Current Medical Imaging - Volume 17, Issue 10, 2021

Finding spurious thrombocytopenia is a common occurrence in clinical practice, whereas pseudothrombocytosis is a very uncommon event. Despite several technical advancements in automated haematology analysers, a careful peripheral smear examination remains standard examination in cases of discrepancy of platelet counts. We are presenting a case of betathalassaemia intermedia who had pseudothrombocytosis, which was falsely labelled as myeloproliferative neoplasm before the patient visited our haematology clinic.

Background: Although imaging findings along with patients’ clinical history may give a clue for the etiology of a pulmonary lesion, the differentiation of benign pulmonary lesions from lung cancer could be challenging. Objective: The aim of this review article was to increase the awareness of carcinoma mimicking lung lesions. Methods: This paper was designed to illustrate rare pulmonary tumors and carcinoma mimickers with emphasis on radiologic-pathologic correlation. Pitfalls encountered on CT images and also false positivity of PET-CT scans were also presented. Conclusion: Several benign pulmonary lesions may grow in size on follow-up and some may show pathologic FDG (18F-fluorodeoxyglucose) uptake, which makes them indistinguishable from lung carcinoma by imaging. In addition, some slow-growing malignant lesions, such as carcinoid, may be false-negative on PET/CT scans.

Background: Post-operative pancreatic fistula (POPF) can be life-threatening, and gadoxetic acid-enhanced MRI is routinely performed in patients undergoing pancreatic surgery. However, previous reports have not investigated if gadoxetic acid-enhanced MRI can be used to predict POPF risk. Objective: This study aims to explore if gadoxetic acid-enhanced MRI can predict pancreatic fibrosis and the need for POPF treatment before surgery. Methods: We retrospectively analyzed gadoxetic acid-enhanced MR images from 142 patients who underwent pancreatic surgery between January 1, 2011, and April 30, 2018. Pre-dynamic signal intensity (SI) and values for the portal, transitional, and hepatobiliary phase standardized based on pre-dynamic study values were analyzed. The diameter of the main pancreatic duct (DMPD) was measured, and the degree of pancreatic fibrosis was classified as F0 – F3. We defined POPF higher than grade B as significant. Results: Odds ratios for combinations that led to any degree of fibrosis higher than grade B were defined as significant risk factors. The highest odds ratio was obtained for F0 vs. F1 – F3 (p = 0.038). DMPD (p < 0.001), pre-SI (p = 0.008), portal-SI/pre-SI (p < 0.001), transitional-SI/pre-SI (p < 0.001), and hepatobiliary-SI/pre-SI (p = 0.012) were significantly correlated with the presence of fibrosis. Moreover, the presence of fibrosis was best detected by DMPD (AUC = 0.777). Individual specificity values of transitional-SI/pre-SI and DMPD were 95.5% and 86.6%, respectively, and their combined specificity was 97.7%. Conclusion: The absence of pancreatic fibrosis is a risk factor for developing POPF higher than grade B. DMPD was the most useful diagnostic indicator for the presence of fibrosis among our analysis, and its specificity increased when combined with transitional-SI/pre-SI.

Objective: Differentiating glioblastoma (GBM) and solitary metastasis is not always possible using conventional magnetic resonance imaging (MRI) techniques. In conventional brain MRI, GBM and brain metastases are lesions with mostly similar imaging findings. In this study, we investigated whether apparent diffusion coefficient (ADC) ratios, ADC gradients, and minimum ADC values in the peritumoral edema tissue can be used to discriminate between these two tumors. Methods: This retrospective study was approved by the local institutional review board with a waiver of written informed consent. Prior to surgical and medical treatment, conventional brain MRI and diffusion-weighted MRI (b = 0 and b = 1000) images were taken from 43 patients (12 GBM and 31 solitary metastasis cases). Quantitative ADC measurements were performed on the peritumoral tissue from the nearest segment to the tumor (ADC1), the middle segment (ADC2), and the most distant segment (ADC3). The ratios of these three values were determined proportionally to calculate the peritumoral ADC ratios. In addition, these three values were subtracted from each other to obtain the peritumoral ADC gradients. Lastly, the minimum peritumoral and tumoral ADC values, and the quantitative ADC values from the normal-appearing ipsilateral white matter, contralateral white matter, and ADC values from cerebrospinal fluid (CSF) were recorded. Results: For the differentiation of GBM and solitary metastasis, ADC3 / ADC1 was the most powerful parameter with a sensitivity of 91.7% and specificity of 87.1% at the cut-off value of 1.105 (p < 0.001), followed by ADC3 / ADC2 with a cut-off value of 1.025 (p = 0.001), sensitivity of 91.7%, and specificity of 74.2%. The cut-off, sensitivity and specificity of ADC2 / ADC1 were 1.055 (p = 0.002), 83.3%, and 67.7%, respectively. For ADC3 – ADC1, the cut-off value, sensitivity, and specificity were calculated as 150 (p < 0.001), 91.7%, and 83.9%, respectively. ADC3 – ADC2 had a cutoff value of 55 (p = 0.001), sensitivity of 91.7%, and specificity of 77.4, whereas ADC2 – ADC1 had a cut-off value of 75 (p = 0.003), sensitivity of 91.7%, and specificity of 61.3%. Among the remaining parameters, only the ADC3 value successfully differentiated between GBM and metastasis (GBM 1802.50 ± 189.74 vs. metastasis 1634.52 ± 212.65, p = 0.022). Conclusion: The integration of the evaluation of peritumoral ADC ratio and ADC gradient into conventional MR imaging may provide valuable information for differentiating GBM from solitary metastatic lesions.

Background: Intrathyroidal ectopic thymus (IET) can be misdiagnosed as thyroid nodules. Purpose: The purpose of this study is to evaluate the sonoelastographic findings of IET in pediatric population. Methods: Twelve children who had been examined with ultrasound (US) and strain elastography between December 2012 and December 2019 were included in this retrospective study. The patients’ demographics and ultrasonographic findings, including the location, margin, shape, diameters, volume, structure, vascularity, and elastography values of the lesions were evaluated. Results: Twelve lesions were detected in 12 asymptomatic patients (3 females and 9 males) with a mean age of 4.67 ± 2.27 years. The most common location of the IET was in posterior part and middle third of thyroid, and the most common appearance on US was a well-defined, ovoid-shaped, and predominantly hypoechoic solid lesion with punctate/linear branching hyperechogenities. The lesions were mostly hypovascular on Doppler US. The mean strain ratio on elastography was found to be 1.10 ± 0.04. In the follow-up of 7 patients with available information, there was no significant change in size or appearance of IET on US. Conclusion: IET should be considered in the differential diagnosis of the lesions within the thyroid. The first step to accurately diagnose an IET is to consider it in the differential diagnosis. In addition to US, strain elastography findings can be used to distinguish IETs from papillary thyroid cancers which can have similar US appearance, and help avoid unnecessary biopsies.

Background: Primary cardiac angiosarcoma is a rare malignancy with high predilection to involve surrounding structures such as pulmonary metastases. We analysed the chest computed tomography (CT) imaging features of patients diagnosed with primary cardiac angiosarcoma with pulmonary metastases in this study. Methods: This study retrospectively reviewed 12 patients with confirmed primary cardiac angiosarcoma, out of which eight (all men) with pulmonary metastasis were included in the analysis. The patients’ age ranged from 17 to 74 (mean: 48) years. CT was performed in all patients with unenhanced, contrast-enhanced, and both scans were done in 1, 3 and 4 patients, respectively. Results: Nodular lesions were observed in 7 patients with multiple solid nodules observed in 6 out of 7 patients. A solitary solid nodule was found in the remaining patient in the upper lobe and apical segment of the right lung with a diameter of 11.7 mm. All solid nodules were distributed along with bronchovascular bundles in the lungs, and their maximum diameter ranged from 2.3 to 19.9 mm. Nodules larger than 10 mm in diameter were heterogeneously enhanced on contrast-enhanced CT images (5/8 patients), whereas those smaller than 10 mm were homogeneously enhanced (3/8 patients). Other imaging features, namely the tree-in-bud pattern, emphysema, pleural effusion, and mediastinal lymph node enlargement, were observed in 4, 3, 3, and 2 patients, respectively. Conclusion: CT enhancement features of pulmonary metastasis in patients with primary cardiac angiosarcoma depend on the size of pulmonary nodules, with larger ones being heterogeneous and smaller ones homogeneous. Other signs are less noticed.

Background: The fabella, which is generally located in the lateral head of the gastrocnemius muscle, is a sesamoid bone that articulates with the posterior face of the lateral femoral condyle. As traditional information, the prevalence of fabella is between 10–30% in the population and is usually present in both knees. Introduction: The objective of this study was to investigate the knee MRIs in the Eastern Anatolia Region of Turkey subjects in order to assess the prevalence of the fabella and analyse the differences between gender, age and laterality and its symmetry pattern. Methods: This study was a retrospective study in patients older than 18 years whose knee MRIs were taken between February 2014 and February 2016. In this study, a total of 531 patients (290 females and 241 males) were included. The radiographs were examined by two orthopedic surgeons and the fabella was located. Later, an expert radiologist made the final decision and confirmed the results. Results: The number of patients included in the study was 531. We detected os fabella in 59 (11.1%) patients. Of the 59 os fabella, 33 were in the right knee and 26 were in the left knee, 38 were female and 21 were male. Conclusion: In this study, we investigated the age and gender differences besides the prevalence and the symmetry pattern of the fabella in the Eastern Anatolia Region of Turkey’s population. Prevalence of the fabella was found to be 11.1% which is different than previously published studies.

Background: The need for accurate and timely detection of Intracranial hemorrhage (ICH) is of utmost importance to avoid untoward incidents that may even lead to death. Hence, this presented work leverages the ability of a pretrained deep convolutional neural network (CNN) for the detection of ICH in computed tomography (CT) brain images. Methods: Different frameworks have been analyzed for their effectiveness for the classification of CT brain images into hemorrhage or non-hemorrhage conditions. All these frameworks were investigated on the CQ500 dataset. Furthermore, an exclusive preprocessing pipeline was designed for both normal and ICH CT images. Firstly, a framework involving the pretrained deep CNN, AlexNet, has been exploited for both feature extraction and classification using the transfer learning method. Secondly, a modified AlexNet-Support vector machine (SVM) classifier is explored, and finally, a feature selection method, Principal Component Analysis (PCA), has been introduced in the AlexNet-SVM classifier model, and its efficacy is also explored. These models were trained and tested on two different sets of CT images, one containing the original images without preprocessing and another set consisting of preprocessed images. Results: The modified AlexNet-SVM classifier has shown an improved performance in comparison to the other investigated frameworks and has achieved a classification accuracy of 99.86% and sensitivity and specificity of 0.9986 for the detection of ICH in the brain CT images. Conclusion: This research has given an overview of a simple and efficient framework for the classification of hemorrhage and non-hemorrhage images. The proposed simplified deep learning framework also manifests its ability as a screening tool to assist the radiological trainees in the accurate detection of ICH.

Objective: The purpose of this study was to explore if the dimensions of the ischiofemoral space on MRI vary with changes in external femoral rotation in Ischifemoral Impingement patients relative to healthy control; if so, to determine the optimal diagnostic cutoff values of these dimensions in Ischifemoral Impingement. Methods: The study included 43 clinically confirmed Ischifemoral Impingement patients and 50 healthy volunteers. All subjects underwent hip MRI examinations with their hips externally rotated at 0°, 30° and 60°. The IFS and QFS were measured respectively at each angle. The measurements were compared between the IFI group and the control group to determine the optimal diagnostic cutoff values for diagnosing IFI by using IFS and QFS measurements. Results: In the IFI group, the spaces were smaller than those of the control group at all rotation angles (P < 0.05 for each). When external rotation angles were increased, the IFS and QFS tended to decrease. QFSs were smaller in the case group than the control group at each rotation angle. The receiver operating characteristic areas under the curves of IFS and QFS in a neutral position of 0° were highest. Conclusion: Both of the IFS and QFS spaces of IFI patients were found to be smaller than those of control group, regardless of the external hip rotation angles. A neutral position of 0° was deemed the best position for diagnosing IFI. The diagnostic cutoff values of IFS and QFS were 2.44cm and 1.34cm in the neutral position, respectively.

Objective: Not all endoscopic clips are compatible with magnetic resonance imaging (MRI). The aim of this study is to investigate the safety of MRI-incompatible endoscopic clips in patients undergoing MRI scans. Methods: We retrospectively reviewed the medical records of patients who had received endoscopic clip placement of Olympus Long Clip MRI-incompatible clips and then had undergone MRI scans within two weeks in our hospital between 2014 and 2019. Results: A total of 44,292 patients had undergone an MRI examination at our hospital. Only 15 patients had MRI scans within two weeks after the endoscopic clip placement. Their median age was 65.5 years, and 12 of the 15 patients were men. At the time of the clip placement and MRI scan, four patients were taking anti-coagulation or anti-platelet agents. The indication for endoscopic clip placement of the 15 patients was mucosal/submucosal defect or hemorrhage and colonic perforation. Endoscopic clips were placed in the colon of 14 patients and in the stomach of only one patient for gastric hemorrhage. One patient experienced clip migration and three displayed artifacts in abdominal images. No patient complications of mortality, hemorrhage, or organ perforation occurred. Conclusion: No serious adverse event occurred during MRI scans of patients with MRI-incompatible clips in this study, suggesting that MRI-incompatible clips may be safe to use in MRI scans. However, this does not guarantee the safety of the Long Clip for MRI scans, as further tests are needed to verify that this clip is safe for use during MRI.

Objective: Medical image processing is an exciting research area. In this paper, we proposed new brain tumor detection and classification model using MR brain images to help the doctors in early detection and classification of the brain tumor with high performance and best accuracy. Materials: The model was trained and validated using five databases, including BRATS2012, BRATS2013, BRATS2014, BRATS2015, and ISLES-SISS 2015. Methods: The advantage of the hybrid model proposed is its novelty that is used for the first time; our new method is based on a hybrid deep convolution neural network and deep watershed auto-encoder (CNN-DWA) model. The method consists of six phases, first phase is input MR images, second phase is preprocessing using filter and morphology operation, third phase is matrix that represents MR brain images, fourth is applying the hybrid CNN-DWA, fifth is brain tumor classification, and detection, while sixth phase is the performance of the model using five values. Results: The novelty of our hybrid CNN-DWA model showed the best results and high performance with accuracy around 98% and loss validation 0, 1. Hybrid model can classify and detect the tumor clearly using MR images; comparing with other models like CNN, DNN, and DWA, we discover that the proposed model performs better than the above-mentioned models. Conclusion: Depending on the better performance of the proposed hybrid model, this helps in developing computer-aided system for early detection of brain tumors and helps the doctors to diagnose the patients better.

Background: Anemia is one of the main consequences of Chronic Kidney Disease (CKD), which causes a bone marrow response determined by Magnetic Resonance Imaging. Objective: The objective of this study was to identify Bone Marrow Reconversion (BMR) by nuclear magnetic resonance imaging in patients with CKD. Methods: A descriptive study was carried in “José Carrasco Arteaga” Hospital, Cuenca-Ecuador. Images of the femurs of patients diagnosed with CKD were acquired by magnetic resonance imaging. Several variables, including age, sex, CKD stage, anemia and BMR, were taken into account. Groups are analyzed according to the stages CKD with the Anova test and logistic regression is obtained for the BMR event with the study variables. Results: Two hundred sixteen patients were included in this analysis. Prevalences of Anemia were 2/40 (5%) in Group 1, 3/35 (8.6%) in group 2, 17/56 (30.4%) in group 3, 23/46 (50%) in group 4 and 25/39 (64.1%) in group 5, Anova P<0.0001. BMR in Group 1 was 12 cases (30%), in group 2: 4 cases (11.4%), in group 3: 18 cases (32.1%), in group 4: 13 cases (28.3%), and group 5: 17 cases (43.6%). P=0.51. Regression equation for BMR were significant with sex (male) OR 0.193 (CI95% 0.092-0.405) P<0.0001, CKD Stage 1 OR 0.195 (0.057-0.668) P=0.009, Stage 2 OR 0.082 (0.020-0.329). Other variables were not significant. Conclusion: In this study, we describe that there is an impaired Reconversion of Bone Marrow in Nuclear Magnetic Resonance Imaging in Patients with Chronic Renal Disease in stages 3, 4 and 5, despite the progressive presence of anemia. The female sex is associated with the presence of bone marrow reconversion. No statistical dependence was observed between anemia and the reconversion of bone marrow.

Introduction: At present, the mechanism of telangiectasia is unknown, but some evidence suggests that it may be related to genetic abnormalities. Telangiectasia may lead to bleeding of multiple sites. CT-negative subarachnoid hemorrhage is rare, which is mostly related to hemorrhage with a little amount of bleeding. CT-negative subarachnoid hemorrhage due to telangiectasia has not been reported. Case Report: In this case report, the patient experienced severe headache with nausea, vomiting, and blurred vision for 12 days, and had a history of hypertension. Physical examination revealed a clear state of mind, normal speech, normal limb muscle strength, 2 transverse fingers of neck stiffness, and negative bilateral Babinski signs. Brain CT, MRI, MRA, and MRV showed no obvious abnormalities. SWI suggested the possibility of capillary dilation. The cerebrospinal fluid was pale yellow in appearance after lumbar puncture. Diagnosis: The patient was diagnosed with subarachnoid hemorrhage (SAH) and capillary dilatation. Interventions: Therapeutic management of blood pressure and brain edema was started. Conclusion: Lumbar puncture should be performed when subarachnoid hemorrhage is clinically suspected and CT is negative. While searching for the cause of subarachnoid hemorrhage, the presence of telangiectasia should be ascertained.

Background: Gastrointestinal schwannoma is not a common type of tumor, and lesions originating from the appendix are extremely rare. Herein, we report a patient with appendiceal schwannoma characterized by lymph node swelling. Case Report: A 67-year-old male patient who had diabetes complained of weight loss. A computed tomography scan revealed a mass in the right side of the pelvic cavity. Moreover, a contrast-enhanced computed tomography scan showed perilesional lymph node swelling measuring up to 28 mm. A low-intensity mass was observed on T1-weighted imaging, heterogeneous high-intensity mass on T2-weighted imaging, and restricted diffusion on diffusion-weighted imaging. There were no abnormal findings on colonoscopy. Based on a preoperative examination, a differential diagnosis of either appendiceal schwannoma, carcinoid, or gastrointestinal stromal tumor was considered. During surgery, a large appendiceal mass and multiple swollen perilesional lymph nodes were observed. Therefore, ileocecal resection and D3 lymph node dissection were performed. Pathological and immunohistochemical analyses confirmed the diagnosis of appendiceal schwannoma. There were numerous swollen lymph nodes in the mesenteric region. The lymph nodes revealed reactive lymphoid hyperplasia, with enlarged follicles of various sizes and shapes with an irregular distribution. Almost all lymphocytes, except those at the germinal centers, were small. Conclusion: Gastrointestinal schwannoma is characterized by lymph node swelling. Appendiceal schwannoma may have characteristics, including peritumoral lymph node swelling, similar to other types of gastrointestinal schwannoma such as that in the stomach. Thus, this characteristic can be a diagnostic clue for appendiceal schwannoma.