Abstract
Aims
Liver fibrosis and cirrhosis are a consequence of a Fontan physiology, and determine prognosis. It is unclear whether non-invasive assessment of liver pathology is helpful to provide ...clinically relevant information. The aims of this study were to assess the spectrum of Fontan-associated liver disease (FALD) and usefulness of non-invasive methods to assess biopsy confirmed liver fibrosis.
Methods and results
Hepatic screening of consecutive patients consisted of a blood panel, ultrasonography, elastography, contrast-enhanced magnetic resonance imaging (MRI)/computed tomography (CT) scan, and liver biopsy (scored with Fontan specific fibrosis scores and collagen proportionate area; CPA). Fibrosis parameters, varices, ascites, and splenomegaly were measured on imaging. Thirty-eight of 49 referred patients (27 ± 6.6 years, 73.7% male) underwent the complete screening protocol. Liver fibrosis on biopsy was present in all patients, and classified as severe (Stages 3–4) in 68%. Median CPA was 22.5% (16.9–29.5) and correlated with individual fibrosis scores. ELF® and liver stiffness were elevated, but MELD-XI scores were low in all patients. Fibrosis severity neither correlated to ELF® and liver stiffness, nor to (semi-) quantitative fibrosis parameters on MRI/CT. Varices were present in 50% and hyperenhancing nodules in 25% of patients, both independent of fibrosis stage, but varices were associated with higher CPA values.
Conclusion
The FALD spectrum includes both hepatic congestion and severe fibrosis, with signs of portal hypertension and hyperenhancing nodules as significant manifestations. Routine imaging, transient elastography, and serum biomarkers are unable to accurately assess severity of liver fibrosis in this cohort. Future research should focus on validating new diagnostic tools with biopsy as the reference standard.
A variety of vascular liver disorders can induce hepatocellular tumors. They may be related to portal venous deprivation, venous outflow obstruction, or arterial diseases. Their common feature is an ...imbalance between hepatic arterial and portal venous blood flow leading to an increased hepatic arterial inflow. Consequently, hepatocellular tumors may arise, most commonly focal nodular hyperplasia-like lesions but hepatocellular adenomas and hepatocellular carcinoma may be seen as well. This article will review the most common vascular liver diseases associated with hepatocellular nodules (Budd–Chiari syndrome, congenital portosystemic shunt, hereditary hemorrhagic telangiectasia, and portal cavernoma). For each condition, imaging findings will be described as well as the differential diagnosis and the diagnostic clues.
Budd–Chiari syndrome (BCS) is defined by clinical and laboratory signs associated with partial or complete impairment of hepatic venous drainage in the absence of right heart failure or constrictive ...pericarditis. Primary BCS is the most frequent type and is a complication of hypercoagulable states, in particular myeloproliferative neoplasms. Secondary BCS involves tumor invasion or extrinsic compression. Most patients present with chronic BCS including a non-cirrhotic, dysmorphic, chronic liver disease with various degrees of fibrosis deposition. Acute BCS is rare, and patients present with hepatomegaly, ascites, and hepatic insufficiency. The diagnosis is based on imaging. Imaging features include (1) direct signs, in particular occlusion or compression of the hepatic veins and/or the inferior vena cava and venous collaterals and (2) indirect signs, in particular morphological changes in the liver with hypertrophy of the caudate lobe and delayed nodule formation. Ultrasound and magnetic resonance imaging are the gold standard for diagnosis. The aim of this review is to provide an overview of the role of imaging in the diagnosis of BCS.
Purpose
To evaluate the ability of dual-energy CT angiography (DECTA) in metal artifact reduction in patients with treated intracranial aneurysms by comparing DECTA-based virtual monoenergetic ...extrapolations (VMEs) and mixed images (MI).
Methods
Thirty-five patients underwent prospectively a dual-source DECTA (Somatom Force, Siemens Medical Solutions, Forchheim, Germany) after aneurysm repair. A total number of 40 aneurysms (23 treated by coil embolization and 17 treated by surgical clipping) were analyzed. Mixed images (equivalent to a conventional single-energy CT angiography) were compared to VMEs at 75, 95, and 115 keV. Artifact severity was assessed quantitatively by measuring the mean attenuation value and standard deviation within regions of interest placed in the most hypodense coil or clip artifact area. Artifact severity score and contrast vessel score were also assessed qualitatively by two independent blinded readers.
Results
In those aneurysms treated by surgical clipping, quantitative and qualitative analyses showed significant reduction of artifacts on VMEs compared to MI with the best compromise being obtained at 95 keV in order to keep an optimal vessel contrast in the adjacent vessel. In those aneurysms treated by coil embolization, there was no significant reduction of artifacts both on quantitative and qualitative analyses.
Conclusion
Dual-source DECTA was helpful in order to reduce clip artifacts on VMEs with the optimal adjacent vessel visualization obtained at 95 keV, whereas this technique was not helpful in aneurysms treated by coiling.
BackgroundMultidisciplinary team (MDT) meetings aim to optimize patient management. We evaluated the impact of MDT discussions on the management and diagnosis of focal pancreatic lesions in a single ...tertiary center.MethodsAll patients with an initial diagnosis of solid or cystic pancreatic lesion discussed in our institution's MDT meeting on pancreatic diseases between January 1, 2020, and December 31, 2021, were included. The impact of MDT discussion on patient management, defined as a modification of the initially proposed therapeutic plan after MDT discussion, as well as the criteria leading to this modification, were the primary outcomes. Impact on diagnosis was the secondary outcome.ResultsA total of 522 patients were included. Of these, 185 (35.4%) and 337 (64.6%) had an initial diagnosis of cystic or solid lesion, respectively. The most common referral query was regarding the management plan (349/522; 66.9%). Endoscopy was the procedure most often proposed before MDT discussion (109/522; 20.9%). Overall, the MDT discussion led to modification of the management plan in 377/522 patients (72.2%), with a statistically significant difference between cystic and solid lesions (63.2% vs. 77.2%; P<0.001). Management modifications were mainly driven by revision of cross-sectional radiological images. MDT discussion led to modification of the diagnosis in 92/522 patients (17.6%), with a significant difference regarding cystic lesions (35.7% vs. 7.7%; P<0.001).ConclusionMDT discussion impacts the management of patients with cystic and solid pancreatic lesions, leading to a modification of the initially proposed management in two-thirds of them, mainly through revision of cross-sectional imaging.
Brain multimodal monitoring including intracranial pressure (ICP) and brain tissue oxygen pressure (PbtO
) is more accurate than ICP alone in detecting cerebral hypoperfusion after traumatic brain ...injury (TBI). No data are available for the predictive role of a dynamic hyperoxia test in brain-injured patients from diverse etiology.
To examine the accuracy of ICP, PbtO
and the oxygen ratio (OxR) in detecting regional cerebral hypoperfusion, assessed using perfusion cerebral computed tomography (CTP) in patients with acute brain injury.
Single-center study including patients with TBI, subarachnoid hemorrhage (SAH) and intracranial hemorrhage (ICH) undergoing cerebral blood flow (CBF) measurements using CTP, concomitantly to ICP and PbtO
monitoring. Before CTP, FiO
was increased directly from baseline to 100% for a period of 20 min under stable conditions to test the PbtO
catheter, as a standard of care. Cerebral monitoring data were recorded and samples were taken, allowing the measurement of arterial oxygen pressure (PaO
) and PbtO
at FiO
100% as well as calculation of OxR (= ΔPbtO
/ΔPaO
). Regional CBF (rCBF) was measured using CTP in the tissue area around intracranial monitoring by an independent radiologist, who was blind to the PbtO
values. The accuracy of different monitoring tools to predict cerebral hypoperfusion (i.e., CBF < 35 mL/100 g × min) was assessed using area under the receiver-operating characteristic curves (AUCs).
Eighty-seven CTPs were performed in 53 patients (median age 52 41-63 years-TBI, n = 17; SAH, n = 29; ICH, n = 7). Cerebral hypoperfusion was observed in 56 (64%) CTPs: ICP, PbtO
and OxR were significantly different between CTP with and without hypoperfusion. Also, rCBF was correlated with ICP (r = - 0.27; p = 0.01), PbtO
(r = 0.36; p < 0.01) and OxR (r = 0.57; p < 0.01). Compared with ICP alone (AUC = 0.65 95% CI, 0.53-0.76), monitoring ICP + PbO
(AUC = 0.78 0.68-0.87) or ICP + PbtO
+ OxR (AUC = 0.80 (0.70-0.91) was significantly more accurate in predicting cerebral hypoperfusion. The accuracy was not significantly different among different etiologies of brain injury.
The combination of ICP and PbtO
monitoring provides a better detection of cerebral hypoperfusion than ICP alone in patients with acute brain injury. The use of dynamic hyperoxia test could not significantly increase the diagnostic accuracy.
Hepatobiliary phase (HBP) images can discriminate between benign and malignant liver lesions, but it is unclear if this approach can be used in patients with Budd-Chiari syndrome (BCS). Thus, we ...aimed to assess the diagnostic utility of HBP images in patients with BCS.
This retrospective study included all patients admitted to our institution with a diagnosis of BCS and focal liver lesions on hepatobiliary contrast agent-enhanced MR imaging (HBCA-MRI) from 2000 to 2019. MR images were reviewed by 2 radiologists blinded to the diagnosis of the lesions. Patient and lesion characteristics were recorded, focusing on HBP imaging features.
Twenty-six patients (mean 35 ± 11 years old 13–65; 21 women 81% 35 ± 12 years old 13–65; 5 men 19% 36 ± 10 years old 19–44) with 99 benign liver lesions and 12 hepatocellular carcinomas (HCCs) were analyzed. Patients with HCC were significantly older than those with benign lesions (mean 50 ± 10 vs. 33 ± 9 years old, p = 0.003), with higher alpha-fetoprotein (AFP) levels (3/4 75% vs. 1/22 5% with AFP >15 ng/ml, p <0.001). Homogeneous hypointense signals were identified on HBP in 14 lesions, including 12/12 (100%) HCCs, and 2/99 (2%) benign lesions (p <0.001). Most benign liver lesions showed either peripheral (n = 52/99 53%) or homogeneous hyperintensity (n = 23/99 23%) on HBP. Lesions with signal hypointensity on HBP in patients with AFP serum levels >15 ng/ml were all HCCs.
Most benign lesions showed homogeneous or peripheral hyperintensity on HBP images while all HCCs were homogeneously hypointense. HBP images are helpful to differentiate between benign lesions and HCCs and outperform other sequences. They should be systematically acquired for the characterization of focal lesions in patients with BCS.
Hepatobiliary phase imaging is an approach that has recently been shown to discriminate between benign and malignant lesions in the liver. However, it was not known whether this imaging approach could be used effectively in patients with Budd-Chiari syndrome. Herein, we have shown that hepatobiliary phase imaging appears to be useful for differentiating between benign and malignant liver lesions in patients with Budd-Chiari syndrome.
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•Most benign lesions showed homogeneous or peripheral hyperintensity on hepatobiliary phase images.•All HCCs were homogeneously hypointense on hepatobiliary phase images.•Hepatobiliary images are helpful to differentiate between benign lesions and HCCs in patients with Budd-Chiari syndrome.•In patients with AFP serum levels >15 ng/ml, lesions with signal hypointensity on hepatobiliary phase were all HCCs.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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•Washout depicted in close to 30% of benign nodules in patients with Budd-Chiari syndrome.•Non-invasive diagnosis of HCC cannot be applied to patients with Budd-Chiari ...syndrome.•Ancillary imaging findings help differentiate benign nodules and HCC.•Alpha-fetoprotein serum rate remains low in patients with benign nodules.
It remains unclear whether the classic imaging criteria for the non-invasive diagnosis of hepatocellular carcinoma (HCC) can be applied to chronic vascular liver diseases, such as Budd-Chiari syndrome (BCS). Herein, we aimed to evaluate the diagnostic value of washout for the discrimination between benign and malignant lesions in patients with BCS.
This retrospective study included all patients admitted to our institution with a diagnosis of BCS and focal lesions on MRI from 2000 to 2016. MRI images were reviewed by 2 radiologists blinded to the nature of the lesions. Patient and lesion characteristics were recorded, with a focus on washout on portal venous and/or delayed phases. Lesions were compared using Chi-square, Fisher’s, Student’s t or Mann-Whitney U tests.
A total of 49 patients (mean age 35 ± 12 years; 34 women 69% and 15 men 31%) with 241 benign lesions and 12 HCC lesions were analyzed. Patients with HCC were significantly older (mean age 44 ± 16 vs. 33 ± 9 years, p = 0.005), with higher alpha-fetoprotein (AFP) levels (median 16 vs. 3 ng/ml, p = 0.007). Washout was depicted in 9/12 (75%) HCC, and 69/241 (29%) benign lesions (p <0.001). A total of 52/143 (36%) lesions ≥1 cm with arterial hyperenhancement showed washout (9 HCC and 43 benign lesions). In this subgroup, the specificity of washout for the diagnosis of HCC was 67%. Adding T1-w hypointensity raised the specificity to 100%. A serum AFP >15 ng/ml was associated with 95% specificity.
Washout was observed in close to one-third of benign lesions, leading to an unacceptably low specificity for the diagnosis of HCC. The non-invasive diagnostic criteria proposed for cirrhotic patients cannot be extrapolated to patients with BCS.
Washout on MRI is depicted in a significant proportion of benign nodules in patients with Budd-Chiari syndrome (BCS), limiting its value for the differentiation between benign and malignant lesions. Criteria proposed for the non-invasive diagnosis of hepatocellular carcinoma in patients with cirrhosis cannot be extrapolated to patients with BCS. Additional imaging findings and patient characteristics, including alpha-fetoprotein serum level, can help determine the probability of a nodule being HCC in patients with BCS.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
•Nodules in Budd-Chiari syndrome and Fontan-associated liver disease show differences on magnetic resonance imaging at diagnosis and during follow-up.•Nodules in Budd-Chiari syndrome exhibit more ...changes in size and imaging features over time.•Almost half of the nodules in Fontan-associated liver disease do not show any changes follow-up.
To compare the magnetic resonance imaging (MRI) features of benign liver lesions developed on Budd-Chiari syndrome (BCS) with those on Fontan-associated liver disease (FALD) and to describe their long-term progression.
Patients with BCS or FALD who underwent MRI between 2010 and 2020 were retrospectively included. MRI features of nodules (≥ 5 mm) at baseline and at final follow-up were reviewed. The final diagnosis of benign lesion was based on a combination of clinical and biological data and findings at follow-up MRI examination.
Two-hundred and thirty benign liver lesions in 39 patients with BCS (10 men, 29 women; mean age, 36 ± 11 SD years; age range: 15–66 years) and 84 benign lesions in 14 patients with FALD (2 men, 12 women; mean age, 31 ± 10 SD years; age range: 20–48 years) were evaluated. On baseline MRI, BCS nodules were more frequently hyperintense on T1-weighted (183/230, 80%) and hypointense on T2-weighted (142/230; 62%) images, while FALD nodules were usually isointense on both T1- (70/84; 83%) and T2-weighted (64/84; 76%) images (all P< 0.01). Most lesions showed arterial phase hyperenhancement (222/230 97% vs. 80/84 95% in BCS and FALD, respectively; P = 0.28) but wash-out was more common in BCS (64/230 28% vs. 9/84 11%; P < 0.01). At follow-up, changes were more frequent in BCS nodules with more frequent disappearance (P < 0.01), changes in size, signal intensity on T2-weighted, portal, and delayed phase, and in the depiction of washout and capsule (all P ≤ 0.03).
MRI features of benign lesions are different at diagnosis and during the course of the disease between BCS and FALD. Changes in size and MRI features are more frequent in benign lesions developed in BCS.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
The purpose of this study was to describe the unenhanced CT appearance of the appendix in adults with cystic fibrosis.
Among adults with cystic fibrosis undergoing follow-up at our hospital, 71 ...patients (35 women, 36 men; mean age, 33 years; range, 18-59 years) without a history of appendectomy or current abdominal pain were prospectively included in this study and underwent unenhanced abdominopelvic MDCT. Two readers coded visualization of the appendix, measured the diameter of the appendix, and described the attenuation of its contents in relation to the intestinal wall. They also coded the presence of colonic wall redundancy, pancreatic fatty replacement, and cirrhosis. Lung transplant status and CFTR gene mutations were recorded. Analysis of variance, linear regression analysis, Student t test, and Pearson test were used.
The appendix was detected in all patients. The mean diameter was recorded as 10.6 ± 3.5 mm. The mean diameter was larger when the appendix contained hyperattenuating material (p = 0.001). There was no association between diameter and the other coded CT findings (p = 0.076-0.466), transplant status (p = 0.788), or CFTR mutation (p = 0.078). In 75% of the patients, the appendix contained hyperattenuating material with a higher proportion in homozygous ΔF508 mutation (p = 0.029) without any significant effect of the other CT features (p = 0.056-0.392), or transplant status (p = 1.000).
The appendix is larger in adults with cystic fibrosis than in those without it and appears hyperattenuating at unenhanced CT in 75% of patients, more commonly in those with ΔF508 homozygous mutation.
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