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Purpose: To examine the usefulness of dual-echo dual-flip angle spoiled gradient recalled (SPGR) magnetic resonance imaging (MRI) technique in quantifying muscle fat fraction (MFF) of pelvic and thighs muscles as a marker of disease severity in boys with Duchenne muscular dystrophy (DMD), by correlating MFF calculation with clinical assessments. We also tried to identify characteristic patterns of disease distribution.Materials and Methods: Twenty consecutive boys (mean age, 8.6 years ± 2.3 [standard deviation, SD]; age range, 5-15 years; median age, 9 years;) with DMD were evaluated using a dual-echo dual-flip angle SPGR MRI technique, calculating muscle fat fraction (MFF) of eight muscles in the pelvic girdle and thigh (gluteus maximus, adductor magnus, rectus femoris, vastus lateralis, vastus medialis, biceps femoris, semitendinosus, and gracilis). Color-coded parametric maps of MFF were also obtained. A neurologist who was blinded to the MRI findings performed the clinical assessments (patient age, Medical Research Council score, timed Gower score, time to run 10 m). The relationships between mean MFF and clinical assessments were investigated using Spearman's rho coefficient. Positive and negative correlations were evaluated and considered significant if the P value was < 0.05.Results: The highest mean MFF was found in the gluteus maximus (mean, 46.3 % ± 24.5 SD), whereas the lowest was found in the gracilis muscle (mean, 2.7 % ± 4.7 SD). Mean MFF of the gluteus maximus was significantly higher than that of the other muscles (P < 0.01), except for the adductor magnus and biceps muscles. A significant positive correlation was found between the mean MFF of all muscles and the patients age (20 patients; P < 0.005), Medical Research Council score (19 patients; P < 0.001), timed Gower score (17 patients; P < 0.03), and time to run 10 m (20 patients; P < 0.001). A positive correlation was also found between the mean MFF of the gluteus maximus muscle and the timed Gower score. Color-coded maps provided an efficient visual assessment of muscle fat content and its heterogeneous distribution.Conclusion: Muscle fat fraction calculation and mapping using the dual-echo dual-flip angle SPGR MRI technique are useful markers of disease severity and permit patterns of disease distribution to be identified in patients with DMD. [ABSTRACT FROM AUTHOR]

Posterior reversible encephalopathy syndrome (PRES) is an encephalopathy characterized by a rapid onset of symptoms including headache, seizures, confusion, blurred vision, and nausea associated with a typical magnetic resonance imaging appearance of reversible subcortical vasogenic edema prominent and not exclusive of parieto-occipital lobes. Vasogenic edema is caused by a blood-brain barrier leak induced by endothelial damage or a severe arterial hypertension exceeding the limits of cerebral blood flow autoregulation. Although the exact pathophysiological mechanism is still unclear, frequent conditions that may induce PRES include severe hypertension, eclampsia/pre-eclampsia, acute kidney diseases and failure, immunosuppressive therapy, solid organ, or bone marrow transplantation. Conversely to other conditions, which may induce PRES, the link between severe infection or sepsis and PRES, often associated with gram-positive bacteria, is still poorly understood and less well known. Clinicians from multiple disciplines, such as neurologists and internists, may encounter during their profession patients with severe infection or sepsis and should consider the possible association between PRES and these conditions. We systematically reviewed the literature about this association in order to provide a helpful clinical insight of such complex pathophysiological mechanism, highlighting the importance of recognizing PRES in such a complex clinical scenario.

Background: Osteomyelitis is a progressive infection of bone and bone marrow by microorganisms, resulting in inflammatory destruction of bone, bone necrosis, and new bone formation. Skull involvement is a rare occurrence which mainly affects children with chronic inflammatory diseases of paranasal sinusitis, or malignant otitis. In adults, cranial vault osteomyelitis can occur after cranial surgery or head trauma., Case Description: We describe an unusual case of chronic cranial osteomyelitis occurred 3 months following a mild traumatic brain injury. The causative mechanisms along with the diagnostic modalities are discussed., Conclusion: Focal cranial vault osteomyelitis, in the absence of severe trauma, can be challenging to diagnose. Imaging findings and patient history should be carefully investigated to make a correct diagnosis., Competing Interests: There are no conflicts of interest.

We report a rare case of iatrogenic right coronary artery (RCA) dissection complicated by a retrograde subtle aortic dissection, which occurred during a primary percutaneous transluminal coronary angioplasty (PTCA). A 65-year-old female, with acute anterior ST-elevation myocardial infarction (STEMI), promptly underwent primary PTCA in the left anterior descending artery. After 5 h, the patient's condition becomes worse with recurrence of chest pain and new electrocardiogram modifications suggestive of inferior STEMI. A second coronary angiography revealed a spiral dissection extending from the ostium to the medium tract of the RCA. At the same time, a contrast media extravasation due to coronary ostium fissure occurred. Coronary stents were implanted from the medium tract of the right coronary to the ostium, to promptly arrest the active bleeding and to treat the dissection. After cardiosurgical advice, the patient was referred to the radiology department, where she underwent computed tomography angiography (CTA), which showed a small hematoma in the anterior wall of the ascending aorta. The stable clinical conditions of the patient suggested a conservative therapeutic approach. During the following 6 weeks CTA and transesophageal echocardiography were performed to rule out any other complication, and the patient was fortunately discharged with almost complete resolution of the hematoma., Competing Interests: There are no conflicts of interest.

Clinical evaluation and ultrasound examination are the first steps in the evaluation of a patient with a swelling of the parotid region. After the detection of a nodular lesion, cytological or histological confirmation is usually performed to achieve the diagnosis, while the choice of cross-sectional imaging (computed tomography scan and magnetic resonance imaging) may significantly vary from one physician to another, on the basis of the degree of confidence that both radiologist and surgeon have with this kind of imaging. This work focuses on some essential "reporting points" in cross-sectional imaging evaluation of parotid nodules, chiefly helpful to the radiologist when the ultrasonography assessment is considered incomplete and requires a further evaluation., Competing Interests: There are no conflicts of interest.

BACKGROUND Superior mesenteric artery syndrome is caused by vascular compression of the third portion of the duodenum between the aorta and the superior mesenteric artery. It may occur with acute or chronic symptomatology, such as vomiting or postprandial abdominal pain, and it is usually caused by a lack of mesenteric fat pad under conditions of severe weight loss. Crohn's disease can be one of them. CASE REPORT We report 2 cases of Crohn's disease patients with clinical suspicion of jejunal stricture who underwent MR-enterography with a novel approach. In fact, the examinations were performed including prone position of the patients inside the scanner, drinking of contrast medium during the examination, and prompt acquisition of fluoroscopic sequences. Both the exams showed an abrupt termination of the duodenum on its third portion and a decreased aortomesenteric distance, allowing the diagnosis of superior mesenteric artery syndrome. CONCLUSIONS A correlation between Crohn's disease and superior mesenteric artery syndrome has never before been reported in the literature. The present study provides some practical steps that may be useful in order to improve MRE standard protocol in recognizing this condition while evaluating Crohn's disease bowel lesions.

Systemic lupus erythematosus (SLE) increases the risk of cerebrovascular events due to vascular changes, resulting in the weakening of the vessel walls. Moreover, patients with SLE have more incidence of arterial lesions such as dissections. Internal carotid dissection (ICA) is an infrequent cause of ischemic stroke, representing 2% of all ischemic events. We present a case of ischemic stroke, caused by a spontaneous dissection of intracranial ICA, treated with endovascular stent implantation, in a 22-year-old woman affected by SLE, newly diagnosed. ICA dissection with consequent ischemic stroke is an unusual first presentation of SLE disease. Our case highlights how, despite an infrequent occurrence, ICA dissection should be considered for young adults presenting with ischemic stroke, especially in those affected by SLE. This paper also shows the good technical result in the use of stenting in case of intracranial ICA dissection.

Background: An understanding of the natural history of unruptured intracranial aneurysms (IAs) has always played a critical role in presurgical or endovascular planning, to avoid possibly fatal events. Size, shape, morphology, and location are known risk factors for rupture of an aneurysm, but morphologic parameters alone may not be sufficient to perform proper rupture risk stratification., Methods: We performed a systematic PubMed search and focused on hemodynamics forces that may influence aneurysmal initiation, growth, and rupture., Results: We included 223 studies describing several hemodynamic parameters related to aneurysm natural history. In these studies, different modalities of aneurysm model creation have been used to evaluate flow and to comprehensively analyze the evolution of IAs. Controversy exists about the correlation between these parameters and initiation, growth, rupture risk, or stabilization of the aneurysmal sac. Recent findings have also shown the importance of flow patterns in this process and the relationship between unruptured IA geometry and hemodynamic parameters., Conclusions: The role of hemodynamic forces in evaluation of the natural history of unruptured IAs presents is inherently complex and is still not completely understood. In this complex scenario, although several attempts have been described in the literature, a proper risk rupture stratification and treatment strategy selection based on hemodynamic forces has not yet been created. Further efforts should be made to accomplish this important goal., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Intramedullary spinal ependymoma is a tumor, hardly characterizable with conventional magnetic resonance (MR) imaging only. MR diffusion tensor imaging (DTI) with three-dimensional fiber-tracking reconstructions allows the evaluation of the relationship between neoplasm and white matter fiber tracts, being a powerful tool in presurgical planning. We present DTI findings in a case of a young female with an extensive cervicothoracic spinal ependymoma., Case Description: The patient complained of a 2-month history of acute urinary retention, weakness and numbness on the lower limbs and the upper left limb. She underwent MR imaging that showed an extensive cervicothoracic spinal mass, difficult to characterize with conventional MR sequences. DTI showed peripherally displacement of fibers, without involvement of the spinal cord, findings consistent with an ependymoma. The patient underwent surgery with a complete resection " en bloc " of the lesion, which showed clear cleavage planes, as detected by DTI. Histopathological findings confirmed the diagnosis of ependymoma., Conclusions: DTI is a useful tool in presurgical planning, helping in differentiating not infiltrating neoplasms, such as spinal ependymomas, from other infiltrative and more aggressive neoplasms, which are considered not resectable., Competing Interests: There are no conflicts of interest.

BACKGROUND MR cholangiopancreatography is widely performed before laparoscopic cholecystectomy to rule out choledocholithiasis and to avoid iatrogenic injuries that may be related to the high frequency of anatomical variations of the biliary tree. Although most of these variants have already been demonstrated surgically and by endoscopic retrograde cholangiopancreatography and CT cholangiography, there are no references in which MR cholangiopancreatography has shown a cystic duct draining into the right hepatic biliary duct. CASE REPORT A 51-year-old woman with a history of recurrent abdominal pain underwent an abdominal ultrasound in an outside center, which revealed gallbladder cholelithiasis. In this patient, an MR cholangiopancreatography was performed and the laboratory data were obtained. Laboratory findings showed only a mild increase of cholestasis. MRCP did not reveal significant dilatation of intra- or extrahepatic biliary ducts, while the cystic duct showed an atypical insertion, draining directly into the right hepatic duct. CONCLUSIONS To avoid unintentional bile duct injuries, MRCP evaluation of the biliary anatomy is particularly important for pre-operative evaluation of patients undergoing laparoscopic cholecystectomy. In particular, in the case we describe, the right hepatic duct might have been mistaken for the cystic duct, with potentially severe surgical complications and clinical consequences.

Peritoneal inclusion cystarises when fluid produced by ovary is trapped within peritoneal adhesions. In this article, we describe a case series of patients affected by Crohn's disease, undergoing to magnetic resonance enterography, in whom it was possible not only to monitor the pathological findings of small bowel but also to primarily diagnose the presence of peritoneal inclusion cysts. The current knowledge of peritoneal inclusion cyst concomitant to Crohn's disease is still limited, often leading radiologists to misdiagnose it., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Transcaval ureter is a rare congenital anomaly characterized by an inferior cava vein duplication producing a vascular ring around the right ureter, usually determining hydroureteronephrosis. The knowledge of this vascular anomaly on imaging examinations permits to avoid erroneous diagnosis of retroperitoneal masses or adenopathy and preoperatively advise the surgeon of potential sources of complications. We describe a case of transcaval ureter studied with multidetector computed tomography. To our knowledge, this is the first case in which computed tomography multiplanar and volume-rendering reconstructions show this rare anomaly., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Neoplasms of retromolar trigone have important peculiarities due to their spatial relationships with the surrounding structures. Tumours that involve this area can extend to nearby muscles; adipose spaces; and other anatomic structures, such as the soft palate, the tonsillar fossa, the parapharyngeal space, and the floor of the mouth. In spite of a relatively quick diagnosis, the real extent of these tumours is typically underestimated at clinical examination. Our purpose was to propose a systematic approach to the use of multiplanar computed tomography reconstructions to evaluate normal retromolar trigone anatomy and the main pathways of spread for tumours that arise in this area. To our knowledge, only few reports exist in literature about this topic and none are about the usefulness of multidetector computed tomography and multiplanar reconstructions., (Copyright © 2014 Canadian Association of Radiologists. Published by Elsevier Inc. All rights reserved.)

Rationale and Objectives: To investigate the value of diffusion-weighted (DW), perfusion-sensitive, and dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI) techniques in assessing the response of bone metastases from breast cancer to radiotherapy, with particular emphasis on the role of intravoxel incoherent motion (IVIM)-DW parameters as a potential valuable imaging marker of tumor response., Materials and Methods: Fifteen women having breast cancer and bone metastases underwent MRI before and after radiotherapy (3 weeks [time 1], 2 months [time 2], and 4 months [time 3]), consisting of DW, perfusion-sensitive (IVIM), and DCE acquisitions. MR-based DW and perfusion parameters, including water diffusivity (D), perfusion fraction (f), pseudodiffusion (D*), total apparent diffusion coefficient (ADC-total), fractionated ADCs (ADC-high and ADC-low), and initial area under the gadolinium concentration curve after the first 60 seconds (IAUGC60), were determined. The morphologic MRI findings were also recorded. A one-way repeated measures analysis of variance was used to compare the value of MR-based parameters at the different time points., Results: A significant variation between pretreatment (time 0) and post-treatment (times 1, 2, and 3) was found for ADC-total and D parameters (P < .001). A statistically significant reduction was also found for IAUGC60 values between times 0 and 3 (P < .001). A significant change across the different time points was observed for D* and IAUGC60 parameters (P < .001). On the contrary, there was no statistically significant change over time for parameters ADC-total, D, f, and IAUGC60 comparing response between each metastasis, that is, the response to therapy was similar for each metastasis., Conclusions: DW, IVIM, and DCE-MRI techniques show effectiveness in assessing the response to radiotherapy in bone metastases from breast cancer., (Copyright © 2014 AUR. Published by Elsevier Inc. All rights reserved.)

Background: The State-Trait Anger Expression Inventory 2 (STAXI-2) is a psychometric instrument measuring anger experience and expression. Associations between the STAXI-2 and risk of breast cancer (BC) are rarely considered together in a prospective study., Patients and Methods: A total of 117 women with breast symptoms referred for breast examination were selected and assessed before any diagnostic procedures., Results: Twenty-four patients with BC, 44 with benign breast disease (BBD) and 49 healthy individuals (HHS) were included. Scores for parameters state anger/feel like expressing anger physically (SANGP) were significantly higher in the HHS group (HHS vs. BBD: p=0.027; HHS vs. BC: p=0.025). BC patients showed a trend to lower scores in almost all scales of STAXI-2, except for the scales trait anger/angry temperament (TANGT), anger expression-in (AX-I), and anger control-out (AC-O), that were higher than the two other groups' scores., Conclusion: The results of this study do not support a specific link between STAXI-2 and breast cancer risk., (Copyright © 2014 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.)

Objective: The purpose of this study was to assess the value of dual-source dual-energy CT in the evaluation of complex cystic renal masses., Subjects and Methods: Seventy patients underwent contrast-enhanced dual-energy CT that included true unenhanced images acquired in single-energy mode, corticomedullary phase images acquired in dual-energy mode, and nephrographic phase images acquired in single-energy mode. Virtual unenhanced, blended weighted-average, and color-coded iodine overlay images were reconstructed. The acceptance level and image quality of virtual and true unenhanced images were evaluated. Contrast enhancement on both true unenhanced or blended weighted-average images and color-coded iodine overlay images was evaluated with both calculation in regions of interest and use of confidence level scales. Radiation dose parameters were estimated., Results: Virtual unenhanced images of 70 lesions (97.2%) and true unenhanced images of 72 lesions (100%) were judged acceptable (p = 0.5). The mean quality score of virtual unenhanced images was 2.0 ± 0.7 and of true unenhanced images was 1.5 ± 0.5 (p < 0.001). Mean contrast enhancement measured on true unenhanced and blended weighted-average images was 45.9 ± 15.9 HU (range, 21-78 HU) and on color-coded iodine overlay images was 47.3 ± 16.8 HU (range, 22-75 HU) with no significant differences. Enhancement was excluded on color-coded iodine overlay images with a significantly (p < 0.03) higher level of confidence than it was on true unenhanced and blended weighted-average images. The mean dose reduction with use of a combined dual- and single-energy dual-phase CT protocol was 29.1% ± 11.9% (p < 0.001)., Conclusion: Dual-source dual-energy CT is a reliable imaging technique in the evaluation of complex cystic renal masses. True unenhanced images can be replaced by virtual unenhanced images with considerable radiation dose reduction. The color-coded iodine overlay technique is a useful tool for both excluding and identifying endocystic enhancement.

Objective: The purpose of our study was to evaluate the value of dual-source dual-energy CT with colored iodine overlay for detection of endoleaks after endovascular abdominal aortic aneurysm repair. We also calculated the potential dose reduction by using a dual-energy CT single-phase protocol., Subjects and Methods: From November 2007 to November 2009, 74 patients underwent CT angiography 2-7 days after endovascular repair during single-energy unenhanced and dual-energy venous phases. By using dual-energy software, the iodine overlay was superimposed on venous phase images with different percentages ranging between 0 (virtual unenhanced images) and 50-75% to show the iodine in an orange color. Two blinded readers evaluated the data for diagnosis of endoleaks during standard unenhanced and venous phase images (session 1, standard of reference) and virtual unenhanced and venous phase images with colored iodine overlay images (session 2). We compared the effective dose radiation of a single-energy biphasic protocol with that of a single-phase dual-energy protocol. The diagnostic accuracy of session 2 was calculated., Results: The mean dual-energy effective dose was 7.27 mSv. By using a dual-energy single-phase protocol, we obtained a mean dose reduction of 28% with respect to a single-energy biphasic protocol. The diagnostic accuracy of session 2 was: 100% sensitivity, 100% specificity, 100% negative predictive value, and 100% positive predictive value. Statistically significant differences in the level of confidence for endoleak detection between the two sessions were found by reviewers for scores 3-5., Conclusion: Dual-energy CT with colored iodine overlay is a useful diagnostic tool in endoleak detection. The use of a dual-energy single-phase study protocol will lower radiation exposure to patients.

Anterior urethral valves in the fossa navicularis is an exceptionally uncommon causes of lower urinary tract obstruction in newborn. The authors report a case of anterior urethral valves in thefossa navicularis in an 5 days-old boy, that observation of the voided stream revealed a filiform micturition and marked ballooing of the penile urethra. The meatus was located normally and of normal calibre. Voiding cystourethrography showed obstruction at the fossa navicularis, and a hyghly trabeculated bladder. Ultrasonography showed a severe bilateral hydroureteronephrosis. After a temporary soprapubic cystostomy, the urethroscopy revealed a valve on the floor of the fossa navicularis, excised with tenotomy scissor. Postoperatively ,urethral obstruction was relieved immediately by a good urinary stream. At 6 months follow-up the patient voided with a good stream and ultrasonography revealed complete disappearance of hydroureteronephrosis.

Objective: The purpose of this study was to describe the MR imaging findings of Nuck canal endometriosis (NCE)., Materials and Methods: In a 10-year period, 486 out of 612 patients, with laparoscopically and/or surgically proven diagnosis of pelvic endometriosis, underwent MR imaging examination. The examinations were reviewed by two urogenital experienced radiologists working in consensus. Data analysis included: lesions location, size, morphological and signal intensity pattern, involvement of the adjacent muscles, and tendons., Results: In 372 out of 486 patients an MRI diagnosis of endometriosis was made. NCE was found in eight patients. All the lesions were located on the right side. The mean size of the lesions was 2.5 cm (range 1.5-4.5 cm). Two patterns of NCE were found: type 1, prevalently cystic (n = 2); and type 2, prevalently solid with small scattered cysts within lesion (n = 6). In all the patients, hemorrhagic hyperintense cysts could be seen on T1-weighted images. In four patients, the lesions involved the inguinal canal, and in another four patients, the lesions were only outside the inguinal canal. Involvement of the abdominis rectus muscle was seen in two patients, and of the adductor common tendon in two patients., Conclusion: MR imaging permits the diagnosis of NCE as well as the evaluation of exact extension of the disease.