Iranian Journal of Radiology
Volume:17 Issue: 3, Jul 2020

Various manifestations may appear in chest computed tomography (CT) scan of patients with coronavirus disease 2019 (COVID-19). In this pictorial review, we present chest CT manifestations of 14 patients with laboratory-confirmed COVID-19 disease and various manifestations including ground-glass and consolidative opacities, reticular opacities, halo sign, and other findings.

The preoperative assessment of cervical lymph node metastasis (LNM) is considered a challenging clinical problem in papillary thyroid microcarcinoma (PTMC) patients. Ultrasonic examination is significant for the cervical LNM in PTMC patients, but there are difficulties and limitations in observing lymph nodes in the cervical central region.

To investigate the diagnostic value of dual-energy CT iodine for characterization of PTMC and better prediction of metastatic cervical lymph nodes of PTMC.

Ninety-five patients with PTMC who underwent dual energy (DE) CT examinations were retrospectively enrolled in the study. The iodine image morphological features of primary tumor were analyzed in the arterial phase and quantitative DECT parameters of the primary tumor were recorded in the arterial and venous phase. Chi-square test and independent-sample t test were performed to compare the differences of morphological features and quantitative parameters of tumors between LNM and non-LNM groups. Receiver operating characteristic curves were generated to assess the diagnostic performance of each DECT parameter and their combinations.

Six primary tumor morphological features of the LNM group demonstrated significant differences compared with the non-LNM group (all p < 0.05). Normalized iodine concentration (NIC) and normalized CT value in the LNM group were significantly higher than those of the non-LNM group in both arterial and venous phase, respectively (all p < 0.001). The area under the curve (AUC) was improved from 0.814 to 0.843 after adding maximum diameter compared with incomplete thyroid capsule alone. In addition, the combination of NICs in arterial and venous phases had higher AUC than other quantitative parameters.

Morphological features and quantitative parameters of DECT are valuable for predicting cervical LNM in patients with PTMC.

A totally implantable venous access port (TIVAP) is an essential component of care for oncology patients. Conventional placement of the TIVAP is performed through the internal jugular vein or the subclavian vein using a tunneled catheter, which involves creating two incisions. However, the conventional technique has several potential limitations. To address these limitations, a single-incision technique without a second incision or subcutaneous tunneling has been extensively tested since first being introduced by Glenn in 2007.

The purpose of this study was to evaluate the technical success, clinical outcomes, and complications of the single-incision technique for the placement of TIVAPs.

Between January 2013 and June 2017, 182 TIVAPs were placed by a single-incision technique in 175 patients, including 79 men and 96 women (mean age, 62.4 years; range: 20 - 88 years). Electronic medical records were retrospectively reviewed to obtain patient data, outcomes, and complication rates.

A total of 40,594 catheter maintenance days (median, 221.9 days; range, 1 - 889 days) were recorded for 182 TIVAPs in 176 patients. Technical and clinical success rates were both 100%. A total of 25 complications (complication rate, 13.74%) occurred, including catheter occlusion (5.49%), catheter-related infection (5.49%), wound dehiscence (1.10%), catheter kinking (0.55%), venous thrombosis (0.55%), and extravasation during infusion (0.55%).

The single-incision technique for TIVAP via the axillary vein was safe and efficient with high technical and clinical success rates. This new technique may be a good alternative to conventional techniques.

Superficial circumflex iliac artery perforator (SCIP) flap is a promising reconstructive candidate for head and neck, trunk and extremity reconstruction. In order to reduce intraoperative errors, preoperative planning is essential for evaluation of the possible variations in vascular anatomy of the groin region. However, the use of these modalities has not been compared.

The three commonly used imaging modalities [color Doppler ultrasound (CDUS), computed tomography angiography (CTA), and magnetic resonance angiography (MRA)] were therefore compared in this study for the relative accuracy in the SCIP flap planning.

This study was conducted on eight patients who underwent CDUS, CTA and MRA [3-dimensional time-of-flight magnetic resonance angiography, (3D TOF-MRA)] and received reconstructions with the SCIP flaps for head and neck defects. The perforators’ locations, courses and calibers were measured or marked for each flap. These imaging preoperative measurements were later compared with intraoperative findings.

CDUS, CTA and 3D TOF-MRA were able to effectively identify the courses of the perforators. 3D TOF-MRA was more accurate at measuring the pedicle calibers of SCIP flaps in comparison with CTA and CDUS.

Three D-TOF-MRA may be a more valuable imaging modality for the preoperative assessment of the vascular anatomy of SCIP flaps.

Pulmonary thromboembolism (PTE) is an important cause of morbidity and mortality in hospitalized patients and computed tomographic angiography (CTA) has become the gold standard diagnostic examination for suspected PTE. Dual energy computed tomography (DECT) not only detects thromboembolic filling defects but also provides functional perfusion information by generating iodine distribution maps.

The objective of the study is to determine the value of perfusion defect score (P score) in detection of the severity of acute pulmonary thromboembolism (PTE) and to correlate it with pulmonary obstruction score (Qanadli score), other CTA parameters and clinical findings.

Fifty five patients, with acute PTE who underwent DECT were reviewed. We calculated P score, Qanadli score, ratio of the right ventricle diameter to the left ventricle (RV/LV ratio) and the main pulmonary artery (PA) diameter by using the dual energy CTA images. The correlation between CTA parameters and clinical- echocardiographic data was investigated.

Correlation analysis showed a significant positive correlation between the P score and Qanadli score (r = 0.748, P < 0.001). There was also a significant positive correlation between P score and RV/LV ratio (r = 0.432 P = 0.001) and between Qanadli score and RV/LV ratio (r = 0.424 P = 0.001). Echocardiographic data was present in 39 patients (70.9 %). P score was significantly higher in patients with RV dilatation (P = 0.022) and RV dysfunction (P = 0.001) on echocardiography. Likewise, similar interaction was present in between Qanadli score and RV dilatation (P = 0.023) and RV dysfunction (P = 0.003). No correlation was present between P score and blood gas analysis [partial pressure of oxygen in arterial blood (PaO2) , partial pressure of arterial carbon dioxide ( PaCO2),(PaO2)/fraction of inspired oxygen (FiO2), oxygen saturation] and hemodynamic data (blood pressure, and pulse).

P score is seen as a good adjunctive tool to other CTA parameters and echocardiography in detection of PTE severity. Addition of perfusion changes to clinical risk assessment will help in the management of patients.

Puncture from the hepatic vein to the portal vein to create a shunt is the most challenging step in transjugular intrahepatic portosystemic shunt (TIPS) procedure

To evaluate the feasibility and effectiveness of the hepatic artery guiding technique in TIPS procedure.

From January 2009 to December 2018, 41 patients (36 men, five women; mean age, 57.9 years; range, 33 - 77 years) who underwent TIPS were retrospectively evaluated. Total procedure times, puncture times, and total procedure radiation doses as radiation quantity (mGy) and dose area product (μGym2) from each procedure were compared using the Mann-Whitney U test between those in the simple blind puncture group and those who underwent hepatic artery guiding technique.

Technical success was achieved in all patients. Out of 41 patients, simple blind puncture was performed in 11 patients (26.8%), and hepatic artery guiding technique was performed in 30 patients (73.2%). No complications were observed in either group. The mean puncture time among those who underwent hepatic artery guiding technique (26.67 ± 11.46 min) was significantly shorter than the mean puncture time in the simple blind puncture group (38.50 ± 29.69 min) (P = 0.045). There was no statistical significance in total procedure time and radiation dose (P > 0.05).

Hepatic artery guiding technique could increase the feasibility of portal vein puncture in TIPS without a significant increase in radiation dose.

Male breast cancer (MBC) is an infrequent disease and a scarcely researched topic. Since the incidence of male breast cancer is increasing and so far, management advices have been concluded from results of trials in female patients, there has been a growing interest in this field of research.

In this study, we aimed to evaluate the general, radiological and pathological features of MBC patients.

We retrospectively reviewed the medical records of MBC patients who had been referred to breast clinic, Shahid Motahari in Shiraz, Iran, between 2005 and 2018. Data regarding general characteristics of patients such as demographic information, age, and also past history of any cancer, family history of breast cancer, mammogram and ultrasound findings, stage, size and location of tumor, histopathology of tumor, metastasis, treatment modalities and follow-up time were attained by reviewing medical records.

Fifty-one patients with MBC were included with the mean age of 58.4 years. Invasive ductal carcinoma was the most prevalent pathologic type. By use of the Kaplan Meier survival estimate, survival probability of patients for each time interval after diagnosis was calculated. There was a decline over time until about 85 months after diagnosis when it reached a plateau state above 50%. Age, HER2 and metastasis showed to lower the survival time by increasing the hazard ratio. Only 13 patients had mammography and 22 had an ultrasound, which are less than 50% of the total number of patients.

This study showed that there is still unfulfilled need to evaluate MBC in order to find the best management guidelines such as screening in high risk populations, diagnosis, treatment, and follow-up. Risk factor evaluation, survival time, and diagnostic radiologic modalities have not been well assessed in MBC so far.

The incidence of venous thrombosis based on access route after implantation of the totally implanted venous access port (TIVAP) is controversial. Symptomatic TIVAP-related venous thrombosis remains relatively rare. However, characteristics of symptomatic axillary vein thrombosis after TIVAP implantation via access of the axillary vein has not been reported.

In this historical cohort study, the incidence and characteristics of venous thrombosis associated with TIVAP via the axillary vein in cancer patients were evaluated.

A total of 4,773 TIVAPs were placed via the axillary vein in patients with various types of cancer between May 2012 and July 2018. Eighteen patients experienced symptomatic venous thrombosis associated with TIVAPs. Radiologic findings for venous thrombosis were evaluated using computed tomography (CT) including scans of the axillary vein. Medical records were retrospectively reviewed.

The prevalence of symptomatic thrombosis was 0.38% (18/4,773). The patients with symptomatic venous thrombosis included 14 males and four females. Among the 18 patients, the most common types of cancer were lung cancer (n = 7) and pancreatic cancer (n = 4), with the incidence rates of 0.79% (lung cancer, 7/882) and 1.58% (pancreatic cancer, 4/253), respectively. The median time between placement of the TIVAP and diagnosis of thrombosis was 35.5 days (range: 6 - 292 days). All symptomatic patients had thrombosis in the axillary vein on CT images. Symptoms were improved in all patients with treatment including removal of TIVAP at the time of diagnosis and following anticoagulation therapy. From the multiple binary logistic regression, pancreatic cancer and lung cancer were statistically significant risk factors of symptomatic axillary vein thrombosis.

After insertion of TIVAPs through the axillary vein, symptomatic axillary vein thrombosis rarely developed. Pancreatic cancer and lung cancer were associated with the risk of symptomatic axillary vein thrombosis.

There are several factors may have an impact on the prognosis of developmental dysplasia of the hip (DDH). They may change the outcome and treatment if they are present in a patient.

The objective of this study is to determine the association of those factors with the outcome.

The study was performed on 74 infants with DDH in Children’s Medical Centre. After obtaining informed consent and ethical approval, patients with DDH confirmed by ultrasound were included, and possible risk factors including severity of DDH based on the Graf criteria, follow-up length, age, gender, laterality, type of delivery, amniotic fluid index, fetal anomalies, birth order of children, and methods of treatment were collected and compared against treatment response.

There were 58 female and 19 male patients with a mean age of 6.54 weeks. Bilateral DDH was found in 31 females and nine males. The average alpha and beta angles were 53.19 ± 5.7 and 66.53 ± 6.6 degree, respectively. The severity of DDH had a significant association with treatment response (P = 0.003). Recovery was better in females than in males (P = 0.031). In addition, the first‐born infants had a better response (P = 0.001). A meaningful connection (P = 0.01) was noted between the amniotic fluid index as well as renal/limb anomalies and treatment response. Type of delivery (cesarean versus vaginal) or fetal presentation had no significant association with treatment response (P > 0.05).

Factors with a negative impact on DDH outcomes include the severity of DDH, male gender, higher birth order, oligohydramnios, renal and limb anomalies.

The clinical and imaging presentations of primary tumors and tumor-like lesions in the clavicle are not clear.

To investigate the clinical and imaging presentations of primary tumors and tumor-like lesions in the clavicle for better diagnosis.

Patients with clavicular diseases between 1963 and 2018 confirmed by pathology who had plain radiography, computed tomography (CT) scan and magnetic resonance imaging were enrolled. The age, sex, imaging data, radiological signs and location of the tumor at the clavicle of patients were analyzed and compared.

Eighty-one patients with clavicular diseases were identified including 49 males and 32 females with an age range of 2 - 76 years (mean, 42.6). There were malignant tumors in 50 cases (61.7%), intermediate in 12 (14.8%), and benign in 19 cases (23.5%). Malignant tumors included metastatic tumors in 31 cases (38.3%), plasma-cell myeloma in ten (12.3%), and osteosarcoma in four (4.9%). The intermediate bone tumors were mainly eosinophilic granuloma in six cases (7.4%), and aneurysmal bone cyst in three (3.7%). Benign tumors were mainly osteochondroma (6.2%), bone cyst (3.7%), and chondroma (3.7%). Malignant tumors had bone destruction, periosteal reaction, ill-defined margins and soft tissue masses. Benign tumors and tumor-like lesions had well-defined margins.

Many tumors may occur at the clavicle with more malignant than benign tumors with no specific imaging features in most lesions. A lesion near the sternal end with atypical benign imaging features should be considered as malignant.

Brain tumors are among the most lethal and devastating cancers. Medulloblastoma tumor is a common solid brain malignancy, arising in the posterior fossa. Stereological methods are used in combination with magnetic resonance imaging (MRI) to obtain unbiased estimation of the total volume of the structure of interest.

In the current study, we evaluated cerebellar tumor volume pre- and post-operative in patients suffering from meduloblastoma tumor using MRI and Cavalieri method.

The study was performed on 16 subjects consisting of two groups of eight people including patient and control groups. Slide direction were in both sagittal and axial planes. Pre- and post-operative volume of medulloblastoma tumor were determined on MR scanning images using the point-counting approach of Cavalieri method.

The post-operative tumor volume in both sagittal (P = 0.028) and axial (P = 0.046) MR images was statistically reduced by 90% compared to the pre-operative volume. Moreover, the pre-operative volume of the cerebellum in patients increased by 38% in patients as compared to the normal subjects (P = 0.028).

It could be concluded that MRI-estimated tumor-volume might be useful in evaluating the efficiency of surgical treatment and prognostication of tumor regression rate.

Central venous catheter (CVC) is located within the proximal third of the superior vena cava, inferior vena cava, or the right atrium. The confirmation of right location of catheter’s tip is done by chest X-ray (CXR) routinely.

In this study, we compared the proper location of the tip of the catheter by ultrasonography with CXR.

One hundred and seventeen patients were included in this study. The CVC was placed according to the underlying disease. The proper location of the catheter was checked by ultrasonography and then CXR was carried out. The results of both methods were recorded and finally the statistical analysis was performed for comparison.

The tip of the catheter was observed by ultrasonography in 111 patients, but in the six other ones, the tip of the catheter was not observed by ultrasonography and observed in CXR. Therefore, the sensitivity of ultrasonography was 94.9 % in this study.

The results showed that ultrasonography shows the catheter in 94.9% of the cases, although the risk of exposure to X-ray does not exist. The cost and time for evaluation of the tip of the catheter is significantly less by using ultrasonography compared to CXR.

The imaging presentation of primary bone lymphoma is unclear.

The present study aimed to investigate the imaging presentations of primary bone lymphoma especially a specific “floating-ice” sign.

Forty one patients with primary bone lymphoma confirmed by pathology with 27 males and 14 females and an age range of 2 - 76 (mean = 40) years were enrolled. The clinical and imaging data were analyzed.

The tumor involved long bones in 17 cases, flat bones in 12, spine in eight and irregular bones in four cases. The imaging presentations were divided into five types: infiltrative type in nine cases (22%), osteolytic in 14 cases (34.1%), osteosclerotic in four cases (9.8%), mixed in 11 cases (26.8%) including four cases with a “floating-ice” sign and cystic in three cases (7.3%). In plain radiography, only three of four long bone lesions in children had a varying degree of periosteal reaction. Among 20 cases with CT scanning, sixteen had soft tissue masses, seventeen had ill-defined margins, and three had well-defined margins with sclerotic rims. Among twelve patients with MRI, ten had soft tissue masses with well-defined margins. MRI demonstrated a greater extent of lesion than CT. In MRI T1 weighted image (T1 WI), isointense signal was seen in three cases, hypointense signal in five and mixed signal in four. In T2 WI, isointense and hypointense signal was detected in five cases, hyperintense signal in three and mixed hyperintense signal in four.

Primary bone lymphoma occurs most frequently in long and flat bones as infiltrative osteolytic destruction, and combined plain radiographs, CT and MRI help obtain a correct diagnosis.

Removal of a double J (DJ) stent has been conventionally performed with conventional snare wires, tissue forceps, or stone baskets under fluoroscopic guidance. However, if the lumen is collapsed, is very wide, or if the tip of the DJ stent is lodged in the bladder wall, the procedure becomes difficult.

We retrospectively reviewed four patients who had undergone retrieval or replacement of their DJ stents by interventional radiologists with an alternative loop snare technique using a guide-wire after conventional attempts using a snare catheter had failed.

Five DJ stents were completely removed without any complications.

The loop snare technique using a guide-wire could be an alternative and inexpensive approach for difficult DJ stent removal.

Uterine cavernous hemangioma is a rare vascular tumor that is more commonly reported as an acquired disease in pregnant women. Rarity of the case impeded the radiologist to be able to find characteristic imaging findings to diagnose the disease before surgery. We report a 40-year-old premenopausal woman with cavernous hemangioma of the uterus that was misdiagnosed as a low-grade sarcoma because of the non- typical imaging feature of this pathology that has not been reported before. The ultrasound exam of the patient only demonstrated global enlargement of the myometrium. Magnetic resonance imaging (MRI) showed diffuse myometrial edema with multiple linear low signal strands, without endometrial involvement and with mild restriction in diffusion-weighted imaging (DWI) that resulted in a lobulated border of uterine contour. MRI could be a helpful imaging modality for proper diagnosis of uterine hemangioma before surgery.

Hereby, the case of an 8-month-old girl diagnosed with partial anomalous left pulmonary artery (PLPA) is presented. Echocardiography and computed tomography (CT) examination demonstrated that the anomalous artery originated from the right pulmonary artery supplying the left upper lobe. PLPA is sometimes associated with tracheobronchial anomaly and congenital cardiovascular defects. A relationship between PLPA and Kabuki syndrome has also been suggested. Echocardiography and CT angiography can be used as accurate tools for identifying an anomalous left pulmonary artery and adjacent abnormal anatomic structures.

Calcific tendinitis of flexor carpi ulnaris (FCU) at the wrist is an extremely rare cause of ulnar side pain of the wrist. Owing to the infrequency of this entity, most cases are misdiagnosed as other diseases such as fractures, tendinopathies or infection. We present a case of recent-onset ulnar side wrist pain and swelling with a normal radiography. This case was referred to the imaging clinic to obtain magnetic resonance imaging (MRI) to rule out Kienbock disease. Multimodality imaging examination confirmed the correct diagnosis of acute calcific tendinitis. After two weeks of rest, wrist immobilization by splinting and consumption of anti-inflammatories, the patient’s symptoms were resolved. To conclude, this case emphasizes the requirement of awareness about this uncommon but important cause of acute wrist pain and the need of applying imaging methods for an early and accurate diagnosis in order to avoid misdiagnosis and unwarranted treatments.

Lipoid proteinosis (LP) is a rare autosomal recessive genodermatosis. Genetic mutation leads to deposition of abnormal amounts of hyaline like material in the skin and viscera, which is the cause of clinical manifestations. It mostly involves the skin, intracranium, and the larynx. In this case report, we present a case with a long history of hoarseness. Imaging findings include bilateral true vocal cord (TVC) mucosal irregularity with hyperdense depositions, bilateral medial temporal amygdala parallel bean shape calcification (pathognomonic sign), and bilateral striatal (caudate and putamen) hypoattenuation. The patient also had multiple warty papules on the hands. Biopsy of the right TVC showed submucosal deposition of periodic acid-Schiff (PAS)-positive amorphous hyaline material and confirmed the diagnosis of lipoid proteinosis. Typical imaging findings especially in the brain could be very helpful in interpretation of laryngeal imaging findings in cases of lipoid proteinosis who manifest with long term voice changes and hoarseness.