cystic fibrosis (CF) or with non-CF bronchiectasis, but little data exist on catheter-related complications in this setting. Methods Prospective follow-up of consecutive PICCs inserted for intravenous (IV) antibiotics in adults with CF or with non-CF bronchiectasis at Cochin Hospital (Paris, France). Results Between March 2009 and December 2011, 182 PICCs were prescribed in 117 adults (67 CF and 50 non-CF patients). Ultrasound-guided placement of catheter was successful in 174/182 (95.6%) procedures; no insertion complication occurred. The mean ± SD catheter dwell time was 15 ± 9 days. No catheter-associated bloodstream infection occurred; main complications were symptomatic upper limb deep vein thrombosis (2%), catheter obstruction (18%) and persistent pain after catheter insertion (18%). Patients' satisfaction was high and PICC could be used to perform antibiotic courses in most patients. Conclusions PICCs were generally safe for performing IV antibiotic courses in patients with CF or non-CF bronchiectasis, but prolonged pain and/or catheter obstruction occurred in approximately 20% of cases.

TECHNOLOGICAL PROGRESS: Although cardiac magnetic resonance imaging (MRI) is now recognised as the imaging method of choice for the morphological study of the heart, recent technological progress have widened its indications to functional analysis of the heart rate, perfusion and contractility. FUNCTIONAL ASSESSMENT: The possibility of conducting pharmacological stress tests enhances the functional exploration of cardiac perfusion and contractility. The rapid sequences in apnea, tissue marking and injection of contrast products are all elements that help to refine the study of the locoregional consequences of an ischemia: does the myocardial tissue contract normally? Is it sufficiently perfused? Is it still viable? THE BENEFITS OF A NON-INVASIVE TECHNIQUE: The MRI offers clinicians a non-invasive and non-radiating imaging technique that is the perfect supplement to echocardiography. A reliable angio-coronary LRI technique would, for the first time, permit exploration of the coronary vascularisation, tissue perfusion and resulting contractility.

This study aimed to determine the value of CT, endoscopic sonography, and a combined protocol for preoperative detection of insulinomas.All patients treated in our institution for surgically proven insulinoma between 1987 and 2000 were retrospectively reviewed. Thirty patients with 32 pancreatic insulinomas underwent preoperative CT and endoscopic sonography and were included in the study. These 30 patients also underwent dual-phase thin-section multidetector CT (group 1: n = 15), dual-phase multidetector CT without thin sections (group 2: n = 8), or sequential CT (group 3: n = 7). CT scans were interpreted separately and retrospectively by three radiologists in consensus. Sensitivity values for CT, endoscopic sonography, and a combined protocol were determined.The overall diagnostic sensitivity for dual-phase helical CT was 94.4% for group 1, 57.1% for group 2, and 28.6% for group 3. Endoscopic sonography showed proven insulinomas in 30 of 32 cases (sensitivity, 93.8%). Differences between dual-phase thin-section CT and endoscopic sonography were not statistically significant. The overall diagnostic sensitivity for combined biphasic thin-section helical CT and endoscopic sonography was 100%.The most effective method for revealing insulinomas is a combined imaging protocol that consists of both dual-phase thin-section multidetector CT and endoscopic sonography.

Objective To determine whether left ventricular hypertrophy can be correctly evaluated in hypertensive rats with a new nuclear magnetic resonance (NMR) imaging modality that is relatively simple to operate and provides results of constant quality while offering a high signal-to-noise ratio. DESIGN Left ventricular mass as calculated from the NMR imaging analysis was compared with the actual left ventricular mass measured by gravimetry. Methods Single-shot ultrafast spin-echo (SSFSE) imaging of hearts of Wistar-Kyoto rats and spontaneously hypertensive rats was performed at 4 T. Left ventricular mass was determined by using Simpson's rule on stacks of images acquired in systole and diastole. Results SSFSE NMR imaging performed in systole or in diastole evaluated and quantified left ventricular hypertrophy in hearts of spontaneously hypertensive rats very similarly to gravimetry. The left ventricular mass as determined by NMR was in good accordance with the actual left ventricular weight (SEE: 30.39 and 35.86 mg for the systolic and diastolic NMR acquisitions, respectively). Conclusion Using an SSFSE sequence, high-quality NMR images of the rat heart can be generated very reliably with sufficient contrast and temporal and spatial resolution, and allow precise, non-invasive and fast characterization of left ventricular hypertrophy in a hypertensive rat model.

Purpose: To assess the follow-up of patients with sarcoidosis and myocardial MRI abnormalities. Materials and methods: Twelve patients with histologically proven sarcoidosis and highly suspected cardiac involvement underwent initial and 12-month follow-up cardiac assessment including cardiac MRI (T2-weighted, functional gradient echo, and T1-weighted gadoliniumdiethylenetriamine penta-acetic acid-enhanced sequences). MRI abnormalities and clinical and MRI progression were scored by two observers. Results: Six patients receiving corticosteroid therapy (including three patients with clinical cardiac involvement) were scored as having cleared or improved at MRI follow-up, while others were seen to have worsened or remained stable. The stability, improvement, or clearing of MRI findings were correlated with clinically stable, improved or cleared sarcoidosis, while a worsening at MRI follow-up was correlated with a worsening of sarcoidosis and, in one patient, was predictive of clinical cardiac involvement. Conclusion: Cardiac MRI is a useful noninvasive method for the early diagnosis and follow-up of cardiac sarcoidosis. (CHEST 2002; 122:1895–1901)

To prospectively determine whether a relationship exists between magnetic resonance (MR) imaging abnormalities of the right ventricle (RV) and intracardiac electrophysiologic (EP) test results in patients with myotonic dystrophy.Conventional T1-weighted single-shot black-blood fast spin-echo and gradient-echo MR imaging of the heart was prospectively performed in 32 patients with myotonic dystrophy who required EP testing. Patients were divided into two groups according to EP test results: (a) inducible (n = 15), indicating inducible ventricular tachyarrhythmias, and (b) noninducible (n = 17). Morphologic and functional MR data were analyzed by two independent investigators. Nonparametric statistical methods and kappa statistics were used.No morphologic or functional abnormalities of the RV wall were observed in noninducible patients. Increased signal intensity of the RV wall, indicative of fatty replacement, was identified in 13 inducible patients. Myocardial thinning of the RV was observed in six inducible patients. An overlap of morphologically abnormal areas and areas of hypo- or dyskinesis were present in 11 inducible patients. RV outflow tract diameter was larger and RV ejection fraction was smaller in inducible patients than in noninducible patients, although differences were not significant. Interobserver agreement for MR findings was good (increased signal intensity: kappa = 0.87, P.30 [pairwise Wilcoxon signed rank test]; myocardial thinning: kappa = 0.87, P.30; hypo- or dyskinesis: kappa = 1.00, P.99). There was a strong relationship between MR abnormalities and inducibility during EP testing (increased signal intensity, P.001; myocardial thinning, P.01; hypo- or dyskinesis, P.01).The relationship between MR morphologic and functional RV abnormalities and EP testing suggests potential for the use of MR imaging as a noninvasive method to estimate the individual risk of arrhythmia in patients with myotonic dystrophy.

At liver magnetic resonance (MR) imaging in 38 patients, a breath-hold T2-weighted fast spin-echo (SE) pulse sequence optimized with fast recovery was compared with a conventional respiratory-triggered fast SE sequence and a breath-hold single-shot fast SE sequence. Mean signal-to-noise ratios for liver and contrast-to-noise ratios for hepatic lesions were higher with the breath-hold fast-recovery fast SE sequence than with the respiratory-triggered fast SE sequence (P < .05). Breath-hold fast-recovery images displayed better lesion clarity than did single-shot fast SE images (P < .05) and fewer image artifacts than did respiratory-triggered fast SE images (P < .05). The ability to determine lesion size and the overall image quality was best with the breath-hold fast-recovery sequence (P < .05). These results may justify use of the breath-hold fast-recovery fast SE pulse sequence for first-line T2-weighted MR imaging of the liver. © RSNA, 2002

Purpose To compare the reproducibility of left ventricular (LV) mass measurements using a black-blood half-Fourier single-shot fast spin-echo (SSFSE) and a segmented gradient echo magnetic resonance (MR) pulse sequence. Material and Methods Breath-hold SSFSE and segmented gradient echo cardiac MR examinations were performed twice in 32 patients and manual detection of the LV endocardium and epicardium was applied by two blinded reviewers. The SSFSE pulse sequence allowed whole-heart coverage in a single breath hold, while multiple breath holds were required using the segmented gradient echo sequence. Spatial presaturation slabs were used with the SSFSE pulse sequence to reduce the field of view (FOV) and thereby achieve higher spatial resolution. Results Intraclass correlation coefficients were higher with the SSFSE pulse sequence than with the segmented gradient echo pulse sequence: intraobserver reproducibility reached 0.999 vs. 0.991; interobserver reproducibility: 0.997 vs. 0.981; and interstudy reproducibility: 0.998 vs. 0.936. These higher levels of reproducibility were confirmed on Bland and Altman plots. Conclusion LV mass measurements can be assessed more reproducibly with the single breath-hold SSFSE technique than with the standard multiple breath-hold segmented gradient echo method. J. Magn. Reson. Imaging 2002;15:654–660. © 2002 Wiley-Liss, Inc.

Summary Background Because cadaveric organ donors are in short supply, living donors are increasingly being used in transplantations. We have developed a safe and reproducible method for laparoscopic liver resection. Methods Left hepatic lobectomy (resection of segments 2and 3) was done by laparoscopy in one woman aged 27years and one man aged 31 years. The grafts were prepared under laparoscopy, without any vascular clamping, and were externalised through a suprapubic Pfannenstiel incision. Both grafts were transplanted conventionally to the patients' respective sons, who were both aged 1 year and had biliary atresia. Findings Donor operations lasted 7 h for the woman and 6 h for the man, and warm ischaemia times were 4 and 10 min, respectively. Blood loss was 150 and 450 mL, respectively, and no transfusions were required. Neither patient had complications during or after sugery; and hospital stay was 7 and 5 days, respectively. Both recipients are alive and have excellent graft function. Interpretation We have shown the feasibility of laparoscopic living donor hepatectomy from parent to child. If the safety and feasbility of this procedure can be shown in larger series, laparoscopic donor left lobectomy could become a new option for paediatric living donor liver transplantation.

We report a case of severe mitral stenosis caused by Libman-Sacks endocarditis, as an initial manifestation of systemic lupus erythematosus (SLE) in a 20-year-old woman. Cardiac magnetic resonance imaging (MRI) demonstrated a thickening of the mitral valve with basal endocardial thickening exhibiting defect on first-pass perfusion short-axis acquisition and delayed enhancement in keeping with extensive fibrous endocarditis. The patient underwent successful mechanical mitral valve replacement. This case illustrates that MRI is useful in diagnosing this recognised but uncommon cardiac complication of SLE and excluding differential diagnosis such as valve tumour and infective endocarditis with perivalvular abscesses.

A 63-year-old woman was referred to our center for the workup of a 6-month history of diffuse myalgia and severe proximal weakness. Physical examination did not find any sign of heart failure. The patient had a medical history of diabetes mellitus. Serum creatine kinase and aldolase levels were increased at 2262 U/L (normal

To validate magnetic resonance (MR) imaging cine phase-contrast blood flow mapping in vitro and in patients with chronic liver disease, with or without portal hypertension, and to assess the accuracy of azygos, splanchnic, and systemic blood flow measured with MR imaging in the detection of high-risk esophageal varices and compare these measurements with endoscopic evaluation, the reference standard.The local ethics committee approved this study. Patients gave written informed consent. Two phantoms were used to validate the MR imaging phase-contrast flow sequence. Patients with liver cirrhosis (n = 59), chronic liver disease without cirrhosis (n = 12), and nodular regenerative hyperplasia (NRH) (n = 11), and healthy control subjects with no liver disease (n = 25) were included. The patients underwent upper digestive system endoscopy. Mean abdominal aorta, portal venous, and azygos blood flow was measured on MR images, which were reviewed by two blinded observers to determine the presence and grade of esophageal varices. The reproducibility and intra- and interobserver variability of the blood flow measurements were assessed with intraclass correlation coefficients (ICCs). The performance of the MR blood flow measurements in staging high-risk varices was determined with receiver operating characteristic curve analysis. The correlation between MR visual analysis and endoscopic grading was assessed by using κ statistics.MR flow rate measurements had excellent correlations with actual flow values in vitro (ICC0.990 for phantoms 1 and 2). Mean aortic flow was significantly higher in patients with cirrhosis than in control subjects (P.001). Mean azygos flow was significantly higher in patients with cirrhosis than in patients with chronic liver disease without cirrhosis (P = .005) and control subjects (P.001). Low intra- and interobserver variability (ICC0.990 for each blood flow type) and high reproducibility (ICC0.850 for each blood flow type) were demonstrated. The optimal cutoff mean azygos flow value was 2.3 mL/sec for varices with grades of 2 or higher.MR imaging azygos flow measurement appears to be a promising technique for detecting high-risk esophageal varices in patients with portal hypertension.

Portal hypertension, the most important complication with cirrhosis of the liver, is a serious disease. Sorafenib, a tyrosine kinase inhibitor is validated in advanced hepatocellular carcinoma. Because angiogenesis is a pathological hallmark of portal hypertension, the goal of our study was to determine the effect of sorafenib on portal venous flow and portosystemic collateral circulation in patients receiving sorafenib therapy for advanced hepatocellular carcinoma. Porto-collateral circulations were evaluated using a magnetic resonance technique prior sorafenib therapy, and at day 30. All patients under sorafenib therapy had a decrease in portal venous flow of at least 36%. In contrast, no specific change was observed in the azygos vein or the abdominal aorta. No portal venous flow modification was observed in the control group. Sorafenib is the first anti-angiogenic therapy to demonstrate a beneficial and reversible decrease of portal venous flow among cirrhotic patients.

First described in the mid 1980s, Carney complex is a rare dominantly heritable multiple endocrine neoplasia syndrome that affects endocrine glands as the adrenal cortex, the pituitary and the thyroid. It is associated with many other nonendocrine tumors, including cardiac myxomas, testicular tumors, melanotic schwannoma, breast myxomatosis, and abnormal pigmentation or myxomas of the skin. The Carney complex gene 1 was identified 10 years ago as the regulatory subunit 1A of protein kinase A (PRKAR1A) located at 17q22-24. An inactivating heterozygous germ line mutation of PRKAR1A is observed in about two-thirds of Carney complex patients. This last decade many progresses have been done in the knowledge of this rare disease and its genetics. This review outlines the current state of this knowledge on Carney complex.

To evaluate the effects of immunosuppressive therapy on cardiac abnormalities observed by cardiac magnetic resonance imaging (CMRI) in patients with Churg-Strauss syndrome (CSS).We studied 8 patients with CSS and myocardial involvement on initial CMR images, who underwent follow-up CMRI after 6 months of immunosuppressive therapy.Among the 8 patients (mean age: 43 years; 4 women), 7 had clinical cardiac signs at CSS onset (cardiac insufficiency, 3; angina pectoris, 2; atrial fibrillation, 1; and pericarditis, 1); 4 of them had myocardial-delayed enhancement, 2 had perfusion defects and 1 had both CMRI anomalies. The patient without clinical manifestations of heart disease had myocardial delayed enhancement on CMRI. After 6 months of therapy, CMR images normalised for the patient without clinical cardiac signs at diagnosis, and 3 symptomatic patients, and abnormalities had regressed for 2 other symptomatic patients. Theses 5 initially symptomatic patients became asymptomatic after immunosupressive treatment. The last 2 patients with cardiac insufficiency at CSS diagnosis are still symptomatic with unchanged CMRI abnormalities.CMRI is a sensitive, non-invasive method to detect cardiac lesions in patients whose conventional investigations indicated no cardiac disease and to assess the extent of cardiac involvement in symptomatic patients. CMRI can help evaluate the therapeutic effect of immunosuppressants in CSS.

Patients treated with anti-VEGF agents are at increased risk for arterial thrombo-embolic events (ATEs). However, the pathophysiology of such acute vascular complications remains unclear. We report on a case of bowel infarction in a renal cancer patient treated with the anti-VEGF agent sunitinib. An abdominal CT-scan evidenced the rupture of an atherosclerotic plaque located at the emergence of the superior mesenteric artery. In view of this report, we suggest that evaluation of the risk of ATE in patients receiving anti-VEGF agents should include not only age and past history of ATE as suggested by previous studies, but also assessment of atherosclerotic lesions on CT-scan.

To assess the diagnostic accuracy of multisection (64-section) computed tomography (CT) versus coronary angiography in detection of and assignment of grades for coronary artery stenoses in a high-risk population and to investigate causes for discordance between the two.The protocol was approved by the local ethics committee. Patients gave informed consent. The study included 114 patients (103 men, 11 women; mean age, 63 years +/- 8.2 [standard deviation]) with potential myocardial ischemia. Multisection CT images were interpreted independently by two radiologists with unequal experience in reading coronary CT angiograms. Diagnostic performance of 64-section CT in detection of stenoses of 50% or more was assessed per patient, per artery, and per segment. Interrater agreement was assessed by using the Cohen kappa coefficient. Agreement between 64-section CT and coronary angiography for assigning grades to stenoses was assessed by using Bland-Altman analysis.Sixty-eight percent of patients had stenoses of 50% or more. Good interrater agreement was found, with kappa values of 0.77-0.85. For the most experienced radiologist, the sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were 73.4%, 95.0%, 14.7, and 0.28 per segment, 95.2%, 94.7%, 18.0, and 0.05 per artery, and 100%, 89.2%, 9.26, and zero per patient, respectively. Discordance between 64-section CT and coronary angiography was related to either under- or overestimation of the degree of stenosis, anatomic misclassification, and coronary artery segments that were not assessable at 64-section CT. Bland-Altman analysis showed poor agreement, especially for intermediate stenosis (mean bias, 1.3%; 95% limits of agreement: -27.3%, 29.9%).Despite excellent sensitivity and negative likelihood ratios in a per-patient or per-vessel analysis, some coronary artery stenosis remained misdiagnosed with 64-section CT, resulting in limited sensitivity on a per-segment basis owing to anatomic discordance and failure to accurately quantify intermediate stenosis.

Most patients with hepatocellular carcinoma (HCC) are not eligible for curative treatment, which is resection or transplantation. Two recent series have emphasized the potential benefits of preoperative arterio-portal embolization prior to surgical resection of such tumours. This preoperative strategy offers a better disease free survival rate and a higher rate of total tumor necrosis. In case of non resectable HCC it is now widely accepted that transarterial chemoembolization (TACE) leads to a better survival when compared to conservative treatment. Thus, the question remains whether combined portal vein embolization (PVE) may enhance the proven efficiency of TACE in patients with unresectable HCC. We herein report the case of a 56-year-old cirrhotic woman with a voluminous HCC unsuitable for surgical resection. Yet, complete tumour necrosis and prolonged survival could be achieved after a combined porto-arterial embolization. This case emphasizes the potential synergistic effect of a combined arterio-portal embolization and the hypothetical survival benefit of such a procedure, in selected patients, with HCC not suitable for surgery or local ablative therapy.

The purpose of this study was to use a single-breath-hold T2-mapping MRI sequence to evaluate the reversibility of myocardial edema in patients treated for acromegaly.Before and after treatment, 15 patients with acromegaly underwent myocardial T2 mapping with an experimental single-breath-hold black-blood fast spin-echo sequence. Myocardial T2 mapping with both a multiple-breath-hold fast spinecho sequence and the experimental sequence also was performed on 14 volunteers. T2 relaxation times were calculated with a standard linear least-squares fit applied to myocardial signal intensity. The T2 relaxation times of patients were compared with those of volunteers and correlated with levels of serum growth hormone and insulinlike growth factor 1. Left ventricular function and mass index were determined with cine MRI.T2 values before treatment were higher in patients (71 +/- 12 milliseconds) than in volunteers (55.9 +/- 3.6 milliseconds) (p = 0.0003). These T2 values in patients decreased soon after treatment (57.6 +/- 6.6 milliseconds, p = 0.0007). This reduction correlates with successful reduction of levels of serum growth hormone and insulinlike growth factor 1. In volunteers, myocardial T2 values did not vary significantly between the single-breath-hold sequence and the multiple-breath-hold fast spin-echo sequence. In patients, myocardial mass and left ventricular function did not differ significantly before and after treatment.Patients with acromegaly have increased myocardial T2 values, which decrease soon after treatment, reflecting reversible myocardial edema. T2 value is more sensitive than left ventricular mass index in the detection of early reversal of acromegalic cardiomyopathy. These results highlight the potential role of MRI in direct assessment of the tissular effects of growth hormone and insulinlike growth factor 1 and in evaluation of the efficacy of treatment.

ERMA; International audience; Pyogenic liver abscess is an unusual cause of fever and abdominal pain, but it is potentially fatal. It is rarely caused by a local event, but rather by hematogenous dissemination or biliary tract disease. We report an uncommon case of liver abscess caused by the migration of a fish bone through the gastrointestinal wall.

Cardiac involvement is frequent in myotonic dystrophy type 2 (DM2) with dilated cardiomyopathy and severe arrhythmias having been reported. Left ventricular non-compaction is a cardiomyopathy often associated with neuromuscular disorders. We report the case of a 61-year-old man with DM2 treated for 5 years for a suspected dilated cardiomyopathy. Echocardiography showed left ventricular non-compaction typical pattern, with prominent apical trabeculations and intertrabecular spaces perfused from ventricular cavity. MRI confirmed the diagnosis. Physicians should be aware of the risk of severe cardiac complications in DM2 patients. Left ventricular non-compaction diagnosis is often overlooked. Neurological examination should be performed in all patients with left ventricular non-compaction.

Acute coronary syndrome, with an estimated prevalence of 300 000 cases annually in France, is one of the principal diagnostic and therapeutic emergencies in atheroma. In cases of atypical chest pain, with or without signs of severity, coronary, aortic and pulmonary CT should allow emergency specialists to rule out rapidly diagnoses of coronary disease, pulmonary embolism, aortic dissection or other chest conditions. Should acute coronary syndrome develop after immediate therapeutic management, a cardiac MRI will provide the cardiologist with the additional data necessary to assess the patient's prognosis--especially by assessing myocardial viability--and decide on subsequent management. In cases of acute coronary syndrome with normal coronary angiography, cardiac MRI can distinguish myocardial infarction from myocarditis or from Tako Tsubo syndrome.

Summary Introduction Cardiac involvement is a rare manifestation of Wegener granulomatosis (WG). Because its prognosis can be poor, it must be diagnosed early to be treated adequately. We report the disease course of a patient who received rituximab to treat cardiac involvement documented by contrast-enhanced cardiac magnetic resonance imaging (ceCMR). Case This WG patient developed myocarditis with atrioventricular block. CeCMR proved useful in the diagnosis and follow-up of cardiac involvement. Several unsuccessful regimens preceded the prescription of rituximab. Two months later, regression of the myocarditis shown by ceCMR images was correlated with electrophysiological improvement. Discussion CeCMR assessment of a heart conduction defect in a patient with WG showed that this tool was useful for the diagnosis and follow-up of cardiac involvement in this vasculitis. Rituximab was an effective treatment in this patient.

Churg-Strauss syndrome and Wegener granulomatosis are the two principal ANCA-associated vasculitides. Cardiac damage is frequent and prognosis poor. This damage is often subclinical initially and undetectable with standard cardiac imaging techniques (such as cardiac ultrasound or myocardial scintigraphy). Cardiac MRI permits early diagnosis of the different types of cardiac damage (myocarditis, pericarditis, and impaired myocardiac perfusion) that may occur during ANCA-associated vasculitis, even before the onset of symptoms. Early detection of this cardiac damage is crucial for it enables faster implementation of aggressive treatment, which may significantly improve disease prognosis. The widespread, even routine, practice of cardiac MRI in patients with ANCA-associated vasculitis thus seems justified, for this noninvasive examination provides essential diagnostic and prognostic information and helps guide therapeutic management.