Macrocystic pancreatic tumors seem to play an important role among neoplastic lesions of the pancreas as they sometimes either show a malignant potential or they already have neoplastic foci inside the cystic tumor. Differential diagnosis is a key factor in comparison with other cystic tumors which are not malignant as Serous Cystic Tumors (SCTs) and Mucinous Cystic Tumors (MCTs). So diagnostic imaging has become more and more important. Since May 2009 we have observed more than 200 patients with cystic lesions of the pancreas. All the patients underwent a CholangioPancreato MagneticResonance (CPMR) after an Ultrasound and/or a CT scan. Then we excluded from our study solid lesions, pseudocysts and tumors with clear signs of malignancy. CPMR was sometimes performed also using a secretine test. Finally 51 patients were evaluated and underwent a follow up programme till now. Among these patients we found 34 Intraductal Papillary Mucinous Neoplasia (IPMN), 7 MCTs and 10 SCTs. As we know that all SCTs show a lobulated septate pattern, differential diagnosis with IPMN is mandatory in order to give to the patient the treatment of choice. CPMR revealed in 32 out of 34 IPMN patients a communication between the lesion and the main pancreatic duct (MPD); so this sign, which is patognomonic of IPMN neoplasia, confirmed the diagnosis. All lesions > than 3 cm were resected by surgery (4 MCTs and 3 IPMN). Definitive histology always confirmed preoperative diagnostic imaging. Now the patients are all disease free at follow up. The other 44 patients undergo CPMR every 6 months following a “wait and see” policy. CPMR seems to be fundamental for the diagnostic screening of IPMN. This is a simple, safe and non invasive procedure which allows an early diagnosis and a better chance of cure for this kind of patients.

Pancreatic cystic tumors represent an heterogeneous group of neoplasms with a various clinical outcome. The incidence of these neoplasia is growing if compared with the past and this is mainly due to the larger use of more and more performing imaging techniques. The role of MRI and in particular of Cholangio-Pancreato Magnetic Resonance (CPMR) seems to be fundamental in the characterization of these cystic lesions. Between May 2009 and May 2011 a hundred and seventy six (176) patients with a suspect cystic lesion of the pancreas were evaluated. All patients had already undergone ultrasound and/or CT scan. CPMR was realized in each patient. Among these patients we only considered 51 without neither solid lesions or pseudocysts nor clear signs of malignancy. We found 10 Serous Cystic Tumors (SCT), 7 Mucinous Cystic Tumors (MCT) and 34 Intraductal Papillary Mucinous Neoplasia (IPMN). Thirty two (32) out of 34 IPMN revealed at CPMR a communication with the main pancreatic duct. This sign is pathognomonic of these lesions. CPMR seems to be mandatory to discriminate IPMN among the other pancreatic cystic neoplasia. Its role is fundamental for an early diagnosis and to give the best chance of cure in these aggressive and insidious tumors.

PURPOSE:The aim of our work was to design, implement and evaluate an e-learning programme in favour of trainee radiologists enrolled at the many specialty schools located throughout Italy, in the spirit of "sharing culture".MATERIALS AND METHODS:Once a common educational programme and time slot had been identified and planned, the programme was delivered via Internet-based video conferencing once a week for 2-h lectures. Each lecture was followed by interaction between the teaching staff and trainees at the individual sites. The universities involved were Trieste, Udine, Verona, Milano Bicocca, Novara, Varese, Genova, Sassari, Rome "Campus", Rome "Cattolica", Chieti, Foggia, Catania, Modena and Firenze. The University of Rome "Cattolica" participated in the project with two locations: Rome "Policlinico Gemelli" and Rome "Cattolica Campus of Campobasso".RESULTS:Eighteen lectures were conducted, for a total of 36 h. "Transient" connection interruption occurred 13 times for a total of 33 min over 2,160 min of lessons. Video quality and, in particular, details of radiological images shown in slides or moving pictures, were rated as very good by 71% of trainees, good by 24% and satisfactory by 4.5%; no one gave a rating of unsatisfactory.CONCLUSIONS:Based on our experience, whereas e-learning in radiology has become established and compulsory, there is the need for legislation that on the one hand protects online teaching activity and on the other allows study and continuing medical education (CME) credits to be recognised.

Purpose . The aim of our work was to design, implement and evaluate an e-learning programme in favour of trainee radiologists enrolled at the many specialty schools located throughout Italy, in the spirit of “sharing culture“. Materials and methods . Once a common educational programme and time slot had been identifi ed and planned, the programme was delivered via Internet-based video conferencing once a week for 2-h lectures. Each lecture was followed by interaction between the teaching staff and trainees at the individual sites. The universities involved were Trieste, Udine, Verona, Milano Bicocca, Novara, Varese, Genova, Sassari, Rome “Campus”, Rome “Cattolica”, Chieti, Foggia, Catania, Modena and Firenze. The University of Rome “Cattolica” participated in the project with two locations: Rome “Policlinico Gemelli” and Rome “Cattolica Campus of Campobasso”. Results . Eighteen lectures were conducted, for a total of 36 h. “Transient” connection interruption occurred 13 times for a total of 33 min over 2,160 min of lessons. Video quality and, in particular, details of radiological images shown in slides or moving pictures, were rated as very good by 71% of trainees, good by 24% and satisfactory by 4.5%; no one gave a rating of unsatisfactory. Conclusions . Based on our experience, whereas e-learning in radiology has become established and compulsory, there is the need for legislation that on the one hand protects online teaching activity and on the other allows study and continuing medical education (CME) credits to be recognised. Obiettivo . Scopo del nostro lavoro e stato progettare, realizzare e valutare un percorso didattico di e-learning per la formazione degli specializzandi in radiodiagnostica, coinvolgendo piu scuole di specializzazione distribuite su tutto il territorio nazionale, nell’ottica della condivisione culturale. Materiali e metodi . Previa identifi cazione e pianificazione di un programma didattico temporale condiviso, la modalita tecnica di e-learning in teleconferenza ha previsto un collegamento via internet il mercoledi pomeriggio e due ore di lezione, alla lezione e seguita una interazione didattica delle singole sedi con il discente. Il ciclo didattico e iniziato il 21.10.2009 per terminare il 14.07.2010. Le Universita che hanno aderito sono state: Trieste, Udine, Verona, Milano Bicocca, Novara, Varese, Genova, Sassari, Roma Campus, Roma Cattolica, Chieti, Foggia, Catania, Modena, Firenze. L’Universita Cattolica di Roma ha partecipato al progetto con due sedi di collegamento: Roma Policlinico Gemelli e Roma Cattolica sede di Campobasso. Risultati . Complessivamente sono state effettuale 18 lezioni, per un totale di 36 ore di lezione effettive. Su un totale di 2160 minuti complessivi di collegamento le interruzioni momentanee della linea internet sono state 13 per un totale di 33 minuti. Relativamente al giudizio sulla qualita del video e, in particolare, sul dettaglio delle immagini radiologiche proposte in diapositiva e/o in fi lmati il 71% dei discenti ha espresso un giudizio “ottimo”, il 24% un giudizio “buono”, il 4,5% un giudizio “sufficiente” non vi e stato alcun giudizio “insufficiente”. Relativamente alla qualita audio il 72% dei discenti ha espresso un giudizio “ottimo”, il 25% un giudizio “buono”, il 3% un giudizio “sufficiente”, non vi e stato alcun giudizio “insufficiente”. Conclusioni . Da quanto esposto e dall’esperienza vissuta se la via dell’e-learnig in radiologia e, a nostro parere, ormai segnata ed obbligatoria, si impone la necessita legislativa di normative che, da una parte, tutelino l’attivita didattica in rete e, dall’altra, consentano il riconoscimento di crediti formativi e di educazione continua in medicina (ECM) .

Magnetic resonance (MR) is the investigation of choice in studying the anatomy of the brachial plexus given its wide range of features: scanning on all spatial planes essential because of the oblique path of the plexus, high intrinsic contrast between different structures identifying the position of the plexus; high spatial resolution necessary to display the tiny nerve roots. The brachial plexus was investigated in 15 healthy subjects aged between 17 and 53 years. Two series of T1-weighted SE sequences were performed on the sagittal plane positioned separately over the whole stretch of the plexus. Further sequences included T2-weighted TSE axial scans, T2-weighted TSE scans with fat signal suppression (MR neurography), T1-weighted SE coronal scans and T1-weighted TurboFieldEcho coronal scans. T1-weighted SE scans offered the most information as the brachial plexus is constantly related to the subclavian vessels on this plane and can be identified by the hyperintensity of its surrounding fat tissue. For accurate identification of the main branches of the plexus, we divided sagittal scans into five contiguous mediolateral levels. The first level identifies the emergence of the nerve roots from the root canals; the second corresponds to a section over the scalenus muscles, the third level is over the supraclavicular triangular space; the fourth comprises the sections over the axilla and the fifth corresponds to a more lateral plane through the pectoralis muscles. The three primary trunks, superior, middle and inferior, can be identified in the second level, constantly positioned above and behind the subclavian vessels and clearly identified by the hyperintensity of the adipose tissue. The primary trunks divide into the anterior and posterior rami in level three and in level four the nerve branches surround the subclavian vessels running in a joint sheath. The fifth level contains the secondary lateral, middle and posterior trunks. The coronal plane positioned obliquely depending on the orientation of the plexus, will identify the emergence of the roots from the spine and their initial stretch partly visible on the coronal plane. The nerve branches appear slightly hyperintense in T2-weighted sequences with fat signal suppression and these scans are useful in studying plexus pathology. High field intensity systems (1.5T) and phased array surface coils gave good spatial resolution. In the near future, multiple dedicated surface coils will be available for MR study of the brachial plexus, thereby improving the spatial resolution and the signal-to-noise ratio, essential factors in identifying small structures like the peripheral nerve branches.

Nello studio dell'anatomia del plesso brachiale la RM è l'esame di scelta in rapporto alle principali caratteristiche della metodica: possibilità di eseguire le scansioni su tutti i piani dello spazio, elevato contrasto intrinseco e grazie al costante miglioramento della tecnologia, strati sottili con elevata risoluzione spaziale. La sequenza SE T1 dipendente sul piano sagittale è sicuramente quella con il più alto contenuto informativo: le varie diramazioni sono infatti riconoscibili come strutture ad intensità di segnale intermedia tra l'arteria e la vena succlavia con cui mantengono un rapporto anatomico costante e l'elevatà intensità di segnale del tessuto adiposo circostante. Il piano coronale obliquato secondo l'orientamento delle radici nervose fornisce informazioni sul primo tratto del decorso del plesso a partire dalla fuoriuscita delle radici che costituiscono il plesso dai forami di coniugazione. L'uso di bobine di superficie phased array ha permesso di ottenere una buona risoluzione spaziale associata ad un elevato rapporto segnale-rumore. In particolare la bobina tipo sinergy spine ha consentito anche un buon comfort per il paziente anche nel caso di studio di entrambi i plessi brachiali. È da ritenere che la possibilità in un futuro immediato, di impiegare in RM, multiple bobine di superficie dedicate al plesso brachiale, incrementerà ulteriormente le conoscenze anatomiche del plesso base indispensabile, anche in questo campo, per un corretto approccio allo studio della patologia della regione del plesso brachiale.

PURPOSE:To report our experience with helical CT evaluation of transient hepatic attenuation differences (THAD), and in particular of those not associated with focal lesions, in an attempt to provide an aetiopathogenetic picture that accounts for the morphology, evolution and density of THAD.MATERIALS AND METHODS:Between January 1998 and January 2001 we observed THAD in 130/988 biphasic helical CT liver examinations performed in the arterial and portal dominant phase. THAD were associated to focal hepatic lesions in 87 patients; in 43 patients there was no such association. This second group of patients, composed of 23 males and 20 females ranging in age from 17 to 80 years (average = 58.8), was enrolled in the study. THAD were associated to: Budd-Chiari syndrome (9), portal venous thrombosis (10), liver cirrhosis (7), acute inflammation of an adjacent organ (4), dilatation of the entire biliary tree (3), hepatic stasis caused by heart failure (2) and constrictive pericarditis (1), fine-needle percutaneous biopsy (2), arterioportal shunting (2), parenchymal compression by fractured ribs (2) and by a strengthened phrenic pillar (1). THAD were evaluated according to extension, morphology and density. For each case at least 10 density measurements were performed by sampling regions of interest on the parenchyma with THAD and on the contralateral parenchyma. The results (mean and standard deviation) were compared to those relative to 30 healthy patients. 22/43 patients were followed up for 6#150;24 months by at least one US and helical CT examination. During CT, the direct appreciation of vascular thrombus during the portal dominant phase was also considered.RESULTS:We detected 18 localised and 25 diffuse THAD. The localised sectoral THAD (11), wedge-shaped with clear border sign, were associated to thrombosis of a portal branch (6), fine-needle percutaneous biopsy (2), arterioportal shunting (2) and partial Budd-Chiari syndrome (1). The localised non-sectoral THAD (7), with variable morphology and without the clear border sign, were associated to acute inflammation of an adjacent organ (4) and to parenchymal compression by the ribs or diaphragm (3). Diffuse THAD associated to Budd-Chiari syndrome (8) and to heart failure (3) showed mosaic enhancement of hepatic parenchyma (patchy pattern); those linked to portal trunk thrombosis (4) and cirrhosis (7) revealed predominant enhancement of external hepatic parenchyma (central-peripheral phenomenon); finally, those concurrent with dilatation of the entire biliary tree showed parenchymal enhancement close to the dilated bile ducts (peribiliary pattern). Follow-up (22/43) demonstrated complete THAD regression after removal (5/22) and less conspicuity of THAD after partial overcome of the stoppage (1/22). In 2/22 cases of arterioportal shunting no substantial changes were seen. The remaining 14/22 cases showed a gradual, slow tendency towards THAD regression with hypotrophy of the involved parenchyma and compensatory contralateral hypertrophy even in the case of endurance of the causative agents.CONCLUSIONS:Based on our experience and the literature we suggest a classification for THAD unrelated to focal hepatic lesions. We recognise 4 causes: portal vein stoppage-obstruction, portal in-flow diversion, trauma and inflammation. When THAD is related to the first three causes pathogenesis is portal hypoperfusion. In the fourth group the mediators of the arterial phenomena are those of inflammation even though portal hypoperfusion might be involved as well. THAD identification makes the detection of vascular thrombi easier by comparison with their direct finding during the portal dominant phase. Finally, THAD are to be investigated for their potential utility in the detection and characterisation of several hepatic diseases. As a consequence, hepatic CT studies cannot ignore arterial dominant phase evaluation, even if no focal hepatic lesions are expected.

We measured by ultrasound the spleen, the kidneys, the pancreas in 323 children (age 0-12), the thyroid in 60 children of same age range, and all these organs in 180 adults (in adults we measured additionally the testis, the gallbladder and the choledochus). Children and adults were all healthy, without evidence of pathologies potentially involving these organs. The children have been selected looking at clinical and hematological parameters, while the adults have been selected among a military population, that is the most significant sample of healthy young adults. We measured the length, the transversal diameter and the thickness of the spleen, kidneys, pancreas, testis and thyroid, the diameter of the choledochus and the maximum length of the gallbladder (pre and post stimulus). We found a good correlation between age and dimensions for pancreas, kidneys and spleen in children, representing the progressive growth of these organs. Our data represent an assessment of the normal dimensions of these organs in vivo by means of ultrasound, and therefore they are an useful tool to discriminate pathologically enlarged or reduced organs, both in children and in adults.

A rare case of bilateral diaphragmatic hernia, containing a long segment of transverse colon in the left breach and most of the omentum and a short segment of colon in the right one, is described. Diaphragmatic hernia can occur at any age in both males and females and it is often asymptomatic and diagnosed by chance. The epidemiological, etiopathogenic, clinic, diagnostic and therapeutic aspects of the disease are discussed. The only treatment, which is advisable in asymptomatic patients too, is the closure of the hernial orifice. This closure can be done directly or through the insertion of prosthetic material. The conventional access can be thoracic or abdominal, but laparoscopy is going to replace both of them successfully in the future.

In aorto-iliac occlusive disease a diversion of blood flow from visceral arteries to lower limbs rarely occurs. This condition is known as aorto-iliac steal syndrome. This report is about the case of a male patient affected by chronic atherosclerotic occlusion of the aorta associated with an aorto-iliac steal supported by an anomalous vessel coming from the left renal artery to the homolateral external iliac artery to the detriment of the renal blood flow. Renal sequential scintiscan (RSS) at rest and after stress test was employed to assess renal blood flow and excretory functions before and after an aorto-bifemoral bypass. Surgical revascularization permitted reversal of the steal phenomenon and the improvement of left renal blood flow.

INTRODUCTION:US of some muscular components of the stomatognathic system (orbicularis oris and masseter muscles) has proved to provide important information about their morphologic features. The purpose of this study is to explore the US features of the perioral and masticatory muscles in patients affected with any type of malocclusion and to analyze the correlations between dento-skeletal characteristics and muscle changes.MATERIAL AND METHODS:We examined 26 untreated patients (10 men and 16 women); we measured their cephalometric parameters on lateral skull teleradiographs and then we measured with US both the masseter and orbicular muscles dimensions. The US images were acquired with 5 MHz and 7.5 MHz probes, measuring the masseter muscle with transversal and longitudinal scans, and the two parts of the orbicularis oris with longitudinal scans. The cephalometric measures were calculated with: angular parameters useful to determine the sagittal relationships, both angular and linear parameters to define the vertical relationships and angular measures that define the incisor position. We applied the Spearman test to assess if there was a relationship between the US dimensions of the orbicularis oris and the masseter, and the dento-skeletal characteristics of these 26 patients.RESULTS:Our results show that there is a strong correlation between mandibular morphology, the palatal plane, respectively, and the masseter length. There is a direct correlation with the masseter dimension for the palatal plane obliquity, and an inverse correlation for the mandibular morphology. The incisor position is influenced by the orbicular oris muscle dimension and by the asymmetric position of the superior and inferior incisors.CONCLUSIONS:This noninvasive diagnostic examination is a useful aid to the clinical examination of the muscles, especially in orthodontic diagnosis, together with MRI and CT, respectively more expensive and unhealthier.

The width of the articular space of the lateral atlantoaxial joint was measured to evaluate normal range values and possible variations according to age and sex. The study was based on X-rays of the lateral atlantoaxial joint of 52 females (age range: 18-82 ys) and 50 males (age range: 20-82 ys). The radiograms were taken using a semiautomatic computerized morphometric system (Videoplan II, Image Analysis system-Kontron, Munich, Germany). The articular space width of the lateral atlantoaxial joint was measured on both sides, at the medial, lateral and median levels. The mean value at these levels, on both sides, was calculated. Regression analysis was performed to evaluate the relationships between the width of the articular space at the three different levels and the patient's age and gender. No significant differences were found in the mean values of the articular space width at the three levels as regards gender. However, a significant inverse correlation was found between the articular space width and the patients' age in both males and females. Comparative analysis of regression lines showed that the slope of these lines was not significantly different when the sexes were compared. On the contrary, the intercept of the regression lines at the medial and median levels was significantly higher in the females than in the males; the contrary was encountered at the lateral level. This feature is probably due to the different types of inclination of the articular facets of the axis or of those of the atlas in the two sexes.