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Objective: Formation mechanisms and treatment of the urinary stones are different, depending on their chemical structure. Therefore, determining the stone type plays a key role in planning treatment and preventive measures. Computed tomography (CT), with the use of dual-energy technology in recent years, has made it possible to do in vivo analysis of urinary stones. In this study, we aimed to evaluate the diagnostic efficacy of dual-energy CT (DECT) and compare its results with in vitro analysis, which is accepted as a gold standard for analysis of urinary stones., Materials and Methods: The DECT examinations were performed on 373 patients using 128-slice dual-source CT scanner. Analysis of attenuation ratios in the high and low kilovoltage peak values of the stone was performed at workstation, and stones were classified as hydroxyapatite, calcium oxalate, cystine, and uric acid. On follow-up, the stone was obtained in 35 patients as a result of surgery or passed spontaneously. The DECT analysis and in vitro analysis results were compared and statistically evaluated., Results: In all patients, 136 hydroxyapatite, 160 calcium oxalate, 57 uric acid, and 20 cystine stones were detected with DECT. In vitro analyses of the stones were performed in 35 patients, and 8 hydroxyapatite, 18 calcium oxalate, 6 uric acid, and 3 cystine stones were revealed. When DECT analysis results were compared with in vitro analysis results, stone types were detected correctly in 32 (91.4%) patients and incorrectly in 3 (8.6%) patients. Especially all uric acid and cystine stones were correctly detected with DECT., Conclusions: With advanced postprocess analysis methods, DECT is able to analyze urinary stones. The DECT is found superior especially in detecting uric acid and cystine stones. Its success in detecting hydroxyapatite and calcium oxalate stones is also high. When in vivo analyses of the stones are performed with DECT, it will be possible to make a contribution to the personalization and optimization of the treatment.

Purpose: We aimed to demonstrate the success and reliability of a novel puncture, aspiration, injection, and reaspiration (PAIR) technique in liver hydatid cysts., Methods: Percutaneous treatment with ultrasonographic guidance was performed in 493 hepatic hydatid cysts in 374 patients. Patients were treated with a new PAIR technique by single puncture method using a 6F trocar catheter. The results of this novel technique were evaluated with regards to efficacy and safety of the procedure and complication rates., Results: Out of 493 cysts, 317 were Gharbi type I (WHO CE 1) and 176 were Gharbi type II (WHO CE 3A). Of all cysts, 13 were referred to surgery because of cystobiliary fistulization. Recurrence was observed in 11 cysts one month later. Therefore, the success rate of the PAIR technique was 97.7% (469/480). Minor complications (fever, urticaria-like reactions, biliary fistula) were seen in 44 treated patients (12%, 44/374); the only major complication was reversible anaphylactic shock which was observed in two patients (0.5%, 2/374)., Conclusion: This novel modified PAIR technique may be superior to catheterization by Seldinger technique due to its efficiency, easier application, lower severe complication rate, and lower cost. Further comparative studies are required to confirm our observations.

Background and Aim: Trendelenburg positioning (TP) is a common approach used during internal jugular vein (IJV) cannulation. No evidence indicates that TP significantly increases the cross-sectional area (CSA) of the IJV or decreases the overlap between the carotid artery (CA) and the IJV in dialysis patients. The primary aim of this study was to investigate the effects of the TP on the CSA of the right IJV and on its relationship to the CA., Methods: Thirty-seven consecutive hemodialysis patients older than 18 years of age were enrolled. We measured the CSA of the right IJV and overlap rate (at end-expiration at the level of the cricoid cartilage) between the CA and the IJV in two positions: State 0, table flat (no tilt), with the patient in the supine position; State T, in which the operating table was tilted to 15° of TP., Results: Data were collected for all of the 37 patients enrolled in the study. The change in CSA and overlap between the CA and the IJV from the supine to the TP was not significantly different. The CSA was paradoxically decreased in 11 of 37 patients when changed from State 0 to State T., Conclusions: TP does not significantly increase the CSA of the right IJV or decrease the overlap between the CA and the IJV in dialysis patients. In fact, in some patients, it reduces the CSA. Therefore, the use of the TP for IJV cannulation in dialysis patients can no longer be supported.

Atherosclerosis-induced premature vascular diseases are the leading cause of mortality among patients with chronic kidney disease (CKD). The pathogenetic mechanism of atherosclerosis in patients with CKD has not been fully explained. Experimental studies have demonstrated that high dietary sodium intake not only increases circulatory volume and blood pressure, but also facilitates development of atherosclerosis by reducing production-bioavailability of nitric oxide due to oxidative stress and accordingly by enhancing endothelial and arterial stiffness. In this study, we investigated the relationship between sodium consumption and carotid artery intima-media thickness, which is the indicator of atherosclerosis, by determining daily urinary sodium excretion, which is a reliable indicator of sodium consumption, in our patient group. Our patient group included 193 patients with stage 2-4 non-diabetic CKD and without a history of atherosclerotic disease. We determined that 77% of our patients have been consuming more than 2  g of sodium per day, which is the upper limit of sodium consumption recommended for patients with CKD. We determined a positive linear correlation between carotid artery intima-media thickness and patient age (p < 0.001), C-reactive protein (p < 0.001), urinary sodium excretion (p < 0.001), body mass index (p = 0.002), systolic blood pressure (p = 0.002), hemoglobin (p = 0.030), triglycerides (p = 0.043), and diastolic blood pressure (p = 0.049). We also found a negative linear correlation between carotid artery intima-media thickness and glomerular filtration rate (p = 0.008). We found that urinary sodium excretion is the determinant of intima-media thickness even if all factors associated with intima-media thickness are adjusted, and that intima-media thickness increases by 0.031 (0.004-0.059) mm per 2  g increase in daily sodium excretion, independent from overall factors (p = 0.025). Our results reveal a relation between urinary sodium excretion and carotid artery intima-media thickness and suggest that excessive sodium consumption predisposes development of atherosclerosis in patients with CKD.

Purpose: The aim of the study is to assess the predictive power of DCE-MRI semi-quantitative parameters during treatment of breast cancer, for disease-free (DFS) and overall survival (OS)., Materials and Methods: Forty-nine women (age range, 28-84 years; mean, 50.6 years) with breast cancer underwent dynamic contrast enhancement MRI at 1.0T imaging, using 2D FLASH sequences. Time intensity curves (TICs) were obtained from the regions showing maximal enhancement in subtraction images. Semi-quantitative parameters (TICs; maximal relative enhancement within the first minute, E (max/1); maximal relative enhancement of the entire study, E(max); steepest slope of the contrast enhancement curve; and time to peak enhancement) derived from the DCE-MRI data. These parameters were then compared with presence of recurrence or metastasis, DFS and OS by using Cox regression (proportional hazards model) analysis, linear discriminant analysis., Results: The results from of the 49 patients enrolled into the survival analysis demonstrated that traditional prognostic parameters (tumor size and nodal metastasis) and semi-quantitative parameters (E(max/1), and steepest slope) demonstrated significant differences in survival intervals (p<0.05). Further Cox regression (proportional hazards model) survival analysis revealed that semi-quantitative parameters contributed the greatest prediction of both DFS, OS in the resulting models (for E(max/1): p=0.013, hazard ratio 1.022; for stepest slope: p=0.004, hazard ratio 1.584)., Conclusion: This study shows that DCE-MRI has utility predicting survival analysis with breast cancer patients., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Pancreatic fistulas are rare clinical entities associated with severe pancreatitis. A 39-year-old man who had been diagnosed and treated for severe pancreatitis 2 months ago presented with abdominal pain, fever, and vomiting. The abdominal computed tomography (CT) demonstrated a peripancreatic abscess and a duodenal fistula communicating the first part of duodenum, which was also verified with fluoroscopy. A size 14-French catheter with pig-tail tip was inserted primarily with a Seldinger 2-step technique through percutaneous route under CT-guidance to avoid intervening bowels or solid organs. The patient's clinic improved and treatment was stopped on the 18th day. On the 26th day of the first intervention, the patient had fever and abdominal pain and his clinic was deteriorated. A second fluoroscopic examination revealed that the duodeno pancreatic fistula was closed while a new 1 has developed into the ascending colon. With aggressive nutrition support, antibiotics and repeated drainage of the abscess pouch a dramatic clinical improvement was observed. Control abdominal CT demonstrated the resolution of pancreatic abscess on the 62nd day.

Hemobilia is a rare phenomenon. In this case report we present an emergent transcatheter glue embolization (in which N-butyl cyanoacrylate is used as an embolizing agent) due to arteriobilary fistula occurred following the laparoscopic cholecystectomy in a 41-year-old woman.

Purpose: The purpose of this study was to describe the computed tomography (CT) findings of pancreatic lipomas of 9 cases, with emphasis to diagnostic challenges., Methods: Between March 2006 and April 2008, 9 patients with pancreatic lipomas that were diagnosed by CT were reviewed in the present study. Clinical data and CT features of these 9 cases were retrospectively analysed. The patient population included 5 men and 4 women, aged 42-81 years (mean age, 65.8 years). The patients were followed up for at least 2 years with control CTs., Results: In all 9 cases, a well-bordered nodular fat density lesion was incidentally detected in the pancreas. Four of the lesions had a lobulated contour, and 2 of them had septations. Two of the lipomas were located in the head, 3 in the neck, 3 in the corpus, and 1 in the tail. The CT densitometric values were between -90 and -120 HU, with a mean value of -106 HU. No pancreatic or biliary dilatation or compression to the adjacent structures was seen. All the cases had control CTs, and the lipomas remained unchanged during the follow-up period. Histopathologic confirmation of the diagnosis was not planned for the cases., Conclusion: Lipomas are rarely encountered in the pancreas. They often are diagnosed coincidentally as small, well-circumscribed, encapsulated, homogeneous, mature adipose masses on imaging studies. Imaging follow-up strategy or histopathologic confirmation is not necessary in asymptomatic patients., (Crown Copyright 2010. Published by Elsevier Inc. All rights reserved.)

Background: In this study, we evaluated the efficacy of celiac plexus block for the treatment of feeding intolerance in critically ill patients., Methods: Nineteen mechanically ventilated medical patients intolerant of enteral nutrition and receiving metoclopramide underwent bilateral celiac plexus block. The anterior procedure was accomplished under sonographic guidance with the injection of either 25 mL bupivacaine 0.25% (celiac group, n = 10) or saline (control group, n = 9) bilaterally. Gastric emptying was assessed by the acetaminophen absorption method. After the block, nasogastric feeding was commenced, and nasogastric aspirates were collected once every 24 hours. Successful feeding was defined as 24-hourly gastric residual volume <250 mL with a feeding rate > or = 40 mL/h., Results: Demographic data were similar for the 2 groups. The area under the plasma paracetamol absorption curve (383.8 +/- 248.1 mg . min . L(-1)) and the peak plasma paracetamol concentration (C(max); 3.28 +/- 2.15 mg/L) in the celiac group were significantly lower than the area under the curve value (1233.5 +/- 771.2) and C(max) value (10.14 +/- 6.04) in controls (P < 0.001 for all). After treatment, celiac plexus block reduced the mean gastric residual volume (celiac group: 430 +/- 32 mL to 205 +/- 30 mL, P < 0.001; control group: 450 +/- 33 mL to 461 +/- 19 mL, P > 0.05) and improved the proportion of patients with successful feeding (celiac block 80% vs controls 0%, P < 0.001)., Conclusion: In critical illness, celiac plexus block is effective for treating feeding intolerance when IV drug therapy has failed to improve gastrointestinal dysfunction.

Inflammatory myofibroblastic tumor of the abdominal wall is a rare soft-tissue tumor presentation in adults. A 50-year-old woman was referred with abdominal pain and a palpable mass in the left lower quadrant. Computed tomography scan and magnetic resonance investigation revealed an 8-cm heterogeneous abdominal wall mass. Tumor markers were within normal limits. Fine-needle aspiration cytology and tru-cut biopsies yielded necrotic material. A preoperative diagnosis of a resectable rhabdomyosarcoma was suggested. On exploration a tumor measuring 8 x 8 x 6 cm was resected along with the involved structures. Histopathologic examination of specimen revealed an inflammatory myofibroblastic tumor of the abdominal wall. The patient has been followed up for the last 12 months without clinical or radiographic evidence of recurrence. Inflammatory myofibroblastic tumor arising from the anterior abdominal wall in adults is an unusual manifestation of soft-tissue tumors, which can be managed by a multidisciplinary team of surgeons, oncologists, radiologists and pathologists.

Several types of abnormalities of the ribs have been reported. Many of these anomalies usually result in the correct diagnosis thanks to the characteristic radiological appearances. But some of the anomalies are rare and it is important to recognize and get accustomed to differing appearances of these osseous abnormalities in order to differentiate the pathological processes and to diagnose the syndromes which may accompany rib anomalies. The localized costovertebral anomaly with horn-like appearance, which has not yet been described in literature, is presented in this paper.

Methanol is a clear, colorless, and highly toxic liquid with a similar smell and taste to ethanol, and is found in many commercial products such as solvents and cleaning fluids. Severe methanol intoxication occurs after suicidal or accidental oral ingestion of solvents. A few patients with methanol intoxication via the transdermal route have been reported. We present a 47-year-old woman with acute transdermal methanol intoxication admitted to the emergency department with weakness, blurred vision, bilateral areactive mydriasis, and deterioration of consciousness.

Although bee stings can cause local reactions, neurovascular complications are rare. A 60-year-old man developed a focal neurologic deficit 2 hours after multiple bee stings, which was confirmed to be acute cerebral infarctions on magnetic resonance imaging scan.

Lipomas are common benign mesenchymal neoplasms documented in literature. This study aimed to describe the computed tomographic (CT) and magnetic resonance imaging (MRI) findings of gastrointestinal system lipomas, all of which are incidentally found in routine abdominal imaging studies. Lipomas were depicted as homogeneous, nonenhancing, well-marginated lesions consistent with adipose tissue on CT and MRI. The density measurements on CT images consistent with fat are virtually diagnostic. Lipomas can incidentally be found and should be considered in the differential diagnosis of soft tissue gastrointestinal system-related masses. Computed tomographic or MRI examinations can correctly diagnose a lipoma nonoperatively, thereby allowing better treatment planning.

We aimed to determine the degree and extent of parenchymal abnormalities on pulmo-CT in patients with emphysema. The study group consisted of 29 patients (18 male, 11 female; mean age 57.9+/-13). The diagnosis was based on clinical symptoms, pulmonary function tests (PFT) values, and chest CT findings. All of the patients CT scans were obtained during suspended deep inspiration from the apices to the costophrenic angles. The mean lung attenuation (MLD) and parenchymal abnormalities related to emphysema were quantitatively calculated with tables, histograms and graphics at the whole lung. The lung density measurements revealed a mean density of -898.48+/-51.37 HU in patients with emphysema and -825.1+/-25.5 HU in control group. In addition, mean percentage of subthreshold attenuation values was found as 12.03+/-15.75 and 1.07+/-0.83 in patients with emphysema and control group, respectively. Compared with control group, the patients with emphysema had a significantly lower inspiratory MLD (p<0.05). Additionally, statistically significant correlations were seen between the MLD and percentage of subthreshold values (r=0.44, p<0.05). In contrast, there was poor correlation between PFT measurements and the subthreshold values. In conclusion, pulmo-CT is a quick, simple method for quantitative confirmation of the presence of parenchymal abnormalities of lung as mosaic attenuation and should be used in combination with other radiological methods and PFT as it gives additional information to routine examinations in patients with emphysema.

We report a 45-year-old, non-alcoholic woman with ovarian cancer who presented with acute impairment of consciousness. Cranial MRI revealed symmetrical and bilateral increased signal intensities of the corpus callosum and the dentate nucleus, without contrast enhancement. The findings are comparable with Marchiafava-Bignami disease (MBD), although pathological confirmation was not possible. Most of the reported cases of MBD are related to chronic ingestion of red wine and/or related with a nutritional cause. We suggest that this patient may suffer a MBD possible related to the ovarian cancer.

Objectives: To investigate the differences in findings from magnetic resonance imaging (MRI) in the neutral and provocative positions, and to examine the relationship between these differences and the results of physical examination tests in patients with thoracic outlet syndrome (TOS)., Design: Prospective., Setting: University physical medicine and rehabilitation outpatient and radiology clinics., Participants: Twenty-nine patients and 12 healthy controls. All of the patients had positive bilateral TOS stress tests; control group participants were symptom free and had negative TOS stress tests bilaterally., Interventions: Not applicable., Main Outcome Measures: All participants underwent Adson's test, the Halsted maneuver, and a hyperabduction test. All were evaluated with MRI while in 2 positions: the neutral position (upper extremities adducted) and in a provocative position. Measurements were obtained at the interscalene triangle, at the costoclavicular space, and at the retropectoralis minor space., Results: There was a significant difference in MRI findings between the neutral and provocative position in the patients (P<.05), but there were no significant differences in the control group. There was a significant difference in the positional change values in MRI between the patients and the control subjects (P<.05). The difference was found in the minimum costoclavicular distance between patients with a positive Halsted maneuver and a negative Halsted maneuver (P<.05)., Conclusions: Our findings indicate that MRI findings in patients in a provocative position are more valuable in the diagnosis of TOS, and these findings are in accord with findings from the physical evaluation tests.

Background and Purpose: Digital subtraction angiography (DSA) is the current reference standard for the diagnosis, assessment, and management of brain arteriovenous malformations (AVMs). The purpose of this study was to compare the diagnostic utility of three-dimensional (3D) time-of-flight (TOF) magnetic resonance angiography (MRA) and contrast-enhanced 3D MRA in patients with intracranial arteriovenous malformations (AVMs) in different sizes and locations. The AVM diagnosis was proved via DSA and almost half of the patients had also hematoma., Materials and Methods: Two radiologists, experienced on neurovascular imaging and independent from each other, retrospectively reviewed two MRA techniques and DSA with regard to the assessment of feeding arteries, AVM nidus, and venous drainage patterns on 20 patients with 23 examinations by scoring system. Disagreements were resolved by consensus., Results: An excellent agreement between contrast-enhanced MRA and DSA was found in order to assess the numbers of arterial feeders and draining veins (Spearman r=0.913, P<0.001). The average scores in contrast-enhanced MRA for feeders, nidi, and drainers were respectively 2.26, 2.69, and 2.48, while in TOF-MRA they are 1.96, 1.35, and 0.89, respectively., Conclusion: Compared to TOF-MRA, 3D contrast-enhanced MRA is useful for visualization by subtraction technique of malformation components presented by hematoma or by haem product. On the other hand, for the cases presented by slow or complex flow that is especially in around or nidi or around the venous portion is also advantageous because of the independence from flow-related enhancement. Therapeutic effects were clearly demonstrated in three follow-up patients. A major limitation of this technique is the low spatial resolution. Since there is such a limitation, arterial feeder of a case with micro-AVM is not detected by contrast-enhanced MRA and nidus for the same case was observed retrospectively. In this respect, we believe that 3D contrast-enhanced MRA is a less invasive and inexpensive angiographic tool, but not a safe substitute for DSA. Yet, it can be a beneficial supplement to DSA in patients with cerebral AVMs at both initial diagnosis and at follow-up processes after therapy.

We describe a case of pleurosubcutaneous fistula of the left thoracic wall in an oncologic female patient. She presented with left-sided pain and a chest wall mass bulge suspicious for breast neoplasm metastasis.

Objective: Assessed the usefulness of virtual cystoscopy performed with multidetector computed tomography (CT) in patients with different urinary bladder pathologies compared to the conventional cystoscopy., Materials and Methods: Eighteen patients with different bladder pathologies, which consisted of 11 tumors, 3 diverticula, 2 trabecular changes and 2 stones, were assessed with conventional cystoscopy and virtual CT cystoscopy. The results of virtual CT cystoscopy were compared with the findings of conventional cystoscopy. We determined the detection rate and positive predictive value of CT imaging based virtual cystoscopy in the diagnosis of urinary bladder lesions., Results: CT scanning was well tolerated by all patients, and no complications occurred. Images in 16 (88%) of the 18 virtual cystoscopic examinations were either of excellent or good quality. All tumors except one, 2 trabecular changes and 2 stones were characterized with similar findings in the both of methods. The masses ranged from 0.4 to 7.0 cm in diameter. While conventional cystoscopy could not evaluate interior part of the diverticulum, virtual CT cystoscopy could demonstrate clearly within it. There were no false-positive findings in our series., Conclusion: Virtual CT cystoscopy is a promising technique to be used in the detection of bladder lesions. It should be considered especially at the evaluation of bladder diverticula. In the future, it may be possible or even advantageous to incorporate into the imaging algorithm for evaluation of bladder lesion.

The retro-aortic left renal vein (RLRV) is a malformation characterized by the presence of a vessel that drains the left renal blood up to the inferior vena cava crossing behind the aortic artery. Varicocele is defined as venous dilation of the pampiniform plexus, and the left side is the most commonly affected. Several theories concerning the possible aetiology of varicocele are reviewed in the literature, but RLRV was not mentioned as an aetiologic factor of varicocele. in this study we investigated the percentage of RLRVs and their relation with varicocele. A total of 1,125 contrast-enhanced abdominal CT scans was examined to identify RLRVs. RLRVs were found in nine women (1.6%) and ten men (1.7%). We performed scrotal Doppler ultrasonography (US) for all affected men except one. Varicocele of varying degrees was found in seven of the nine male patients with RLRV (77%). RLRV could be one of the aetiological factors in the development of varicocele, and the cases with RLRV should be examined by scrotal Doppler US for the presence of varicocele.

Introduction: The purpose of this study was to determine the increase in diaphragmatic excursion of patients with chronic obstructive pulmonary disease (COPD) treated with theophylline by MR-fluoroscopy which is an innovative method to demonstrate effectiveness of this treatment., Materials and Methods: Investigations were performed on a 0.3 T open MR unit. MR-fluoroscopy images of 30 patients with COPD were obtained before and after theophylline treatment. Diaphragmatic movement values were recorded for evaluation., Results: The response of the diaphragmatic movement in COPD patients treated with theophylline was evaluated by MR-fluoroscopy and an increase of 48% in diaphragmatic contractility was determined after the treatment. The increase in contractility was found to be parallel with respiratory function tests and clinical status., Conclusion: Diaphragmatic movement and response to the medical therapy in patients with COPD can be evaluated by MR-fluoroscopy method which can allow accurate measurements.

We report a case of a 23-year-old man with a cardiac hydatid cyst involving the left ventricle wall. The diagnosis of the cyst was obtained by magnetic resonance (MR) imaging. He was operated on for cardiac hydatid cyst using enucleation and capitonnage procedure under extracorporeal circulation. Histopathologic study confirmed hydatid cyst diagnosis.