Iranian Journal of Radiology
Year:2015 | Volume:12 | Issue:2|Papers Count:26

Hemangiomas of the sinonasal tract are rare, and because these lesions lack the typical signs or symptoms, they can be confused with other malignant conditions. We report a case of cavernous hemangioma of the maxillary sinus in a 68-year-old man that was completely resected by endoscopic sinus surgery. Although computed tomography (CT) and magnetic resonance imaging (MRI) showed several enhancing areas within the tumor, the substantial bone erosion and remodeling made it difficult to differentiate this cavernous hemangioma from other expansile maxillary sinus lesions. We present the CT and MR findings of this lesion and discuss the differential diagnoses and potential therapeutic approaches.

Primary musculoskeletal lymphoma presenting as monoarthritis is very rare. Less than 20 cases have been reported. The ultrasound appearances have not been reported to date. We present a young female of primary knee lymphoma with synovial involvement presenting as monoarthritis. The ultrasound and MRI features are discussed.

Background: The goal of ultrasound guided fine-needle aspiration (USFNA) is to obtain most cellular specimen that represents the nodule. However, there is substantial variability in specimen cellularity depending on the obtaining techniques. While performing USFNA, it is not clear whether the needle tip should be placed at hypovascular or hypervascular site of the nodule to obtain more cells for cytological analysis.Objectives: The aim of the study was to assess whether USFNA of the hypovascular or hypervascular site of a thyroid nodule would reveal more cells for cytological analysis.Patients and Methods: Twenty-three consecutive patients with solid thyroid nodules larger than 2 cm were aspirated under color Doppler sonography guidance. First pass was from the hypovascular site and the second pass from the hypervascular site. The aspirates were scored from 1-3 by cytologist according to number of cell groups.Results: When only hypervascular site was used, adequate sampling was limited to 65% of the cases. When both sites were evaluated together, overall adequate sampling was 91%. Adding a sample from the hypervascular site to hypovascular aspirate increased the adequate sampling by 8%. The highest pathological score was achieved when both hypo- and hypervascular site aspirates were evaluated together.Conclusions: The aspirates from the hypovascular and hypervascular sites of solid nodules are complementary and should be performed consecutively.

Hydatid disease (HD) is a parasitic infection that is most commonly caused by the larval stage of Echinococcus granulosus. Unusual location for this disease can cause diagnostic and therapeutic problems. We herein report a case of sacrococcygeal HD at an unusual location in a 30-year-old woman. She was evaluated using computed tomography (CT) imaging and magnetic resonance imaging (MRI) after the demonstration of the lucent bone lesion on plain pelvic radiography. There was an expansile lytic mass without contrast enhancement suggesting a cystic mass in the sacrococcygeal region. Medical history revealed that she had undergone surgery for liver HD and the serological test results were diagnostic for HD. In light of this, no surgery was carried out for this cystic mass and she was followed with the diagnosis of sacrococcygeal HD.

Calcifying aponeurotic fibroma (CAF) is a rare, benign fibroblastic tumor that typically occurs in the palms of the hands and soles of the feet, in children and adolescents. Due to its infiltrative nature, this tumor can mimic malignancy on preoperative magnetic resonance imaging (MRI) and has a predilection for local recurrence. There are very few reports in the literature that describe features of CAF on MRI, especially those arising in the foot. We present an unusual case of a CAF affecting the dorsum of the foot in a four-year-old boy.

Intraluminal small bowel hematoma has been rarely reported in children, as a rare cause of small bowel obstruction. We present a case of an intraluminal ileal hematoma presenting as small bowel obstruction in a child. Computed Tomography (CT) indicated a large intraluminal hyperdense lesion in the distal ileum as the cause of small bowel obstruction. Abdominal ultrasonography (US) showed an echogenic mass-like lesion with multiple septa in the distal ileum. Small bowel obstruction due to a complicated cystic mass was provisionally diagnosed. Histopathologic examination of the resected mass suggested a submucosal ileal hematoma. Although intraluminal small bowel hematoma is rare in children, it can present as an intraluminal cystic mass and should be considered as a rare cause of small bowel obstruction. The US and CT findings of submucosal ileal hematoma could be useful for the diagnosis of such cases in the future.

Background: Transrectal ultrasound guided biopsy of the prostate is the most common modality used to diagnose prostate cancer.Objectives: The aim of this study was to evaluate the optimal number of cores at prostate biopsy, which have the most diagnostic value with least adverse effects.Patients and Materials: Transrectal ultrasonography (TRUS) guided biopsy was performed in 180 patients suspicious for prostate cancer due to either abnormal rectal examination or elevated PSA. The patients were divided randomly into three groups of six-core, twelve-core and eighteen-core biopsies. The detection rate of prostate cancer in each group with the rate of post biopsy urinary infection and prostatitis were compared.Results: Prostate cancer was diagnosed in 8 (13.3%), 21 (35%) and 24 (40%) patients in six, twelve and eighteen core biopsy groups, respectively. Urinary tract infection and prostatitis occurred in 17 (28.3%), 23 (38.3%) and 35 (58.3%) patients in six, twelve and eighteen core biopsy groups, respectively. Considering the detection rate of prostate cancer, there was a significant difference between 6 and 12 core biopsy groups (P=0.006) and 12-core biopsies detected more cases of prostate cancer, but there was no significant difference between 12 and 18 core biopsy groups (P=0.572). Considering the infection rate, there was no significant difference between 6 and 12 core biopsy groups (P=0.254), but there was a significant difference between 12 and 18 core biopsy groups (P=0.028) and infectious complications occurred more frequently in 18-core biopsy group.Conclusions: The best balance between detection rate of prostate cancer and infectious complications of biopsies achieved in twelve-core biopsy protocol. Twelve-core biopsy enhances the rate of prostate cancer detection with minimum adverse effects.

The presence of tumor thrombus in the right atrium is frequently the result of direct intraluminal extension of infra-diaphragmatic malignancy into the inferior vena cava (IVC) or supradiaphragmatic carcinoma into the superior vena cava (SVC). Right atrial tumor thrombus with extension into both SVC and IVC has not been reported in the literature. We present a patient who presented with symptoms of right atrial and SVC obstruction. Imaging revealed presence of a thrombus in the right atrium, extending to the SVC and IVC, with the additional findings of a left adrenal mass and multiple liver lesions. The histopathological examination of the right atrial mass revealed metastatic adenocarcinoma cells. The patient was given a presumptive diagnosis of metastatic adenocarcinoma, most likely adrenal in origin, with multiple hepatic lesions suspicious for metastasis. The clinical outcome of the patient was not favorable; the patient succumbed before the adrenal mass could be confirmed to be the primary tumor. This case highlights that in patients manifesting with extensive cavoatrial thrombus as, the existence of primary carcinoma should be considered especially in the adrenal cortex or in the lung.

Symptomatic laryngeal chondrometaplasia is rare. To the best of our knowledge, there are only few case reports on laryngeal chondrometaplasia. The imaging appearance of this uncommon disease is even more rarely described. There are only two case reports describing its appearances in computed tomography (CT) and magnetic resonance imaging (MRI). Ultrasound (US) features have not been reported so far. This case report is to show the US, CT and MRI features of this disease entity to stress the role of imaging in this disease.

Background: Susceptibility-weighted imaging (SWI) is extremely sensitive in the detection of superparamagnetic iron oxide (SPIO) nanoparticle-labeled cells. However, no study has compared molecular imaging for stem cell detection using SWI and other MRI pulse sequences.Objectives: This study aims to assess the sensitivity of SWI in detecting SPIO nanoparticle-labeled, human bone marrow-derived mesenchymal stem cells (SPIO-hMSCs) compared with that of T2- and T2*-weighted imaging (T2WI and T2*WI, respectively) in a phantom and in vivo study in rats.Materials and Methods: A phantom was prepared with various cell concentrations. In one normal rat, SPIO-hMSCs were implanted directly through burr holes into both caudate putamens, while in three rats without and six rats with photothrombotic infarction, 2.5×105/ml SPIO-hMSCs were infused into the ipsilateral internal carotid artery (ICA). T2WI, T2*WI, and SWI findings were compared for dark regions representing SPIO-hMSCs.Results: SWI and T2*WI detected 15 mL of 13 SPIO-hMSCs/mL and 15 mL of 27 SPIO-hMSCs/mL in the phantom, respectively and 3 mL of 333 SPIO-hMSCs/mL and 3 mL of 167 SPIO-hMSCs/mL in the normal rat brain (direct implantation). In the normal rat brain (ICA infusion), one of the three cases showed numerous foci of dark regions dispersed throughout the brain on T2*WI and SWI. Dark regions surrounded the infarcts in all six infracted rat brains. The dark region was most prominent on SWI, followed by T2*WI and T2WI in all six rats (P=0.002). Implanted SPIO-hMSCs were confirmed using Prussian blue staining.Conclusions: SWI is the most sensitive in the detection of SPIO-hMSCs, with the dark regions representing SPIO-hMSCs being more prominent on SWI than on T2*WI and T2WI.

A mobile caecum and ascending colon is an uncommon congenital disorder, and it is even rarer as the cause of an acute abdomen during childhood. This report presents the case of a 6-year-old boy with acute gangrenous appendicitis with a mobile caecum and ascending colon. Data from the surgical course, as well as laboratory and imaging studies, were acquired and carefully examined. Emergency ultrasound (US) was performed and revealed no signs of appendicitis in the right lower quadrant. Serial imaging study, including non-enhanced computed tomography (CT), was performed. An imaging study identified epigastric appendicitis with mobile caecum. Surgery was executed under general anesthesia with a median incision extending from the epigastrium to the suprapubic region. The caecum was mobile and placed in the right epigastric area, next to the left lobe of the liver and gallbladder. The gangrenous appendix was discovered posterior to the caecum and transverse colon, enlarging to the left upper quadrant. Appendectomy was executed, the gangrenous appendix was confirmed pathologically, and the patient was released 4 days later. In the US, if there are unusual clinical findings or no findings in patients with abdominal pain, CT is beneficial in determining the location of the caecum and appendix and preventing misdiagnosis in children.

Juvenile fibroadenoma is an uncommon histologic variant of fibroadenoma that frequently shows a remarkable and rapid growth. The development of a carcinoma within a fibroadenoma, either in situ or invasive, is a rare condition. We encountered a 36-year-old woman with a palpable mass in the right breast. The radiologic findings were indicative of a fibroadenoma in the breast. Sonographic guided biopsy using a 14G core needle revealed the presence of ductal carcinoma in situ (DCIS) within the juvenile fibroadenoma. Focal excision was performed and the patient underwent radiation therapy in the right breast after surgery.

Pancreatic neuroendocrine tumors (PNET) are uncommon pancreatic neoplasms, accounting for 1-2% of all pancreatic tumors. However, they have a better prognosis and long-term survival compared to exocrine pancreatic cancer. PNETs can be divided into functional or non-functional based upon whether or not they excrete active substances relevant to specific clinical syndromes. Skeletal muscle metastasis is also a rare condition and differentiation between a primary soft tissue sarcoma and metastatic carcinoma is difficult without biopsy. Thus, skeletal muscle metastases from pancreatic neoplasms are exceedingly rare, with only a few cases reported in the literature. We present a 34-year-old man with metastatic pancreatic neuroendocrine carcinoma that was initially thought to be a primary soft tissue tumor. Pathology and immunohistochemistry demonstrated the tumor to be a metastasis from a pancreatic neuroendocrine carcinoma. A brief review of the literature on this subject is also presented.

Nuchal translucency (NT) measurements in the first trimester screening between 11 and 14 weeks’ gestation are regarded as a clear marker for aneuploidies. The presence of a thickened NT, even if the karyotype is normal, can be associated with structural abnormalities. Having an abnormal screening of NT, parents and physicians could face dilemma over abortion particularly in a case of IVF/ICSI fetuses. Measurement of the NT thickness combined with biochemical markers has a false-positive rate of 5%. Hereby we present six cases of chromosomally normal fetuses with an increased NT thickness in the first trimester, a normal karyotype and normal follow-up scans, who had a good prognosis for a normal early childhood. This report may help increase the confidence of couples who are reluctant to terminate the pregnancy.

Bladder calculi, a rare condition in the pediatric population, occur most commonly as a result of either migration from the kidney or urinary stasis in the bladder. We report the case of a 3-year-old boy with recurrent urinary tract infections (UTI) secondary to bladder calculi formation on the sutures from a previous herniorrhaphy.A 3-year-old boy with previous history of herniorrhaphy presented with recurrent episodes of urinary tract infection, resistant to antibiotic therapy. Physical examination was unremarkable. Ultrasonography (US) showed an echogenic fixed intra-luminal lesion in the bladder. Cystoscopic evaluation was performed and confirmed presence of calculi forming around several permanent silk sutures fixed to the bladder wall. The patient undergone cystotomy and the calculi were resected. The stone analysis revealed 80% uric acid calculi. The final diagnosis was of bladder calculi due to remnant suture from past herniorrhaphy.

Background: Transvaginal Ultrasonography is a noninvasive and inexpensive medical imaging tool used for the diagnosis of various diseases.Objectives: To identify an effective method to identify high-risk patients for developing malignancy after molar evacuation.Patients and Methods: A prospective serial assessment of 19 patients with gestational trophoblastic disease was performed. Clinical and laboratory data, transvaginal ultrasound and Doppler findings were evaluated the day before evacuation. They were followed-up in the first week after evacuation and every two weeks during the next two months, then every month until the sixth month.Results: Ovarian theca lutein cysts (P=0.018) (among pre-evacuation factors) and first week ultrasound (P=0.02) can help in detecting high-risk patients. Even though, when b-hCG titer is not available in a high-risk patient, post evacuation myometrial involvement (P=0.005) is a useful sign for detecting persistency.Conclusions: Some ultrasonographic features of molar pregnancy have capability to predict malignancy in the course of disease.

Background: The present data show a global increase in the rate of cardiovascular disease. Cardiac CT angiography has developed as a fast and non-invasive cardiac imaging modality following the introduction of multi-slice computed tomogaraphy.Objectives: The aim of this study was to measure the radiation dose to the thyroid and pelvis regions in patients undergoing cardiac CT angiography using the Care Dose 4D method of 64-slice scanner.Patients and Methods: Eighty-one patients (41 males and 40 females) who were diagnosed with suspected coronary artery disease and were referred to Golestan Hospital, Imaging Department were recruited. Inclusion criteria were based on the protocol of multi-slice CT coronary angiography. The radiation dose to the thyroid and pelvis regions was measured using thermo luminescent dosimeters (TLDs).Results: The mean radiation dose to the thyroid in male and female subjects was 0.32 mSv and 0.41 mSv, respectively (P=0.032) (total mean, 0.36 mSv). The mean radiation dose to the pelvis in male and female subjects was 81 mSv and 112 mSv, respectively (P=0.026) (total mean, 96.5 mSv), Conclusions: The total mean radiation dose to the thyroid and gonads was 0.36 mSv, and 96.5 mSv, respectively for the subjects. These values were high for one organ in a single study. Gender can affect the radiation dose to the thyroid and gonads. This can be attributed to the anatomical characteristic differences of the male and female subjects.

Enterovesical fistula is an abnormal communication between the bladder and the intestine. The accurate localization of leakage is important for accurate treatment planning. Some imaging techniques can not demonstrate the fistula; therefore, choosing the appropriate imaging technique is necessary. CT enterography (CTE) is a new technique for evaluation of the small bowel and the entire abdomen. CTE examination with multi-detector CT (MDCT) enables us to get excellent quality reformatted images with high spatial resolution. We report a patient with neobladder and enteroneovesical fistula. We showed the exact location of the fistula and its’ association with the bowels and neobladder by CTE. The aim of this report is to show that CTE can be a new and effective modality in the detection of enteroneovesical fistulas and to discuss the efficacy of CTE in the detection and evaluation of enterovesical fistula referring to the literature. In conclusion, CTE may be a useful, sensitive, effective, and non-invasive technique for the evaluation of enteroneovesical fistula, leakage from the anastomose sides, and other extraintestinal complications such as urinary tract obstruction or abscess formation.

Recurrent sigmoid volvulus is a clinical entity characterized by recurrent episodes of partial or complete sigmoid volvulus. Although it is commonly seen in the elderly, it can be occasionally seen in younger patients. Patients with recurrent partial sigmoid volvulus are relatively asymptomatic or present with mild abdominal pain. Early diagnosis and treatment is essential to prevent conversion to acute gangrenous volvulus. We present a case of recurrent partial sigmoid volvulus in association with eventration of diaphragm in a 26-year-old man.

Hyperparathyroidism is an endocrine abnormality that frequently causes diffuse osteopenia in the bones. Osteosclerosis is a rare phenomenon in adults with primary hyperparathyroidism since the usual skeletal manifestation is generalized osteopenia. We describe a patient with generalized osteosclerosis in the jaws and skull in association with primary hyperparathyroidism, while the other skeletal bones had normal or decreased density.

A 22-year-old woman presented with acute left-sided pleuritic chest pain and dyspnea 6 days after surgery for revision of the stenotic central aortopulmonary shunt. She had a history of tetralogy of Fallot (TOF), pulmonary valve stenosis, ventricular septal defect and major aortopulmonary collateral artery. Her Waterston shunt was placed when she was 5 years old and stented and re-dilated after stenosis. Acute pulmonary thromboemboli (PTE) was suspected and pulmonary perfusion scan was performed with 4 mCi 99m Technetium labeled macroaggregated albumin. The left lung was globally hypoperfused with evident uptake in the brain, renal parenchyma and thyroid. SPECT images revealed a segmental wedge-shaped peripheral defect in the posterior segment of the left upper lobe. The scan was interpreted as acute/chronic PTE or vascular abnormality. CT angiography excluded PTE; nevertheless the patient was treated with a therapeutic dose of heparin changed to warfarin and was discharged with improvement of the symptoms. Pulmonary artery angiography was not performed.

Aortoenteric fistula is a rare but significant clinical entity associated with high morbidity and mortality if remain untreated. Clinical presentation and imaging findings may be subtle and prompt diagnosis can be difficult. Herein, we present a patient who initially presented with abdominal pain and computed tomography showed an aortic aneurysm compressing duodenum without any air bubbles. One month later, the patient presented with gastrointestinal bleeding and computed tomography revealed air bubbles within aneurysm. With a diagnosis of aortoenteric fistula, endovascular aneurysm repair was carried out. This case uniquely presented the computed tomography findings in progression of an aneurysm to an aortoenteric fistula.

Dear Editor: Intrauterine Contraceptive Devices (IUDs) are a form of long-term, reversible, and safe contraception, which are commonly used worldwide. A regular medical check-up is necessary to determine its position within the uterus, up to six months after IUD insertion. The complications of translocation have a wide range from displacement of IUD in myometrium to uterine perforation. Predisposing factors which are considered to be associated with dislocation include postpartum insertion, inexperienced operator insertion technique, and position of the uterus (1). Clinical history, physical examination, and transvaginal ultrasonography (US) are common procedures for the evaluation of IUDs and related complications.

Background: Evaluation of the craniofacial bones is the oldest method to measure the facial proportion ratio in orthodontics.Objectives: The purpose of this study was to evaluate the effect of emboss enhancement on the reliability of landmark identification in digital lateral cephalometric images.Materials and Methods: Ten digital lateral cephalograms were selected from the archive of an oral and maxillofacial radiology center. Using DIGORA software, these images were saved in two formats; common images and 3D emboss images. On these images, 32 skeletal, dental, and soft tissue landmarks were marked at least twice with a 2-week interval by four observers (two radiologists and two orthodontists). In order to determine the position of the marked landmarks (in x and y coordinates), a software was designed. The statistical analysis was performed in SPSS software and the reliability of each observer was obtained by means of intraclass correlation coefficient (ICC).Results: In three skeletal landmarks [Orbit (Or), condyl top (Cond), and pogonion (Pog)], the enhancement caused significant reduction in the reliability, and in four skeletal [Anterior Nasal Spine (ANS), B, A, and Basion (Ba)], two dental (U1 root, L1 incisal), and one soft tissue landmark (Menton soft tissue), the enhancement increased the reliability of landmark detection between the two phases of the study. Totally, ICC of embossed images in both x and y coordinates were greater than the typical images, but the difference was not statistically significant. However, the effect of enhancement on the improvement of the reliability of landmark identification was higher in the x-axis than the y-axis.Conclusions: Using embossed images is only effective in increasing the reliability of detection in a few numbers of cephalometric landmarks.

Background: In 1996, Donovan and colleagues represented a scoring system for better prediction of Hirschsprung disease (HD).Objectives: Our objective was to devise another scoring system that uses a checklist of radiologic and clinical signs to determine the probability of HD in suspicious patients.Patients and Methods: In a diagnostic accuracy study, 55 children with clinical manifestations of HD that referred to a training hospital from 1998 to 2011 were assessed. A checklist was used to evaluate the items proposed by contrast enema (CE), based on six subscales, including transitional zone, rectosigmoid index (RSI), irregular contractions in aganglionic region, cobblestone appearance, filling defect due to fecaloid materials and lack of meconium defecation during the first 48 hours after birth. The patients were classified as high score and low score. Sensitivity, specificity, positive predictive value and negative predictive value of our scoring system were calculated for identifying HD, in comparison with pathologically proved or ruled out HD.Results: Of the 55 patients, 36 (65.4%) cases had HD and 19 (34.6%) cases were without HD. In the HD group, 32 patients showed high scores and four patients had low scores. The sensitivity and specificity of our diagnostic scoring system were 88.9% (95% CI: 78.6% - 99.1%) and 84.2% (95% CI: 68.7% - 100%), respectively. Moreover, positive predictive value (PPV) and negative predictive value (NPV) were 91.4% (95% CI: 82.1% - 100%) and 80% (95% CI: 62.5% - 97.5%), respectively.Conclusions: Our new scoring system of CE is a useful diagnostic method in HD. If a patient’s score is high, that patient is highly suspicious to HD and reversely, when one’s score is low, the patient presents a reduced probability to be diagnosed with HD.

Background: Ultrasmall superparamagnetic iron oxide nanoparticles have been used as a blood pool contrast agent for magnetic resonance angiography and perfusion studies. Linear relationship between signal intensity (SI) and nanoparticle concentration is essential for perfusion measurement.Objectives: The aim of this study was to investigate the effect of different flip angles on maximum SI and the linear relationship between SI and different concentrations of iron oxide nanoparticles using T1-weighted Turbo-FLASH (fast low angle shot) inversion recovery sequence to find the optimum flip angle for perfusion measurement.Materials and Methods: This in vitro study was performed using carboxydextran coated iron oxide nanoparticles with 20 nm hydrodynamic size. Different concentrations of nanoparticles between 0 and 500 mmol Fe/L were prepared. MR imaging was performed using T1-weighted Turbo-FLASH inversion recovery sequence. Applied flip angles were 10-45o (interval of 5o). Then the maximum SI resulted by each concentration of nanoparticles was measured. Linear relationship between SI and nanoparticle concentration was evaluated regarding square correlations of 0.95 and 0.99. Coil non-uniformity was considered to obtain accurate SI of each image.Results: The maximum SI was obtained at the highest applied flip angle (45o). The linear relationship between SI and nanoparticle concentration was seen up to 112.21 and 98.83 mmol Fe/L for the short (10o) and the long (45o) flip angles, respectively (R2=0.95). These values were reduced up to 48.54 and 42.73 mmol Fe/L for these flip angles with R2 of 0.99.Conclusions: The maximum SI will be increased at higher flip angles with non-linear relationship between SI and nanoparticle concentration. The result shows that an increase in the flip angle leads to a decrease in the range of the linearity. The optimum flip angle which is suitable for perfusion measurement was obtained at 10o for our imaging parameters and sequence. The results of this study may be used in in vivo perfusion measurements.