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Background Cancer-induced bone pain (CIBP), caused by bone metastases, is a common complication of cancer and strongly impairs quality of life (QoL). External beam radiotherapy (EBRT) is the current standard of care for treatment of CIBP. However, approximately 45% of patients have no adequate pain response after EBRT. Magnetic resonance image-guided high-intensity focused ultrasound (MR-HIFU) may improve pain palliation in this patient population. The main objective of this trial was to compare MR-HIFU, EBRT, and MR-HIFU + EBRT for the palliative treatment of bone metastases. Methods/design The FURTHER trial is an international multicenter, three-armed randomized controlled trial. A total of 216 patients with painful bone metastases will be randomized in a 1:1:1 ratio to receive EBRT only, MR-HIFU only, or combined treatment with EBRT followed by MR-HIFU. During a follow-up period of 6 months, patients will be contacted at eight time points to retrieve information about their level of pain, QoL, and the occurrence of (serious) adverse events. The primary outcome of the trial is pain response at 14 days after start of treatment. Secondary outcomes include pain response at 14 days after trial enrolment, pain scores (daily until the 21st day and at 4, 6, 12 and 24 weeks), toxicity, adverse events, QoL, and survival. Cost-effectiveness and cost-utility analysis will be conducted. Discussion The FURTHER trial aims to evaluate the effectiveness and cost-effectiveness of MR-HIFU—alone or in combination with EBRT—compared to EBRT to relieve CIBP. The trial will be performed in six hospitals in four European countries, all of which are partners in the FURTHER consortium. Trial registration The FURTHER trial is registered under the Netherlands Trials Register number NL71303.041.19 and ClinicalTrials.gov registration number NCT04307914. Date of trial registration is 13–01-2020.

Background: The reasons behind low adherence to the Mediterranean diet (Med-diet) are still not entirely known. We aimed to evaluate the effect of biological (i.e., sex-related) and psycho-socio-cultural (i.e., gender-related) factors on Med-diet adherence. Methods: Baseline Med-diet adherence was measured using a self-administered questionnaire among adults with ischemic heart disease (IHD) from the EVA (Endocrine Vascular Disease Approach) study. A multivariable analysis was performed to estimate the effect of sex- and gender-related factors (i.e., identity, roles, relations, and institutionalized gender) on low adherence. Results: Among 366 participants (66 ± 11 years, 31% women), 81 (22%) adults with low adherence demonstrated higher rates of diabetes, no smoking habit, lower male BSRI (Bem Sex Role Inventory) (median (IQR) 4.8 (4.1 to 5.5) vs. 5.1 (4.5 to 5.6) and p = 0.048), and higher Perceived Stress Scale 10 items (PSS-10) (median (IQR) 19 (11 to 23) vs. 15 (11 to 20) and p = 0.07) scores than those with medium-high adherence. In the multivariable analysis, only active smoking (odds ratio, OR = 2.10, 95% confidence interval, CI 1.14 to 3.85 and p = 0.017), PPS-10 (OR = 1.04, 95% CI 1.00 to 1.08, and p = 0.038) and male BSRI scores (OR = 0.70, 95% CI 0.52 to 0.95, and p = 0.021) were independently associated with low adherence. Conclusions: Male personality traits and perceived stress (i.e., gender identity) were associated with low Med-diet adherence regardless of the sex, age, and comorbidities. Therefore, gender-sensitive interventions should be explored to improve adherence in IHD.

We compared intima-media thickness (IMT) and the prevalence of plaques in the common carotid artery (CCA) and common femoral artery (CFA) in apparently healthy participants. This multicenter study included 322 participants (59.9% female; age 20-78 years, mean 52.1 ± 15.3 years) who underwent Echo-color Doppler examination of the CCA and CFA bilaterally. Prevalence and composition of plaque were recorded. A significant ( P.01) difference between mean CCA-IMT and mean CFA-IMT was detected (0.70 vs 0.73 mm). Plaque prevalence was significantly higher in the CFA compared to the CCA (40.7% vs 30.4%). Atherosclerotic plaques were found in both CFA and CCA in 46% of the cases, solely in CFA in 38%, and in CCA alone in 17%. The observed difference in plaque prevalence was even greater when only fibrolipid isolated plaques were considered (CFA 39.4% vs CCA 22.1%). In a healthy general population, atherosclerotic plaques were present in the CFA but not in the CCA in over one-third of the cases. Further studies must confirm whether ultrasonography of the CFA might be introduced in the screening protocols for cardiovascular risk assessment.

Purpose: The authors performed a preliminary study with blood-pool contrast-enhanced magnetic resonance angiography (MRA) in evaluating the degree of carotid artery stenosis and plaque morphology, comparing the diagnostic performance of first-pass (FP) and steady-state (SS) acquisitions with 64-slice computed tomography angiography (CTA) and using digital subtraction angiography (DSA) as the reference standard. Materials and methods: Twenty patients with ≥50% carotid artery stenosis at Doppler sonography underwent blood-pool contrast-enhanced MRA, CTA and DSA. Two independent radiologists evaluated MRA and CTA examinations to assess the degree of stenosis and characterise plaque morphology. Accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for FP, SS and CTA. The McNemar and Wilcoxon tests were used to determine significant differences (p0.05). Conclusions: Blood-pool contrast-enhanced MRA with SS sequences allow improved diagnostic evaluation of the degree of carotid stenosis and plaque morphology compared with FP and is substantially equal to CTA and DSA. © 2010 Springer-Verlag Italia Riassunto.

Magnetic resonance (MR) imaging-guided focused ultrasound is an alternative noninvasive method for reducing the pain in skeletal metastases. MR imaging-guided focused ultrasound ablation offers several key advantages over other noninvasive treatment modalities. This technology enables the performance of three-dimensional treatment planning with MR imaging and continuous temperature mapping of treated tissue by using MR thermometry, thereby enabling real-time monitoring of thermal damage in the target zone. The concentration of acoustic energy on the intact surface of cortical bone produces a rapid temperature increase that mediates critical thermal damage to the adjacent periosteum, the most innervated component of mature bone tissue. Such thermal ablation has been shown to be an extremely effective approach for pain management. Energy delivered during MR imaging-guided focused ultrasound ablation and accumulated inside the pathologic soft tissue of the metastases can create a variable amount of tissue necrosis. This technique has also a potential role in achieving local tumor control, allowing remineralization of trabecular bone or reduction in lesion size. The current report presents a detailed step-by-step guide for performing MR imaging-guided focused ultrasound ablation of bone metastases, including use of MR thermometry for monitoring treatment, protocol selection for simple palliation of pain or for local tumor control, and a description of imaging features of periosteal neurolysis or metastasis ablation. Two case studies are also presented: in the first, the technique provided palliation of pain in bone metastases, and in the second, the technique achieved tumor control as further proof of primary efficacy. MR imaging-guided focused ultrasound ablation is a promising method for successful palliation of bone metastasis pain and tumor control, because of the bony structure remodeling induced by thermo-related coagulative necrosis.

Massive pulmonary embolism (PE) is a cardiovascular emergency due to a substantial obstruction of the pulmonary vascular bed, resulting in rapid right heart failure with a potentially fatal outcome.We present the case of a 50-year-old woman with massive PE and recent trans-sphenoid surgery because of pituitary adenoma. An occluding embolus, arising from deep venous thrombosis of the lower limbs, was demonstrated in the right pulmonary artery with selective angiography and treated with selective loco-regional infusion of low-dose tenecteplase. To the best of our knowledge, this is the first case of selective administration of low-dose tenecteplase in the pulmonary artery with successful resolution of PE without the need for adjunctive interventional procedures.

Objectives: To optimize the image acquisition parameters for improved steady-state (SS) contrast-enhanced magnetic resonance angiography (CE-MRA) of the carotid arteries with gadobenate dimeglumine. Materials And Methods: An inversion recovery fast low-angle shot (IR-FLASH) sequence for ultrafast determination of the longitudinal relaxation rate R1 was first optimized on phantoms and tested against a routine variable repetition time (TR) spin echo sequence used as reference standard. Different combinations of flip angle (FA, between 6 and 14 degrees) and inversion time (between 134 and 9000 milliseconds) were evaluated to achieve the best trade off between speed and accuracy. The optimized sequence was thereafter used in vivo in 5 subjects to determine the time evolution of blood R1 at 1.5 T after administration of gadobenate dimeglumine at 0.1 mmol/kg bodyweight. An optimal FA for angiographic measurement was thereafter derived from the Ernst equation based on experimental values of R1 previously determined in vivo. Finally, steady-state CE-MRA examinations were performed in 20 subjects to evaluate the improved contrast achieved after optimization of the FA for maximal blood signal enhancement. Results: An ultrafast IR-FLASH sequence with a flip angle of 8 degrees and a properly defined set of inversion time values was shown to give in vitro R1 determinations that were in good agreement with those obtained using a routine, time consuming, variable-TR spin echo sequence. The use of this ultrafast IR-FLASH sequence in vivo allowed the blood signal behavior in the carotid arteries after gadobenate dimeglumine administration to be monitored. Using this sequence, the R 1 decreased from 8.7 ± 0.96 s -1 at 30 seconds after injection to 3.8 ± 0.24 s -1 at 10 minutes after injection. Based on these data for R 1, the optimal FA for SS CE-MRA was calculated to be 18 degrees for a gradient echo acquisition protocol with TR = 7.5 milliseconds, when gadobenate dimeglumine is used. Significantly higher blood signal to noise ratio was achieved on SS images acquired using a three-dimensional spoiled gradient echo sequence with a FA of 18 degrees than on corresponding images acquired with a FA of 35 degrees as used typically for intravascular blood pool contrast agents (52.5 ± 8.3 vs. 29.5 ± 6.0; P < 0.05, Mann-Whitney U test). Conclusion: Detailed experimental knowledge of the in vivo R 1 behavior of blood after gadobenate dimeglumine injection and appropriate modification of the acquisition parameters enables improved signal intensity enhancement on steady-state CE-MRA of the carotid arteries. © 2011 by Lippincott Williams & Wilkins.

This was a prospective, multicenter study designed to evaluate the utility of MDCT in the diagnosis of coronary artery disease (CAD) in patients scheduled for elective coronary angiography (CA) using different MDCT systems from different manufacturers. Twenty national sites prospectively enrolled 367 patients between July 2004 and June 2006. Computed tomography (CT) was performed using a standardized/optimized scan protocol for each type of MDCT system (> or =16 slices) and compared with quantitative CA performed within 2 weeks of MDCT. A total of 284 patients (81%) were studied by 16-slice MDCT systems, while 66 patients (19%) by 64-slice MDCT scanners. The primary analysis was on-site/off-site evaluation of the negative predictive value (NPV) on a per-patient basis. Secondary analyses included on-site evaluation on a per-artery and per-segment basis. On-site evaluation included 327 patients (CAD prevalence 58%). NPV, positive predictive value (PPV), sensitivity, specificity, and diagnostic accuracy (DA) were 0.91 (95% CI 0.85-0.95), 0.91 (95% CI 0.86-0.95), 0.94 (95% CI 0.89-0.97), 0.88 (95% CI 0.81-0.93), and 0.91 (95% CI 0.88-0.94), respectively. Off-site analysis included 295 patients (CAD prevalence 56%). NPV, PPV, sensitivity, specificity, and DA were 0.73 (95% CI 0.65-0.79), 0.93 (95% CI 0.87-0.97), 0.73 (95% CI 0.65-0.79), 0.93 (95% CI 0.87-0.97), and 0.82 (95% CI 0.77-0.86), respectively. The results of this study demonstrate the utility of MDCT in excluding significant CAD even when conducted by centers with varying degrees of expertise and using different MDCT machines.

This study was performed to validate a highresolution whole-body magnetic resonance angiography (MRA) protocol with parallel imaging and biphasic administration of a single bolus of contrast agent in the preliminary assessment of systemic atherosclerotic burden in patients referred for endovascular procedures. Forty patients referred for endovascular treatment of atherosclerotic disease of the carotid arteries (n=23), peripheral vessels (n=14) or aorta (n=3) on the basis of previous clinical and diagnostic examinations underwent high-resolution whole-body MRA at 1.5 T with 3D spoiled gradient recalled echo (GRE) sequences, featuring parallel imaging acquisition technique with ×2 acceleration factor. Sixty-eight surface coil elements and a four-station imaging protocol were employed. Biphasic intravenous administration of a paramagnetic contrast agent [gadolinium benzyloxyproprionic- tetraacetic acid (Gd-BOPTA)] was performed with the following protocol: 10 ml at a speed of 1 ml/s followed by further 10 ml at a speed of 0.5 ml/s. For image analysis, the arterial system was divided into 42 segments for evaluation. The presence or absence of atherosclerotic lesions was evaluated by two observers in consensus; segments were classified as having clinically significant disease (≥50% stenosis or an aneurysmal dilatation) or no significant disease (

To prospectively evaluate accuracy of gadobenate dimeglumine-enhanced magnetic resonance (MR) mammography for depiction of synchronous contralateral breast cancer in patients with newly diagnosed unilateral breast cancer or high-risk lesions, with histologic analysis or follow-up as reference.The study had ethics committee approval; all patients provided written informed consent. One hundred eighteen consecutive women (mean age, 52 years) with unilateral breast cancer or high-risk lesions and negative findings in the contralateral breast at physical examination, ultrasonography, and conventional mammography underwent gadobenate dimeglumine-enhanced 1.5-T MR mammography. Transverse three-dimensional T1-weighted gradient-echo images were acquired before and at 0, 2, 4, 6, and 8 minutes after gadobenate dimeglumine administration (0.1 mmol per kilogram body weight). Breast Imaging Reporting and Data System (BI-RADS) was used to categorize breast density and the level of suspicion for malignant contralateral breast lesions. Results were compared with histologic findings. Sensitivity, specificity, accuracy, and positive and negative predictive values for contrast-enhanced MR mammography were evaluated.Contrast-enhanced MR mammography revealed contralateral lesions in 28 (24%) of 118 patients. Twenty-four lesions were detected in patients with dense breasts (BI-RADS breast density category III or IV). Lesions in eight (29%) of 28 patients were BI-RADS category 4; patients underwent biopsy. Lesions in 20 (71%) patients were BI-RADS category 5; patients underwent surgery. At histologic analysis, 22 lesions were confirmed as malignant; six lesions were fibroadenomas. No false-negative lesions were detected; none of the fibroadenomas were BI-RADS category 5. The sensitivity, specificity, accuracy, and positive and negative predictive values of contrast-enhanced MR mammography for depiction of malignant or high-risk contralateral lesions were 100%, 94%, 95%, 79%, and 100%, respectively. Follow-up findings (12-24 months) confirmed absence of contralateral lesions in 90 of 118 patients with negative contrast-enhanced MR mammographic findings in the contralateral breast.Contrast-enhanced MR mammography is accurate for detection of synchronous contralateral cancer or high-risk lesions in patients with newly diagnosed breast cancer or high-risk lesions.

Purpose To investigate the role of ferucarbotran-enhanced dynamic MR imaging using multishot spin-echo echo-planar sequence in the evaluation of hemodynamics of focal hepatic lesions. Materials and Methods Sixty-three focal hepatic lesions (24 benign and 39 malignant) from 53 consecutive patients who underwent both ferucarbotran-enhanced MR imaging and dynamic computed tomography (CT) were included in this study. MR imaging was performed with a 1.5-T scanner with a phased-array coil. T2-weighted multishot spin-echo echo-planar sequences (TR/TE = 1714–2813/80 msec) were obtained during a single breathhold before and 15, 60, 120, 180, and 600 seconds after intravenous injection of ferucarbotran. The enhancement patterns of lesions were classified into three categories by a study coordinator on the basis of dynamic CT images as hypervascular, hypovascular, and hemangioma type. The study coordinator created mean contrast-to-noise ratio of lesions vs. time curves for each enhancement pattern for quantitative analyses. Moreover, three radiologists separately and blindly reviewed MR images, and then assigned three confidence scores for the three enhancement patterns to each lesion. Sensitivity, specificity, and receiver operating characteristic analyses were performed. Results Quantitative analyses showed characteristic enhancement curves for each enhancement pattern. Mean sensitivities/specificities were 0.816/0.882, 0.897/0.863, and 0.800/0.989 for hypervascular, hypovascular, and hemangioma types, respectively. Mean areas under the receiver operating characteristic curve were 0.886 for hypervascular type and 0.913 for hypovascular type. Conclusion Ferucarbotran-enhanced dynamic MR imaging can be used to successfully characterize the hemodynamics of focal hepatic lesions. J. Magn. Reson. Imaging 2006. © 2006 Wiley-Liss, Inc.

To evaluate the possible role of multislice spiral computed tomography (MSCT) as the sole imaging examination in the preoperative assessment of potential donors undergoing adult-to-adult living donor liver transplantation (LDLT).Fifteen patients underwent MSCT with 0.5-second gantry rotation time. Pre- (4 X 2.5 mm collimation) and post-contrast (4 X 1 mm collimation) acquisitions during arterial and portal venous phases were performed after intravenous administration of 140 ml of non ionic contrast agent at 4-5 ml/s, with a delay time of 25 and 60 seconds, respectively. Pre-contrast scans with 80 and 140 kVp were acquired at the same level used to assess liver density. Real-time interaction with the post-contrast 3D data set was performed on a dedicated workstation to determine total and lobar liver volume, and to assess arterial and venous vascular anatomy.Steatosis was found in three patients, who as a consequence were excluded as possible candidates. MSCT correctly identified five cases of arterial anatomical variations: two cases of the right hepatic artery arising from the superior mesenteric artery, two cases of the common hepatic artery arising from the superior mesenteric artery and one case of the left hepatic artery arising from left gastric artery. In two cases portal trifurcation was considered a criterion for exclusion. A 4% error in the liver volume calculation was found at surgery, in no case considered significant. Two patients underwent surgery and three have been short-listed.MSCT enables complete preoperative evaluation of potential donors undergoing LDLT. Total and lobar volume determination provided accurate and reproducible information. MSCT enabled correct surgical planning without intra-operative complications. One of the limits of the technique was the poor visualization of the biliary anatomy with the need to perform an intraoperative cholangiography in all the patients.

The development of ultrasound contrast agents with excellent tolerance and safety profiles has notably improved liver evaluation with ultrasound (US) for several applications, especially for the detection of metastases. In particular, contrast enhanced ultrasonography (CEUS) allows the display of the parenchymal microvasculature, enabling the study and visualization of the enhancement patterns of liver lesions in real time and in a continuous manner in all vascular phases, which is similar to contrast-enhanced computed tomography (CT) and contrast-enhanced magnetic resonance imaging. Clinical studies have reported that the use of a contrast agent enables the visualization of more metastases with significantly improved sensitivity and specificity compared to baseline-US. Furthermore, studies have shown that CEUS yields sensitivities comparable to CT. In this review, we describe the state of the art of CEUS for detecting colorectal liver metastases, the imaging features, the literature reports of metastases in CEUS as well as its technique, its clinical role and its potential applications. Additionally, the updated international consensus panel guidelines are reported in this review with the inherent limitations of this technique and best practice experiences.

Purpose of our study was to determine the feasibility and accuracy of contrast enhanced Turbo-MRA (CE-MRA) in the evaluation of patients with carotid artery stenosis, using a dynamic technique with multiple acquisitions.37 patients with suspected carotid artery stenosis were studied with a 1.5 T magnet (Siemens Vision Plus) using, with a neck phased array coil, a dynamic tridimensional T1 weighted spoiled GRE (TR/TE/NEX: 3.8/1.4/1; Matrix = 110 x 160; FOV = 163 x 260 mm TA = 10 seconds for each sequence); 4 consecutive sequences were performed during the same breath hold, acquired after i.v. bolus injection with a power injector (Spectris, Medrad) of 15 ml of Gd-DTPA followed by 10 ml of saline solution (flow rate 2 ml/s). The beginning of the sequence coincided with the injection of Gd-DTPA. Images were reconstructed using a standard MIP algorithm, by selecting which of the sequences provided the highest enhancement. In all patients a DSA was also performed. Images were separately evaluated using conventional angiography as the gold standard and assessed for degree of stenosis by using NASCET criteria, and morphology of the plaque.CE-MRA correctly evaluated the degree of stenosis in 71 of the 74 patients, while overestimated the remaining 3 cases correctly evaluated by DSA. In 12 cases ulcerations were adequately demonstrated by one of the radiologist, while 11 on 12 were depicted by the other one. CE MRA allowed to detect tandem lesions of the internal carotid arteries (by both radiologists) in 13 of 74 carotids studied. Stenosis at the origin of the common carotid arteries were correctly detected in 9 cases. Sensitivity, specificity and accuracy were respectively of 98, 97 and 99%.In order to perform an optimal CE-MRA a dynamic technique must be performed to avoid venous filling. The possibility to use ultrafast imaging allows to selectively image the carotid arteries without jugular filling. The well known tendency to overestimate the degree of stenosis has not been found in this group of patients. CE-MRA is a rapid, reliable method to evaluate patients with suspected carotid artery stenosis. These results allow to consider dynamic CE-MRA as a valid method for direct imaging of the carotid arteries.

The role of MR imaging in the assessment of pancreatic adenocarcinoma is in identification, characterization and staging of the neoplastic lesion. Technique optimization is required in order to obtain high qualities images competitive with spiral CT. The choice of imaging protocol is strictly related to the available equipment as well as fast imaging capabilities. Contrast-enhanced study using breath-hold sequences is required if working at high field strength with high gradient performance; on mid-low field strength nonbreath-hold acquisition techniques, using respiratory compensation techniques, can be implemented. The use of fat saturation pulses may increase the sensitivity of MR in detecting pancreatic lesions. Other advantages of MR imaging are represented by the availability of additional noninvasive techniques for the evaluation of the biliary tree (MR-cholangiopancreatography) and splanchnic vessels (MR-angiography). Lesion identification is based on TIw sequences where the lesion appears hypointense compared with the surrounding pancreas; increased lesion-pancreas contrast is obtained when fat suppression is used. On dynamic studies following gadolinium injection, pancreatic tumors are hypovascular compared with surrounding normal pancreatic gland. Problems in correctly defining the size of the lesions may be encountered in patients presenting with inflammatory changes of the pancreatic parenchyma surrounding the carcinoma (epineoplastic pancreatitis). For lesion characterization MRI is not able to characterize focal pancreatic lesions, allowing a differential diagnosis between pancreatic cancer and focal hypertrophic chronic pancreatitis. Even the use of MR-cholangiopancreatography is not helpful for characterizing focal pancreatic masses. MR imaging is accurate in local staging (assessment of peripancreatic fat infiltration) thanks to the higher contrast resolution, but in vascular staging and in the evaluation of lymphnodal involvement it suffers the same limitations as computed tomography. Future perspective are represented by the use of magnetic resonance angiography for the evaluation of vascular encasement and the use of specific contrast agents for lymphadenopathy. Identification of hepatic metastases with MRI has been proven to be high, with sensitivity and specificity comparable to CT. The use of liver-specific contrast agents (either positive or negative) is becoming almost routine and it is proving to further improve the diagnostic value of MRI.

We analyze the peculiar technical features of virtual endoscopy obtained with volume rendering.Our preliminary experience is based on virtual endoscopy images from volumetric data acquired with spiral CT (Siemens, Somatom Plus 4) using acquisition protocols standardized for different anatomic areas. Images are reformatted at the CT console, to obtain 1 mm thick contiguous slices, and transferred in DICOM format to an O2 workstation (Silicon Graphics, Mountain View CA, USA) with processor speed of 180 Mhz, 256 Mbyte RAM memory and 4.1 Gbyte hard disk. The software is Vitrea 1.0 (Vital Images, Fairfield, Iowa), running on a Unix platform. Image output is obtained through the Ethernet network to a Macintosh computer and a thermic printer (Kodak 8600 XLS).Diagnostic quality images were obtained in all the cases. Fly-through in the airways allowed correct evaluation of the main bronchi and of the origin of segmentary bronchi. In the vascular district, both carotid strictures and abdominal aortic aneurysms were depicted, with the same accuracy as with conventional reconstruction techniques. In the colon studies, polypoid lesions were correctly depicted in all the cases, with good correlation with endoscopic and double-contrast barium enema findings. In a case of lipoma of the ascending colon, virtual endoscopy allowed to study the colon both cranially and caudally to the lesion. The simultaneous evaluation of axial CT images permitted to characterize the lesion correctly on the basis of its density values.The peculiar feature of volume rendering is the use of the whole information inside the imaging volume to reconstruct three-dimensional images; no threshold values are used and no data are lost as opposite to conventional image reconstruction techniques. The different anatomic structures are visualized modifying the reciprocal opacities, showing the structures of no interest as translucent. The modulation of different opacities is obtained modifying the shape of the opacity curve, either using pre-set curves or in a completely independent way. Other technical features of volume rendering are the perspective evaluation of the objects, color and lighting. In conclusion, volume rendering is a promising technique to elaborate three-dimensional images, offering very realistic endoscopic views. At present, the main limitation is represented by the need of powerful and high-cost workstations.

MR cholangiopancreatography (MRCP) is a new noninvasive imaging technique for the study of biliopancreatic disorders, providing projectional images of the biliary tree and pancreatic duct without any contrast agent.We used different sequences, with both breath-hold and nonbreath-hold techniques, to acquire MRCP images, first based on GE and then on FSE sequences. FSE images provide higher SNR and are less susceptible to artifacts (metal objects, motion and blood flow artifacts). At the Department of Radiology of the University of Rome La Sapienza, we acquired MRCP images with non breath-hold, 3D fat-suppressed TSE sequences (TR = 3000-2000, TE 700, turbo factor 128) optimized on a .5T magnet with 15 mT/m gradients. No patient preparation or sedation was required, although antiperistaltic drugs and oral administration of tap water were preferred. Four hundred and thirty patients were examined, all of them with an indication to conventional cholangiography.MRCP depicted the whole common bile duct and the first-order intrahepatic branches in all the normal cases. Its accuracy in identifying biliary obstruction level and site was 100%, versus 94.6% in characterizing its cause. MRCP had 96.3% diagnostic accuracy in choledocholithiasis, with some false positives and false negatives caused by: 1) small stones missed on MIP reconstructions; 2) signal loss due to complete CBD obstruction by stones; 3) pneumobilia; 4) differential diagnosis between small stones and air bubbles. The main role of MRCP in benign strictures is to provide a detailed map of the biliary tract for better treatment planning. In particular, MRCP is extremely useful in hepaticojejunostomy patients, where ERC is not indicated because of postoperative anatomical changes. Both conventional MRI and MRCP are important in malignant strictures to identify the lesion and to characterize and stage it. Finally, MR pancreatography is very useful to follow up chronic pancreatitis patients because it shows Wirsung duct strictures and dilatations, intraductal filling defects and, in some cases, the communication between the pseudocyst and the pancreatic duct.MRCP combined with conventional MRI can completely replace CT and ERCP in bilio-pancreatic disorders.

We investigated MR cholangiopancreatography (MRCP) findings in patients with pancreatic conditions, which are mainly diagnosed based on US and CT morphologic findings. Sixty-three patients were submitted to MRCP using a .5T magnet. MRCP was performed with non-breath-hold fat-suppressed 3D turbo spin echo sequences (TR = 3000 ms, TE = 700 ms, ETL = 128, NEX = 6) with 3 min acquisition time. For better depiction of Wirsung duct and secondary ducts in the last 11 patients, a high resolution technique with a 128 x 256 matrix, 8 NEX and 8 min 36 s acquisition time was developed. MRCP images were studied both on MIP reconstructions and on single slices as well as T1- and T2-weighted TSE axial images. The diagnosis was compared with endoscopy, percutaneous procedure or CT findings in all cases. A hypointense focal mass was observed on T1-weighted TSE images in 39 pancreatic carcinoma patients (100%) and parenchymal atrophy was shown in 13 patients (33%); a sudden obstruction of the Wirsung duct was observed in 16 cases (41%) with homogeneous dilatation in 11 cases (28%). A tapered appearance of the distal Wirsung duct was demonstrated in 19 chronic pancreatitis patients, with diffuse patchy signal changes in 12 patients (63%); bead-like appearance of the Wirsung duct was shown in 6 cases (32%) and pseudocysts in 7 cases (37.3%). MRCP is the only imaging method demonstrating pancreatic conditions between carcinoma and pancreatitis, similarly to ERCP.

The aim of our work was to investigate Magnetic Resonance Cholangiography (MRC) capabilities in detecting common bile duct (CBD) stones in patients to be submitted to laparoscopic cholecystectomy. MRC was performed as the only preoperative imaging modality in 45 selected patients (16 men and 29 women; age range: 28-72 years, mean age: 54.4 years) before laparoscopic cholecystectomy. MRC images were obtained with 3D Turbo Spin-Echo sequences (TR = 3000 ms, TE = 700 ms, echo train length = 128) with an acquisition time of 5 min 48 sec. Diagnostic confirmation was obtained in all the patients at intraoperative cholangiography. When a stone was detected, it was removed by transcystic or transcholedochal approach. Eighteen of 45 patients (40%) had CBD stones. MRC correctly demonstrated 16 of 18 stones, with 88.9% sensitivity, 100% specificity, 100% positive predictive value, 90% negative predictive value and 95.6% accuracy. Despite the good results we obtained with MRC, this technique cannot be proposed as a screening method to be performed in all the patients candidate to laparoscopic cholecystectomy because of its high cost and of the limited number of MR units available. In conclusion, only selected patients should be submitted to MRC before laparoscopic cholecystectomy.

This work was aimed at investigating the CT anatomy in patients submitted to Nissen's fundoplication. Forty patients (mean age: 61 years) with peptic esophagitis (9 patients), refractory gastroesophageal (GE) reflux (11 patients) and hiatal hernia (20 patients) were examined. CT studies were performed with a third generation unit (CT Pace, General Electric, USA) with the patients in the prone position, after Gastrovison (Schering) and barium paste administration. In 34 patients, CT demonstrated surgery-related anatomical changes, such as the presence of a soft tissue mass at the distal third of the esophagus. In 4 patients, functional incompetence of the fundoplication (3 patients) and a recurrent hyatal hernia (1 patient) were demonstrated. In conclusion, CT studies performed with a dedicated technique permitted the accurate assessment of the anatomy of the GE junction after Nissen's fundoplication. In our study, CT demonstrated the presence of postoperative fluid collections and specific signs related to fundoplication incompetence. Our results suggest a possible application of CT to the postoperative follow-up of the patients submitted to Nissen's fundoplication, with a complementary role that of to endoscopy and functional exams.

Magnetic resonance pyelography (MRP) is a new noninvasive method which demonstrates dilated urinary tracts with no need of contrast agent injection. This study was aimed at technique optimization, using new fast sequences with high intrinsic contrast, to demonstrate the urinary tract in obstructive uropathy patients. Twelve consecutive patients and 4 healthy volunteers were included in this prospective study; all the exams were performed with a high gradient power 0.5-T unit using T2- weighted turbo SE sequences, acquired three-dimensionally on the coronal plane. Obstructive uropathy was caused in 9 patients by neoplastic lesions, in 2 by postoperative strictures and in 1 by inflammatory tissue. In all patients MRP depicted the dilated urinary tract optimally, with good morphological detailing and the accurate assessment of both level and cause of obstruction. In the healthy volunteers, the absence of dilatation did not permit the complete visualization of the urinary tract. To conclude, MRP is a new technique which permits high-quality imaging of the urinary tract. Further studies are needed to assess its actual potentials and clinical role.

Magnetic Resonance cholangiopancreatography (MRCP) is a new noninvasive imaging technique for the visualization of the biliary ducts with cholangiographic images similar to those obtained with ERCP and PTC, but with no contrast agent injection. In this paper, we report on our preliminary experience with a mild-field strength magnet (0.5T) and TSE sequences, acquired with respiratory compensation. The images were compared with ERCP images to compare diagnostic quality. Eighteen patients were examined: the biliary tract was dilated because of chronic pancreatitis in 3 patients, because of choledochal stones in 9, of carcinoma of the pancreatic head in 4, of lymphadenopathy in one patient. A patient submitted to choledochoduodenostomy and waiting for cholecystectomy was also examined. MRCP was performed with a superconductive magnet at 0.5T. Volumetric images on coronal planes were acquired; a T2-weighted TSE sequence (TR = 5000, TE = 244, Nex = 4, ETL = 45; acquisition time = 14 min 10 s) with respiratory compensation was also performed. The images were reconstructed on coronal planes at different angles with the MIP algorithm. All patients were then submitted to ERCP and one to PTC. In all patients, the intrahepatic biliary tracts, hepatic ducts and choledochus were completely demonstrated, with very good image quality in 16 cases and good in 2. The Wirsung duct was always visualized in all the 9 patients with mild to severe dilation. In conclusion, MRCP can be considered a valuable alternative to diagnostic ERCP. Further studies are necessary for better assessment of the potential advantages and pitfalls of this technique.

Magnetic resonance imaging of the pancreas has been, limited by a series of artifacts with a resulting poor contrast to noise ratio. Nevertheless, technological progress has allowed to reduce not only scanning time but also the number of artifacts, by increasing the number of excitations and matrix size. Moreover, tissue contrast can now be modified. In our study performed on 5 normal volunteers and 20 patients with different pancreatic diseases conditions, fast SE sequences with and without fat suppression were used, with an overall increase in contrast to noise ratio. In all patients MR images allowed the accurate definition of the lesions: in 8 adenocarcinoma patients the lesion could be depicted, including the 2 lesions CT had poorly demonstrated. Also in the 3 patients with endocrine tumors, MRI depicted small tumors which were later confirmed at surgery. This new protocol makes MRI a very sensitive and accurate tool in the study of neoplastic and inflammatory pancreatic diseases thus, MRI is not only a complementary tool to CT but an even better study technique. In particular, its higher contrast to noise ratio allows a dramatic improvement in the depiction of small solid lesions, especially those not altering pancreatic outline. This study proves that MRI, when adequately performed, is a very accurate tool to study, in a very short time, the pancreas and peripancreatic region, yielding much better results than all the other diagnostic imaging modalities.

MR phlebography was recently proposed as a possible alternative to contrast venography in the detection of deep venous thrombosis. We focused our work on the study of the pelvic veins since it is at this level that contrast venography and the other noninvasive techniques, i.e., phlebography, impedance plethysmography and US, exhibit their major limitations. Thirty patients underwent MR phlebography: 13 of them had a diagnosis of DVT of the pelvic venous district and the other 17 had negative results for this condition. All the patients were also examined with color-Doppler US at the pelvis and legs. In all the patients submitted to MR phlebography, thrombosis site and presence were demonstrated, with diagnostic information also on its extent and adhesion to vein wall. To conclude, MR phlebography can provide contrast venography-like images in a noninvasive way, with high accuracy (100% sensitivity and 90% specificity) especially in the pelvic district where the limitations of other techniques are more apparent. Larger series of patients must be studied to assess the actual role of MR phlebography in the patients with DVT or at high risk for this condition.

The authors have developed a hypermedia program for creating a tutorial of CT and MR anatomy of the upper abdomen. The program was created on a Mcintosh computer, with the Supercard software: it is made up of a series of windows, each of them containing images, texts, schematic representations and sound. Moreover, each window contains buttons which are activated with the mouse and allow different kinds of function, all created by the authors to be displayed. In particular, navigation buttons allow the users to move in the program either sequentially or non-linearly, according to their needs. The possibility of obtaining information and schematic representations is given by specific buttons. There are also multiple buttons hidden in the images which, when activated, allow the name of the selected organ to be displayed. In conclusion, this program can be especially helpful since it allows different data sets to be integrated to provide the user with complete information. Moreover, the program allows learning to be controlled, that is the user to be informed on timing and methods for more effective studying.

This retrospective and observational cohort study investigated chest computed tomography (CT) findings, cycle threshold (Ct) values in RT-PCR of SARS-CoV-2 and secondary infection occurrence to predict prognosis in COVID-19 patients. At hospital admission, CT findings and Ct values were collected. Microbiology tests performed after 48 hours from hospitalization were reviewed. According to in-hospital mortality, patients were grouped into non-survivors and survivors. Among 283 patients evaluated, in-hospital mortality rate was 13.8% (39/283). Secondary infection occurrence was 15.2% (43/283). Cut-off values for CT score13.5 (AUC=0.682 p=0.0009) and for Ct23.4 (AUC=0.749, p0.0001) were predictive of death. Super-additive and synergic effects between high CT score plus secondary infection occurrence as well as between high CT score plus low Ct values affecting patient's outcome were observed. Chest CT score and Ct values in RT-PCR of SARS-CoV-2 could have a combination role for severity stratification of COVID-19 patients.

The early identification of pathogenic mechanisms is essential to predict the incidence and progression of cardiomyopathies and to plan appropriate preventive interventions. Noninvasive cardiac imaging such as cardiac computed tomography, cardiac magnetic resonance, and nuclear imaging plays an important role in diagnosis and management of cardiomyopathies and provides useful prognostic information.Most molecular factors exert their functions by interacting with other cellular components, thus many diseases reflect perturbations of intracellular networks. Indeed, complex diseases and traits such as cardiomyopathies are caused by perturbations of biological networks. The network medicine approach, by integrating systems biology, aims to identify pathological interacting genes and proteins, revolutionizing the way to know cardiomyopathies and shifting the understanding of their pathogenic phenomena from a reductionist to a holistic approach.In addition, artificial intelligence tools, applied to morphological and functional imaging, could allow imaging scans to be automatically analyzed to extract new parameters and features for cardiomyopathy evaluation. The aim of this review is to discuss the tools of network medicine in cardiomyopathies that could reveal new candidate genes and artificial intelligence imaging-based features with the aim to translate into clinical practice as diagnostic, prognostic, and predictive biomarkers and shed new light on the clinical setting of cardiomyopathies. The integration and elaboration of clinical habits, molecular big data, and imaging into machine learning models could provide better disease phenotyping, outcome prediction, and novel drug targets, thus opening a new scenario for the implementation of precision medicine for cardiomyopathies.

To assess the intraoperative neuroimaging findings in patients treated with transcranial MR-guided focused ultrasound (tcMRgFUS) thalamotomy using 1.5T equipment in comparison with the 48-h follow-up.Fifty prospectively enrolled patients undergoing unilateral tcMRgFUS thalamotomy for either medication-refractory essential tremor (n = 39) or Parkinson tremor (n = 11) were included. Two radiologists evaluated the presence and size of concentric lesional zones (zone I, zone II, and zone III) on 2D T2-weighted sequences acquired intraoperatively after the last high-energy sonication and at 48 h. Sonication parameters including number of sonications, delivered energy, and treatment temperatures were also recorded. Differences in lesion pattern and size were assessed using the McNemar test and paired t test, respectively.Zones I, II, and III were visualized in 34 (68%), 50 (100%), and 44 (88%) patients, and 31 (62%), 50 (100%), and 45 (90%) patients after the last high-energy sonication for R1 and R2, respectively. All three concentric zones were visualized intraoperatively in 56-58% of cases. Zone I was significantly more commonly visualized at 48 h (p 0.001). Diameter of zones I and II and the thickness of zone III significantly increased at 48 h (p 0.001). Diameters of zones I and II measured intraoperatively demonstrated significant correlation with thermal map temperatures (p ≤ 0.001). Maximum temperature significantly correlated with zone III thickness at 48 h. A threshold of 60.5° had a sensitivity of 56.5-66.7% and a specificity of 70.5-75.5% for thickness 6 mm at 48 h.Intraoperative imaging may accurately detect typical lesional findings, before completing the treatment. These imaging characteristics significantly correlate with sonication parameters and 48-h follow-up.• Intraoperative T2-weighted images allow the visualization of the zone I (coagulation necrosis) in most of the treated patients, while zone II (cytotoxic edema) is always detected. • Lesion size depicted with intraoperative transcranial MRgFUS imaging correlates well with procedure parameters. • Intraoperative transcranial MRgFUS imaging may have a significant added value for treating physicians.

Magnetic resonance-guided focused ultrasound is one of the emerging non-invasive technologies offering both image guidance and thermal monitoring. In recent years transcranial application of this technology is starting to impact heavily the neuroscience field. We present here the imaging protocol and the technological methods successfully used with a transcranial magnetic resonance-guided focused ultrasound system certified for clinical treatments of functional neurological disorders, integrated for the first time with a 1.5T magnetic resonance scanner. Compared to the body radiofrequency coil (the one commonly used with transcranial magnetic resonance-guided focused ultrasound system integrated with 3T magnetic resonance scanners), the use of a dedicated two channel coil enabled a signal-to-noise ratio gain up to five times higher.

MRI-guided focused ultrasound surgery (MRgFUS) is a minimally invasive treatment guided by the most sophisticated imaging tool available in today's clinical practice. Both the imaging and therapeutic sides of the equipment are based on non-ionizing energy. This technique is a very promising option as potential treatment for several pathologies, including musculoskeletal (MSK) disorders. Apart from clinical applications, MRgFUS technology is the result of long, heavy and cumulative efforts exploring the effects of ultrasound on biological tissues and function, the generation of focused ultrasound and treatment monitoring by MRI. The aim of this article is to give an updated overview on a "new" interventional technique and on its applications for MSK and allied sciences.