The document discusses dynamic contrast intranodal magnetic resonance lymphangiography (DCMRL). It begins by describing the lymphatic system and its role in fluid balance, immunity, and waste removal. DCMRL involves cannulating lymph nodes and injecting contrast, which is then tracked through lymphatic vessels using MRI. Applications include assessing chylothorax, chyloperitoneum, protein losing enteropathy, and lymphatic malformations. DCMRL provides high resolution dynamic imaging of lymphatic flow and leakage, aiding diagnosis and treatment planning for various lymphatic disorders.
Perfusion and dynamic contrast enhanced mrifahad shafi
This document discusses dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) techniques for measuring tissue perfusion. It describes how DCE-MRI analyzes the passage of gadolinium contrast agents through tissue over time to provide quantitative measurements of microvascular properties like permeability and blood flow. The document outlines the principles, image acquisition, and qualitative, semi-quantitative, and quantitative analysis methods for DCE-MRI. It also discusses applications for evaluating brain tumors and other disorders.
Lymphography is an invasive procedure that uses an oil-based radiographic contrast dye to visualize the lymphatic system, including lymph vessels and lymph nodes. A dye is injected into the hand or foot and travels through the lymphatic system. An incision is made and contrast is injected directly into the lymph vessels. Radiographs are taken over time to view the lymph vessels and nodes as the contrast spreads. While MRI and CT have replaced it, lymphography can still help evaluate lymphomas and stage radiation treatment planning by demonstrating obstructions.
Everything regarding the physics of MRA is given along with flow charts and images. Also have covered new advances and refrences taken from MR made easy and some articles related to MRI
CT enteroclysis involves placing a nasojejunal tube and using it to instill contrast into the small bowel under fluoroscopy. CT enterography involves having the patient drink oral contrast. Both techniques use IV contrast to evaluate the bowel wall, enhancement, blood vessels, and for signs of bleeding. CT enteroclysis allows for more distal small bowel evaluation but enterography is more comfortable for patients. Indications include investigating Crohn's disease, small bowel obstruction, and unexplained GI bleeding. The procedure involves bowel preparation, premedication, and imaging the abdomen with thin slices during arterial and venous phases to fully evaluate the small bowel and other organs.
Doppler of Lower Limb Arteries. Technical Aspects.Walif Chbeir
Technique of Doppler of LLA Description: General Rules, Role and place of Real-Time Gray-Scale Imaging, Duplex Doppler Sonography, Color Doppler sonography and of Power Doppler sonography. Scanning Technique is described as well as Interpretation and Reporting.
Perfusion MRI (DSC and DCE perfusion techniques) for radiology residentsRiham Dessouky
This document provides an overview of perfusion weighted MR imaging techniques. It discusses three main types: dynamic susceptibility contrast (DSC) MR perfusion, dynamic contrast enhanced (DCE) MR perfusion, and arterial spin labeling (ASL) MR perfusion. DSC relies on signal loss from gadolinium contrast to measure parameters like relative cerebral blood volume (rCBV) and flow (rCBF). DCE uses T1 shortening effects of contrast to calculate permeability and perfusion. Both techniques are used to evaluate brain tumors and strokes by analyzing signal intensity curves. DCE is also used in breast MRI to classify enhancement curves and measure permeability with the Ktrans parameter.
Progressive muscle weakness for 2 years. Giant cerebral aneurysms are greater than 25mm. Patients can present with mass effect or subarachnoid hemorrhage. On MRI, patent aneurysms appear as flow void or heterogeneous signal. Thrombosed aneurysms depend on clot age. Sturge-Weber syndrome is characterized by facial port wine stains and pial angiomas. CT detects subcortical calcification earlier than plain film. MRI shows signal changes and anatomical volume loss with age. État criblé describes diffusely widened perivascular spaces in the basal ganglia. External auditory canal atresia involves complete or incomplete bony atresia of the external auditory canal.
CT perfusion physics and its application in NeuroimagingDr.Suhas Basavaiah
CT perfusion imaging provides functional information about tissue vascularity by measuring temporal changes in tissue attenuation following intravenous injection of iodinated contrast. It quantifies parameters like blood flow, blood volume, mean transit time. While initially developed for research, advances in multidetector CT and software allow clinical use in evaluating cerebral vasculature in acute stroke and tumor response to therapies in oncology. The technique involves rapid dynamic scanning during contrast first-pass to generate time-attenuation curves and calculate perfusion values using deconvolution or other mathematical models.
Perfusion and dynamic contrast enhanced mrifahad shafi
This document discusses dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) techniques for measuring tissue perfusion. It describes how DCE-MRI analyzes the passage of gadolinium contrast agents through tissue over time to provide quantitative measurements of microvascular properties like permeability and blood flow. The document outlines the principles, image acquisition, and qualitative, semi-quantitative, and quantitative analysis methods for DCE-MRI. It also discusses applications for evaluating brain tumors and other disorders.
Lymphography is an invasive procedure that uses an oil-based radiographic contrast dye to visualize the lymphatic system, including lymph vessels and lymph nodes. A dye is injected into the hand or foot and travels through the lymphatic system. An incision is made and contrast is injected directly into the lymph vessels. Radiographs are taken over time to view the lymph vessels and nodes as the contrast spreads. While MRI and CT have replaced it, lymphography can still help evaluate lymphomas and stage radiation treatment planning by demonstrating obstructions.
Everything regarding the physics of MRA is given along with flow charts and images. Also have covered new advances and refrences taken from MR made easy and some articles related to MRI
CT enteroclysis involves placing a nasojejunal tube and using it to instill contrast into the small bowel under fluoroscopy. CT enterography involves having the patient drink oral contrast. Both techniques use IV contrast to evaluate the bowel wall, enhancement, blood vessels, and for signs of bleeding. CT enteroclysis allows for more distal small bowel evaluation but enterography is more comfortable for patients. Indications include investigating Crohn's disease, small bowel obstruction, and unexplained GI bleeding. The procedure involves bowel preparation, premedication, and imaging the abdomen with thin slices during arterial and venous phases to fully evaluate the small bowel and other organs.
Doppler of Lower Limb Arteries. Technical Aspects.Walif Chbeir
Technique of Doppler of LLA Description: General Rules, Role and place of Real-Time Gray-Scale Imaging, Duplex Doppler Sonography, Color Doppler sonography and of Power Doppler sonography. Scanning Technique is described as well as Interpretation and Reporting.
Perfusion MRI (DSC and DCE perfusion techniques) for radiology residentsRiham Dessouky
This document provides an overview of perfusion weighted MR imaging techniques. It discusses three main types: dynamic susceptibility contrast (DSC) MR perfusion, dynamic contrast enhanced (DCE) MR perfusion, and arterial spin labeling (ASL) MR perfusion. DSC relies on signal loss from gadolinium contrast to measure parameters like relative cerebral blood volume (rCBV) and flow (rCBF). DCE uses T1 shortening effects of contrast to calculate permeability and perfusion. Both techniques are used to evaluate brain tumors and strokes by analyzing signal intensity curves. DCE is also used in breast MRI to classify enhancement curves and measure permeability with the Ktrans parameter.
Progressive muscle weakness for 2 years. Giant cerebral aneurysms are greater than 25mm. Patients can present with mass effect or subarachnoid hemorrhage. On MRI, patent aneurysms appear as flow void or heterogeneous signal. Thrombosed aneurysms depend on clot age. Sturge-Weber syndrome is characterized by facial port wine stains and pial angiomas. CT detects subcortical calcification earlier than plain film. MRI shows signal changes and anatomical volume loss with age. État criblé describes diffusely widened perivascular spaces in the basal ganglia. External auditory canal atresia involves complete or incomplete bony atresia of the external auditory canal.
CT perfusion physics and its application in NeuroimagingDr.Suhas Basavaiah
CT perfusion imaging provides functional information about tissue vascularity by measuring temporal changes in tissue attenuation following intravenous injection of iodinated contrast. It quantifies parameters like blood flow, blood volume, mean transit time. While initially developed for research, advances in multidetector CT and software allow clinical use in evaluating cerebral vasculature in acute stroke and tumor response to therapies in oncology. The technique involves rapid dynamic scanning during contrast first-pass to generate time-attenuation curves and calculate perfusion values using deconvolution or other mathematical models.
MRI sequences involve different combinations of pulse sequences and magnetic field gradients that result in particular tissue appearances on images. The main types of sequences include spin echo, gradient echo, inversion recovery, diffusion weighted, perfusion weighted, functional MRI, and magnetic resonance angiography. Each sequence has different parameters that make it particularly suited for evaluating certain tissues, pathologies, or physiological processes.
This document provides information on performing and interpreting CT angiography of the lower limbs. It discusses scanning techniques, protocols, contrast injection, and principles of timing acquisitions. Image post-processing includes MIP, VR, and MPR. Interpretation requires scrutinizing calcifications and stents to avoid overestimating stenosis. Peripheral CTA is useful for evaluating occlusive disease, aneurysms, trauma, infections, embolism, and postoperative surveillance. Examples demonstrate various vascular pathologies.
Liver transplantation is the standard treatment for end-stage liver disease. Imaging plays a key role in donor and recipient evaluation, surgical planning, post-transplant monitoring, and follow up. The document outlines the various imaging modalities used at each stage of the transplantation process including US, CT, MRI, angiography and interventional radiology. It describes the indications, contraindications, surgical techniques for cadaveric and living donor liver transplantation and complications that may be evaluated with imaging.
This document discusses magnetic resonance angiography (MRA) and its advantages and disadvantages compared to catheter angiography. It describes different MRA techniques including contrast enhanced MRA, time of flight angiography, phase contrast angiography, and non-contrast techniques. It also discusses artifacts that can appear on MRA such as metal artifacts and blooming artifacts. Key features and images of each technique are provided.
Magnetic Resonance Angiography and techniquesAlwineAnto
This document discusses MR angiography techniques and vascular abnormalities. It begins by outlining the major vascular systems in the human body. It then describes various vascular abnormalities like stenosis, aneurysms, and arterial venous malformations. The document goes on to explain different MR angiography pulse sequences like TOF, CE MRA, and PC MRI. It provides details on TOF MRA principles and advantages/disadvantages. Common artifacts seen on TOF MRA like shine-through and susceptibility artifacts are also outlined. Finally, the document discusses CE MRA techniques including test bolus timing and advantages/disadvantages compared to TOF MRA.
This document discusses diffusion weighted imaging (DWI) and its application in evaluating brain pathologies. It provides details on how DWI works using diffusion gradients and endogenous contrast from water motion. Areas of restricted diffusion like cytotoxic edema appear brighter on DWI. DWI is highly sensitive for detecting acute ischemia within minutes. It is useful for distinguishing acute from subacute lesions based on apparent diffusion coefficient (ADC) maps. DWI also has applications in evaluating other conditions like abscesses, tumors, infections and injuries.
This document provides an overview of diffusion weighted imaging (DWI) and its clinical applications. It defines diffusion and how DWI is acquired using Stejskal-Tanner pulsed gradient spin echo sequences. Key terms like b-value and apparent diffusion coefficient are explained. Clinical uses of DWI include detecting acute strokes and differentiating lesions. Body DWI using DWIBS is also discussed. Diffusion tensor imaging is introduced as a technique for visualizing white matter tract orientation using tractography maps.
This document outlines the protocol for performing CT angiography (CTA) from the cerebral arteries to the lower limbs. It discusses indications for CTA including aneurysms, stenosis, dissections, and more. The preparation, positioning, and scanning protocols are provided for CTA of the head to lower limbs as well as the subclavian arteries. Pediatric protocols are also summarized. The document concludes with examples of CTA findings and references.
This document describes enteroclysis, a radiographic study of the small bowel. Enteroclysis involves inserting a tube into the jejunum and using it to instill contrast media to visualize the small bowel. It can detect abnormalities like partial obstructions, tumors, and inflammation. The procedure involves placing a tube, administering contrast, and taking x-rays. Complications are rare but include perforation or aspiration. Capsule endoscopy and ileoscopy are alternative endoscopic methods to examine the small bowel.
This document discusses various MRI sequences. It describes spin echo sequences, inversion recovery sequences, gradient echo sequences, and echo planar imaging. Free induction decay is discussed as a short-lived signal appearing after a 90 degree RF pulse that does not contribute to image formation. Parameters, modifications, and uses of different sequences are outlined.
Magnetic resonance angiography (MRA) uses magnetic resonance imaging (MRI) techniques to image blood vessels. There are three main types of MRA: time-of-flight angiography (TOF), phase contrast angiography (PCA), and contrast enhanced magnetic resonance angiography (CE-MRA). TOF uses gradient echo sequences to create bright vascular images from the signal difference between saturated and unsaturated spins moving through tissue. PCA images blood flow velocity using phase information and velocity encoding gradients. CE-MRA uses gadolinium contrast agents to shorten the T1 time of blood, allowing vessels to be visualized as their signal differs from the surrounding tissue.
Presentation1.pptx. imaging of the cartilage.Abdellah Nazeer
1. Imaging modalities such as radiography, ultrasound, CT arthrography, and MRI are used to evaluate articular cartilage and subchondral bone. MRI is the preferred method as it can detect early cartilage degeneration without radiation exposure.
2. Cartilage damage is graded on MRI from Grade I (mild increased signal) to Grade IV (full thickness defects). Subchondral bone changes like edema, fractures, and osteophytes also provide information about the severity and cause of injury or disease.
3. Techniques like dGEMRIC and T1ρ mapping can detect early biochemical changes in cartilage like glycosaminoglycan loss prior to macroscopic defects, helping evaluate and monitor treatments.
This document discusses renal Doppler ultrasound techniques and findings. It describes three main approaches to imaging the renal arteries - anterior, oblique, and flank. Normal and abnormal Doppler waveforms are presented. Evaluation of renal artery stenosis can be done directly by imaging the renal arteries or indirectly by imaging intrarenal arteries. Findings suggestive of stenosis include increased velocities, renal/aortic ratios over 3.5, absence of the early systolic peak, and tardus parvus waveforms. Pathologies of renal transplants like rejection, infarction, and arterial or venous stenosis are also summarized.
MRI is useful for evaluating various liver conditions. It is superior to CT for detecting small liver lesions and characterizing lesions. MRI can identify diffuse liver diseases affecting hepatocytes or reticuloendothelial cells, causing homogeneous or segmental changes. Cirrhosis appears as numerous low signal regenerative nodules on T2-weighted images. Hemangiomas are intensely hyperintense on T2-weighted images and enhance peripherally on contrast images. Dysplastic nodules are generally hypointense on T1-weighted images and do not enhance with contrast. MRI utilizes multiple sequences and techniques to comprehensively evaluate liver tumors, diffuse diseases, and incidental findings.
MRI uses strong magnetic fields and radio waves to generate images of the inside of the body. It works by aligning hydrogen atoms in water molecules and fat in tissues when placed in a magnetic field. Radio waves are then used to stimulate the hydrogen atoms, which emit signals as they relax back to their original positions. These signals can be used to construct detailed images of tissues and organs inside the body. The document discusses key concepts in MRI physics including precession, relaxation times T1 and T2, spin echo and gradient echo sequences, and how varying pulse sequence parameters affects contrast in the resulting images.
Beam hardening artifact occurs when an X-ray beam passes through multiple materials of varying densities within a scan volume. This causes the beam to become harder as lower energy photons are preferentially absorbed, leading to streaks or shading in the reconstructed CT image. Photon starvation is another cause of streak artifacts, occurring when there is insufficient photon flux passing through areas of higher attenuation, such as across the shoulders. Adaptive filtering and modulating tube current based on attenuation can help reduce these artifacts. Ring artifacts from defective detector elements in older CT scanners appear as rings in the reconstructed images.
Superficial brain structures are drained by cortical veins and the superior sagittal sinus. Central brain structures drain into the deep venous system including the internal cerebral veins, vein of Galen, and straight sinus. The veins of Labbé and transverse sinuses drain the posterior temporal and inferior parietal lobes. MR venography and CT venography can assess the cerebral venous system, with each technique having advantages and disadvantages.
This document discusses lymphatic disorders and lymphoedema. It begins with an introduction to the lymphatic system and its functions. It then discusses causes of lymphatic swelling including acute lymphangitis, filariasis, and elephantiasis. It defines primary and secondary lymphoedema and covers the clinical features, investigations and treatments for lymphoedema including manual lymphatic drainage, compression garments, and surgery. Surgical procedures for lymphoedema including bypass operations, liposuction, and limb reduction techniques are described. The document concludes by discussing chylous ascites, chylothorax, and chyluria.
This document discusses non-contrast MR lymphography for evaluating the lymphatic system. It can be used to diagnose lymphedema through detecting fluid collections, infiltration patterns, and dermal thickening. It also describes evaluating lymph node metastasis, lymphangiomas, and other lymphatic abnormalities and complications. MR lymphography is non-invasive and can uniquely image lymphatic anatomy while having limitations in spatial resolution. It provides diagnosis and localization of various lymphatic diseases and postoperative conditions.
MRI sequences involve different combinations of pulse sequences and magnetic field gradients that result in particular tissue appearances on images. The main types of sequences include spin echo, gradient echo, inversion recovery, diffusion weighted, perfusion weighted, functional MRI, and magnetic resonance angiography. Each sequence has different parameters that make it particularly suited for evaluating certain tissues, pathologies, or physiological processes.
This document provides information on performing and interpreting CT angiography of the lower limbs. It discusses scanning techniques, protocols, contrast injection, and principles of timing acquisitions. Image post-processing includes MIP, VR, and MPR. Interpretation requires scrutinizing calcifications and stents to avoid overestimating stenosis. Peripheral CTA is useful for evaluating occlusive disease, aneurysms, trauma, infections, embolism, and postoperative surveillance. Examples demonstrate various vascular pathologies.
Liver transplantation is the standard treatment for end-stage liver disease. Imaging plays a key role in donor and recipient evaluation, surgical planning, post-transplant monitoring, and follow up. The document outlines the various imaging modalities used at each stage of the transplantation process including US, CT, MRI, angiography and interventional radiology. It describes the indications, contraindications, surgical techniques for cadaveric and living donor liver transplantation and complications that may be evaluated with imaging.
This document discusses magnetic resonance angiography (MRA) and its advantages and disadvantages compared to catheter angiography. It describes different MRA techniques including contrast enhanced MRA, time of flight angiography, phase contrast angiography, and non-contrast techniques. It also discusses artifacts that can appear on MRA such as metal artifacts and blooming artifacts. Key features and images of each technique are provided.
Magnetic Resonance Angiography and techniquesAlwineAnto
This document discusses MR angiography techniques and vascular abnormalities. It begins by outlining the major vascular systems in the human body. It then describes various vascular abnormalities like stenosis, aneurysms, and arterial venous malformations. The document goes on to explain different MR angiography pulse sequences like TOF, CE MRA, and PC MRI. It provides details on TOF MRA principles and advantages/disadvantages. Common artifacts seen on TOF MRA like shine-through and susceptibility artifacts are also outlined. Finally, the document discusses CE MRA techniques including test bolus timing and advantages/disadvantages compared to TOF MRA.
This document discusses diffusion weighted imaging (DWI) and its application in evaluating brain pathologies. It provides details on how DWI works using diffusion gradients and endogenous contrast from water motion. Areas of restricted diffusion like cytotoxic edema appear brighter on DWI. DWI is highly sensitive for detecting acute ischemia within minutes. It is useful for distinguishing acute from subacute lesions based on apparent diffusion coefficient (ADC) maps. DWI also has applications in evaluating other conditions like abscesses, tumors, infections and injuries.
This document provides an overview of diffusion weighted imaging (DWI) and its clinical applications. It defines diffusion and how DWI is acquired using Stejskal-Tanner pulsed gradient spin echo sequences. Key terms like b-value and apparent diffusion coefficient are explained. Clinical uses of DWI include detecting acute strokes and differentiating lesions. Body DWI using DWIBS is also discussed. Diffusion tensor imaging is introduced as a technique for visualizing white matter tract orientation using tractography maps.
This document outlines the protocol for performing CT angiography (CTA) from the cerebral arteries to the lower limbs. It discusses indications for CTA including aneurysms, stenosis, dissections, and more. The preparation, positioning, and scanning protocols are provided for CTA of the head to lower limbs as well as the subclavian arteries. Pediatric protocols are also summarized. The document concludes with examples of CTA findings and references.
This document describes enteroclysis, a radiographic study of the small bowel. Enteroclysis involves inserting a tube into the jejunum and using it to instill contrast media to visualize the small bowel. It can detect abnormalities like partial obstructions, tumors, and inflammation. The procedure involves placing a tube, administering contrast, and taking x-rays. Complications are rare but include perforation or aspiration. Capsule endoscopy and ileoscopy are alternative endoscopic methods to examine the small bowel.
This document discusses various MRI sequences. It describes spin echo sequences, inversion recovery sequences, gradient echo sequences, and echo planar imaging. Free induction decay is discussed as a short-lived signal appearing after a 90 degree RF pulse that does not contribute to image formation. Parameters, modifications, and uses of different sequences are outlined.
Magnetic resonance angiography (MRA) uses magnetic resonance imaging (MRI) techniques to image blood vessels. There are three main types of MRA: time-of-flight angiography (TOF), phase contrast angiography (PCA), and contrast enhanced magnetic resonance angiography (CE-MRA). TOF uses gradient echo sequences to create bright vascular images from the signal difference between saturated and unsaturated spins moving through tissue. PCA images blood flow velocity using phase information and velocity encoding gradients. CE-MRA uses gadolinium contrast agents to shorten the T1 time of blood, allowing vessels to be visualized as their signal differs from the surrounding tissue.
Presentation1.pptx. imaging of the cartilage.Abdellah Nazeer
1. Imaging modalities such as radiography, ultrasound, CT arthrography, and MRI are used to evaluate articular cartilage and subchondral bone. MRI is the preferred method as it can detect early cartilage degeneration without radiation exposure.
2. Cartilage damage is graded on MRI from Grade I (mild increased signal) to Grade IV (full thickness defects). Subchondral bone changes like edema, fractures, and osteophytes also provide information about the severity and cause of injury or disease.
3. Techniques like dGEMRIC and T1ρ mapping can detect early biochemical changes in cartilage like glycosaminoglycan loss prior to macroscopic defects, helping evaluate and monitor treatments.
This document discusses renal Doppler ultrasound techniques and findings. It describes three main approaches to imaging the renal arteries - anterior, oblique, and flank. Normal and abnormal Doppler waveforms are presented. Evaluation of renal artery stenosis can be done directly by imaging the renal arteries or indirectly by imaging intrarenal arteries. Findings suggestive of stenosis include increased velocities, renal/aortic ratios over 3.5, absence of the early systolic peak, and tardus parvus waveforms. Pathologies of renal transplants like rejection, infarction, and arterial or venous stenosis are also summarized.
MRI is useful for evaluating various liver conditions. It is superior to CT for detecting small liver lesions and characterizing lesions. MRI can identify diffuse liver diseases affecting hepatocytes or reticuloendothelial cells, causing homogeneous or segmental changes. Cirrhosis appears as numerous low signal regenerative nodules on T2-weighted images. Hemangiomas are intensely hyperintense on T2-weighted images and enhance peripherally on contrast images. Dysplastic nodules are generally hypointense on T1-weighted images and do not enhance with contrast. MRI utilizes multiple sequences and techniques to comprehensively evaluate liver tumors, diffuse diseases, and incidental findings.
MRI uses strong magnetic fields and radio waves to generate images of the inside of the body. It works by aligning hydrogen atoms in water molecules and fat in tissues when placed in a magnetic field. Radio waves are then used to stimulate the hydrogen atoms, which emit signals as they relax back to their original positions. These signals can be used to construct detailed images of tissues and organs inside the body. The document discusses key concepts in MRI physics including precession, relaxation times T1 and T2, spin echo and gradient echo sequences, and how varying pulse sequence parameters affects contrast in the resulting images.
Beam hardening artifact occurs when an X-ray beam passes through multiple materials of varying densities within a scan volume. This causes the beam to become harder as lower energy photons are preferentially absorbed, leading to streaks or shading in the reconstructed CT image. Photon starvation is another cause of streak artifacts, occurring when there is insufficient photon flux passing through areas of higher attenuation, such as across the shoulders. Adaptive filtering and modulating tube current based on attenuation can help reduce these artifacts. Ring artifacts from defective detector elements in older CT scanners appear as rings in the reconstructed images.
Superficial brain structures are drained by cortical veins and the superior sagittal sinus. Central brain structures drain into the deep venous system including the internal cerebral veins, vein of Galen, and straight sinus. The veins of Labbé and transverse sinuses drain the posterior temporal and inferior parietal lobes. MR venography and CT venography can assess the cerebral venous system, with each technique having advantages and disadvantages.
This document discusses lymphatic disorders and lymphoedema. It begins with an introduction to the lymphatic system and its functions. It then discusses causes of lymphatic swelling including acute lymphangitis, filariasis, and elephantiasis. It defines primary and secondary lymphoedema and covers the clinical features, investigations and treatments for lymphoedema including manual lymphatic drainage, compression garments, and surgery. Surgical procedures for lymphoedema including bypass operations, liposuction, and limb reduction techniques are described. The document concludes by discussing chylous ascites, chylothorax, and chyluria.
This document discusses non-contrast MR lymphography for evaluating the lymphatic system. It can be used to diagnose lymphedema through detecting fluid collections, infiltration patterns, and dermal thickening. It also describes evaluating lymph node metastasis, lymphangiomas, and other lymphatic abnormalities and complications. MR lymphography is non-invasive and can uniquely image lymphatic anatomy while having limitations in spatial resolution. It provides diagnosis and localization of various lymphatic diseases and postoperative conditions.
Lymphedema commonly affects one of the arms or legs. In some cases, both arms or both legs may be affected. Some patients might experience swelling in the head, genitals, or chest. Lymphedema is incurable, but with the right treatment, it can be controlled.
This document provides information about lymphoma, including Hodgkin lymphoma and non-Hodgkin lymphoma. It discusses the workup, tests, staging, prognostic factors like the International Prognostic Index, treatments, and management of lymphoma in both inpatient and outpatient settings. Key points covered include diagnostic testing like biopsies, immunophenotyping, common genetic translocations, associations with infections, and treatment approaches depending on factors like tumor stage and grade.
This document provides information on the hepatobiliary system and various imaging modalities used to evaluate it. It begins with an overview of ultrasound, CT, MRI, ERCP, and nuclear medicine techniques. Key anatomical structures such as the bile ducts and their drainage patterns are described. Various imaging protocols for MRCP, CT cholangiography, and secretin-enhanced MRCP are outlined. Advantages and limitations of different modalities like ERCP are also discussed.
This document provides information about the hepatobiliary system and various imaging modalities used to evaluate it. It begins with an overview of ultrasound, CT, MRI, ERCP, and nuclear medicine techniques. Key anatomical structures such as the gallbladder, bile ducts, and pancreas are described. Various imaging planes and protocols for MRCP and secretin-enhanced MRCP are outlined. ERCP, CT cholangiography, and T-tube cholangiography techniques are also summarized.
This document discusses the management of early laryngeal cancer. It covers diagnosis using laryngoscopy, radiological imaging like CT scans and MRI, and staging of laryngeal malignancies. Recommended treatments for early and late stage cancers are transoral laser microsurgery, radiotherapy, open partial laryngectomy, and total laryngectomy. Transoral laser microsurgery is described as the standard treatment for mid-cord glottic cancers and offers advantages like better voice quality and minimal swallowing difficulty compared to radiotherapy. Radiotherapy is an alternative organ-preserving option for early laryngeal cancers. Open partial laryngectomies include vertical and horizontal procedures tailored to the location and size of the tumor.
This document discusses lymphatic leaks and interventions to treat them. It begins by describing how leaks can occur after surgery and cause life-threatening issues if not treated. The standard treatment is conservative management or surgery, but percutaneous thoracic duct embolization is an alternative. The document then provides extensive details on lymphangiography techniques, anatomy of the lymphatic system, approaches for catheterization and embolization, and complications. It emphasizes the importance of understanding lymphatic anatomy for safely intervening in leaks.
This document discusses the anatomy and components of the lymphatic system. It describes lymphatic capillaries, vessels, trunks, and ducts. It then covers diseases related to the lymphatic system including lymphangitis, filariasis, lymphedema, and lymphangiomas. Diagnostic tests for assessing lymphatic patency like lymphangiography and lymphoscintigraphy are also mentioned. Conservative therapies and compression stockings for treating lymphedema are discussed.
This document discusses non-contrast magnetic resonance lymphography (MR lymphography) for evaluating the lymphatic system. It can provide excellent analysis of lymphatic vessels and nodes without contrast. MR lymphography is useful for diagnosing lymphedema and determining its severity. It can also identify abnormalities like cystic lymphangiomas, lymphatic dilatations, and evaluate postoperative complications involving lymphatic leaks or collections. While the spatial resolution is still suboptimal, MR lymphography provides a unique non-invasive way to examine lymphatic system anatomy and various common and uncommon pathologies.
This document discusses retroperitoneal lymph node dissection (RPLND) and its complications. It provides a history of RPLND, describes the lymphatic drainage patterns of the testis and rationale for RPLND. It outlines the evolution of surgical templates for RPLND including modifications to reduce complications like loss of antegrade ejaculation. The document discusses indications for primary, post-chemotherapy and salvage RPLND. It provides details of surgical techniques including approaches, lymphadenectomy procedures and nerve-sparing techniques.
The document describes the anatomy, blood supply, innervation, and common cancers of the urinary bladder. It discusses the following key points:
- The bladder wall has four layers - serous, muscular, submucosal, and mucosal coats. The detrusor muscle in the muscular layer allows the bladder to expand and contract.
- The main arteries supplying the bladder are branches from the internal iliac arteries. Lymph drainage is to the external and internal iliac and sacral nodes.
- Over 90% of bladder cancers are transitional cell carcinomas. Risk factors include smoking, occupational exposures, schistosomiasis infection, and certain drugs.
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Lymphedema is swelling caused by impaired lymphatic drainage. It is classified as primary or secondary and staged clinically. Treatment involves complex decongestive therapy with skin care, manual lymphatic drainage, compression bandaging, and exercise in two phases. For severe cases, surgery such as lymphovenous anastomosis or tissue resection may be considered after conservative therapy. Proper management can control swelling and prevent complications like infection or lymphangiosarcoma.
1. Endoscopic mucosal resection (EMR) during colonoscopy allows for the complete and safe removal of colorectal lesions, helping to prevent colorectal cancer. EMR has been shown to reduce CRC mortality by up to 50% when removing adenomas.
2. EMR is a multi-step process involving injection of a solution beneath the lesion, followed by snare excision of the lesion in a single piece (en bloc) for smaller lesions, or in multiple pieces (piecemeal) for larger lesions.
3. Complications of EMR include bleeding, perforation, and recurrence of adenomas, but these are generally minor and managed endoscopically or conservatively. Metic
Magnetic resonance cholangiopancreatography pptAnjan Dangal
1. MRCP is a non-invasive MRI technique used to visualize the biliary and pancreatic ducts without the need for intravenous or oral contrast agents.
2. It takes advantage of the inherent contrast between fluid-filled structures and surrounding tissues on heavily T2-weighted sequences.
3. MRCP provides high diagnostic accuracy to evaluate the biliary tree, pancreas, and associated organs for any obstructions or other pathologies.
This document discusses development of percutaneous mitral valve repair techniques and clinical trials. It provides background on chronic mitral regurgitation (MR) and the limitations of medical and surgical treatment. Percutaneous mitral valve repair offers benefits over surgery like reduced morbidity and shorter recovery. The document describes the four main percutaneous repair methods and focuses on the MitraClip edge-to-edge leaflet repair system, including patient selection criteria, procedure steps, and clinical trial results demonstrating safety and effectiveness for treating MR.
This document provides an overview of radiotherapy planning techniques for lymphoma. It discusses the main types of lymphoma and stages. For Hodgkin's lymphoma, involved node radiotherapy (INRT) targets only the originally involved nodes before chemotherapy based on pre-and post-chemotherapy PET/CT scans. For non-Hodgkin's lymphoma, radiotherapy doses and fields depend on the lymphoma type and response to chemotherapy. Techniques have evolved from extended field radiotherapy to involved field and now INRT to reduce normal tissue irradiation. Contouring for INRT involves delineating the pre-chemotherapy involved node volumes on planning CT based on fused pre-treatment PET/CT scans.
1. Treatment of colon carcinoma involves surgical resection of the primary tumor with adequate margins along with lymph node dissection and reconnection of the gastrointestinal tract. The extent of resection depends on the location and spread of the cancer.
2. Thorough knowledge of the blood supply and lymphatic drainage of the colon is important for surgery planning. Nutritional status, bowel preparation with antibiotics, and thromboembolic prophylaxis are important preoperatively.
3. Post-operatively, adjuvant chemotherapy may be administered depending on cancer stage and other risk factors. Patients are monitored closely with follow-up imaging and tumor marker screening.
This document provides an overview of the anatomy and imaging of the lymphatic system. It describes the main functions and components of the lymphatic system, including lymph, vessels, nodes, tonsils, spleen, thymus and bone marrow. It then explains the pathway of lymph flow and structure of lymphatic vessels. Various invasive and non-invasive imaging techniques for the lymphatic system are outlined, such as pedal lymphangiography, intranodal lymphangiography, and retrograde lymphangiography approaches.
Lymphedema is diagnosed clinically through patient history and physical examination. It occurs when lymphatic fluid accumulates in the skin and tissues, stimulating fibroblasts and deposition of collagen. Diagnostic imaging tools include lymphoscintigraphy, MRI lymphography, and CT scans to visualize lymphatic structures and evaluate function. Treatment involves meticulous skin care combined with physical therapy, compression garments, and surgery such as lymph node transplantation or lymphatic-venous bypass to restore lymphatic drainage.
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share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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2. The lymphatic system is an important component of the circulatory system
Lymph constitutes the excess of tissue fluid, which is derived from blood
plasma and removed from the interstitial tissue via the lymphatic system.
Lymph contains nutrients, hormones, fatty acids, toxins, and cellular waste
products.
Most of the lymphatic system consists of a network of small vessels; hence
it is difficult to image it and especially to introduce contrast media into
these small lymphatic ducts. However, in the last few years, the lymphatic
imaging has been advanced by combining soft tissue contrast and
resolution offered by MR imaging, supplemented by the injection of
contrast media via a lymph node.
INTRODUCTION
4. The lymphatic system consists of ,
A) Small terminal lymphatic ducts that be divided into 3 types depending on
their origin,
Soft tissue -Lower concentration of proteins in the peripheral lymph (17%–
30%of the blood level)
Liver - Contains the highest concentration of proteins of all lymph (80%–
90% of the blood level)
Intestinal lymphatic ducts {higher concentration of lipids and proteins
(60% of the blood level)}-CHYLE
ANATOMY OF THE LYMPHATIC SYSTEM
5. B) Lymph nodes- Regulate the composition of lymph and mount an immune
response if pathogens are detected.
7. METHODS OF IMAGING THE LYMPHATIC SYSTEM
Modalities of lymphatic imaging include ,
A) Lymphoscintigraphy
• Lymphoscintigraphy is performed by injection of radioactive tracers
intracutaneously or subcutaneously into the feet or hands. The tracers are
rapidly absorbed into terminal lymphatic ducts.
• Lympho-scintigraphy provides dynamic information but lacks spatial
resolution and anatomic details.
• Lymphoscintigraphy is often used to identify the sentinel lymph node, or
the first node to receive the lymph drainage from a tumor
8.
9. B) Fluoroscopic Peripheral and central Lymphangiography
It is performed through cannulation of peripheral lymphatic ducts on the
dorsum of feet or hands, interstitial injection into interdigital web spaces,
or cannulation of lymph nodes in the groins and injection of iodized oil-
based contrast media(Lipiodol)
Advantages: Excellent spatial resolution
Disadvantages:
Exposure to ionizing radiation
Longer examination time than DCMRL
Limited dynamic information due to slow movement of viscous contrast
media
Paradoxical embolization
12. C) Peripheral Magnetic Resonance Lymphangiography
• Lymphatic ducts in the lower and upper extremities can be imaged by MR
imaging using T2-weighted images or with injection of GBCM into the
dermal plane in the feet and hands on T1-weighted images
• Effectively plan treatments such as lympho-venous bypass in cases of
lymphedema
17. • The patient is placed supine on a detachable MR imaging table, outside the
scanning room, with posterior elements of the torso coil underneath the
patient before the start of cannulation. Anterior elements of the coil are
placed when the patient is taken into the scanner, after the lymph node
cannulation.
Positioning
18. • Both inguinal regions are prepared and draped under sterile conditions.
Under ultrasound guidance, a 22- to 25-gauge needle is placed in the
medulla of an inguinal lymph node on each side.
Lymph Node Cannulation
19.
20. • Endotracheal intubation was considered essential in all patients
because of age or coexisting morbidities that resulted in an
inability to perform repeated breath-hold sequences for 20–
30seconds, which are required for the dynamic T1-weighted
high-resolution imaging with volumetric excitation
(THRIVE)sequence.
21. • Any routinely used GBCM can be used for DCMRL.
• Dose : 0.1 mmol/kg used for routine intravenous injection. 0.2 mmol/kg
can be used occasionally in larger patients.
• Dilution: Diluted with normal saline 1:1 for older children and adults and
1:2 or 1:3 for younger children to reduce T2 effects of concentrated
gadolinium causing darkening from paramagnetic effects of undiluted
gadolinium.
• The total volume is divided and half of the amount is injected on each
side. The entire tubing is primed with contrast containing solution. A
syringe with normal saline is also attached to the 3-way stopcock on each
side to flush the system and push the contrast remaining in the tube.
Contrast Media
22. • FOV: Mid-neck to the lesser trochanter
• The 16-channel torso phased arraycoil, with a 55-cm area of coverage by
the MR coil was preferred,
• The 2 main components of central MR lymphangiography include T2-
weighted imaging and postcontrast dynamic T1-weighted imaging
(DCMRL), both acquired with fat suppression.
MR Imaging Examination
23.
24. T2-weighted images
Advantages:
• T2-weighted images help to localize areas of lymphedema, which may
remain undetected by DCMRL.
• They also provide anatomic information of the cisterna chyli and
thoracic duct that can be complementary to DCMRL in cases where the
contrast does not propagate into the thoracic duct due to distal
obstruction or lymph leak.
• Static, noncontrast T2-weighted MR lymphangiography can be useful in
procedural planning for DCMRL and potential intervention. There are
no data on frequency of visualization of cisterna chyli and thoracic duct
on heavily T2-weighted images.
25.
26. Limitations:
• Difficulty to visualize smaller lymphatic ducts because of insufficient
signal from small amounts of fluid within them and difficulty to
differentiate lymphatic ducts from other overlapping fluid-containing
structures and veins.
• It is a static imaging technique that lacks dynamic information,
which is important when it comes to demonstrating lymphatic reflux
or leakage
31. • PB is a potentially fatal condition involving airway obstruction caused by
casts that can lead to significant asphyxia.
• It is characterized by expectoration of branching bronchial casts that are
formed by exudation of proteinaceous material and sometimes cells in the
airway. PB can occur in patients,
• After single-ventricle palliation, cystic fibrosis, sickle cell anaemia, asthma,
and lymphangiomatosis.
• Fontan patients(prevalence 4%)
• Lymphatic plastic bronchitis
1) PLASTIC BRONCHITIS
38. Chylothorax and chyloperitoneum can be congenital and isolated or
associated with lymphatic dysplasia. They can occur secondary to trauma,
surgery, severe infection such as tuberculosis or fungal infestations, as well
as malignancy
2) CHYLOTHORAX AND CHYLOPERITONEUM
42. • Protein losing enteropathy (PLE) is characterized by rapid loss of serum
proteins into the gut lumen. The resulting hypoproteinemia can lead to
edema, ascites, pleural, and pericardial effusions due to an imbalance
between oncotic and hydrostatic pressures.
• PLE is either caused by lymphatic abnormalities or chronic mucosal injury
as occurs in inflammatory bowel disease or neoplasm.
• elevated CVP
• Abnormal lymphatic flow /lymphangectasia
3) PROTEIN LOOSING ENTEROPATHY
43.
44.
45. • Biko and colleagues have reported intrahepatic DCMRL that involves
injection of GBCA directly in the liver lymphatics and tracking the
passage of contrast using T1-weighted MR images
• Liver lymphangiography is performed by inserting a 25- gauge needle in
the periportal space. This technique facilitates the diagnosis of protein-
loosing enteropathy and chylous ascites.
57. • DCMRL is a novel technique to image CCLs performed by injecting GBCA
into groin lymph nodes and following the passage of contrast through
the lymphatic system using T1-weighted MR images. To date, it has been
successfully applied to image and guide treatment of the lymphatic
abnormalities associated with Fontan procedure such as plastic
bronchitis. It is also useful in the assessment of chylothorax and
chyloperitoneum and their potential treatment planning. Its role in other
areas such as intestinal lymphangiectasia and lymphatic anomalies is
likely to increase.
Summary
58. References
Magnetic Resonance Lymphangiography -Govind B. Chavhan,
MD, DABR,*, Christopher Z. Lam, MD, Mary-Louise C. Greer, MD,
Michael Temple, MD, Joao Amaral, MD, Lars Grosse-Wortmann, MD
Chavhan GB, Amaral JG, Temple M, et al. MR lymph-angiography in
children: technique and potential applications. Radio graphics
2017;37(6):1775–90.
Betterman KL, Harvey NL. The lymphatic vasculature: development and
role in shaping immunity. Immunol Rev 2016;271(1):276–92.
Dori Y, Zviman MM, Itkin M. Dynamic contrast-enhanced MR
lymphangiography: feasibility study in swine. Radiology
2014;273(2):410–6.
which result from accumulation of tissue fluids due to impaired lymphatic drainage.
These advances have focused on the visualization of the central conducting lymphatics (CCLs) such as the cisterna chyli and thoracic duct by dynamic contrast-enhanced magnetic resonance lymph-angiography (DCMRL) as well as in the imaging of the extremity’s lymphatic system. This review discuss the anatomy of the lymphatic system and various methods of imaging of the lymphatic system and focus on the DCMRL technique along with its current and potential clinical applications.
The right lymphatic duct is short (approximately 1.25 cm)
The thoracic duct is a long channel, measuring approximately 38 to 45 cm in adults.
The cisterna chyli measures approximately 5 to 20 mm in width and 5 to 7 cm in craniocaudal dimension in adults
The anatomy of the thoracic duct is variable. Similarly, the cisterna chyli can have variable shape including an inverted Y or V and a string of pearls.
The thoracic duct transports approximately 1.5 to 2.5 L of lymph/chyle daily.
Over the years, imaging of the lymphatic system has evolved from direct lymphangiography through cannulation of peripheral lymphatic ducts on the dorsum of feet and hands and interstitial in-jection of contrast media into interdigital web spaces to injection of contrast media directly into lymph nodes.1
Tc-99 sulphur colloid-45min- static/dynamic
Melanoma
Gamma camera
Spect ct
35-year-old man with left chylothorax after lung biopsy using video-assisted thoracoscopy.
A. Axial CT scan obtained one week prior to LG shows large amount of left pleural effusion (chylothorax). B. Isolated lymphatic of dorsum of right foot was cannulated using 30-G LG needle and both needle and lymphatic were firmly tied (arrow). C. Radiographic image obtained 5 minutes following Lipiodol injection shows Lipiodol extravasation (arrows) at calf level. D Radiographic images obtained 15 minutes following Lipiodol injection show good opacification of inguinal and pelvic lymph nodes as well as ascending lymphatics. F, G. Radiographic anteroposterior and lateral images obtained one hour following Lipiodol injection show pseudoaneurysm-like leakage (arrows) of Lipiodol at 9th thoracic spine level. H. CT reconstructed image obtained 5 hours following LG shows leakage site (arrow) adjacent to descending thoracic aorta and prominent Lipiodol leakage to left lung. Left chest tube draining 700 mL per day was eliminated three days after LG. LG = lymphangiography
21-year-old woman with bilateral primary lymphoedema. Angled three-dimensional (3D) spoiled gradient echo magnetic resonance lymphography (MRL) maximum intensity projection (MIP) image, obtained 45 min after Gadoteridol injection, clearly depicts a reticular network of enlarged lymphatic vessels in both lower legs (small arrows). Furthermore, areas of dermal backflow are revealed bilaterally, indicating delayed lymphatic flow with neovascularization due to obstruction (asterisks). Note the concomitantly enhanced veins in both lower legs (arrowheads).
A small volume of saline is gently injected to confirm the needle is appropriately located within the medulla and to ensure there is no extravasation. Injection of saline increases the size of the node
The needle is then connected to long 21-inch tubing with a 3-way stopcock on the end and taped in place
Syringes with contrast media (dilute gadolinium) and saline flush are connected to the 3-way stopcock
The patient is then transferred to the MR imaging scanner.
Groin lymph node cannulation for MR lymphangiography in an 8-month-old baby. Longitudinal ultra-sound image of the left groin (A, B) shows a lymph node (arrowheads) with a needle (arrow) within the central echogenic medulla. The lymph node size increases with injection of saline (B).
The patient is placed on the detachable MR table in the preparatory room, just outside the imaging room, with the posterior elements of a 16-channel torso phased-array coil in place. Both inguinal regions are prepared and draped. Each angiographic catheter is connected in sequence to a short T-connector, a proximal three-way stopcock, 21-inch tubing, and a distal three-way stopcock. The distal three-way stopcock is connected tosyringes that are prefilled with the mixture of gadolinium-based contrast material and normal saline. A, The configuration of the connections. B, A plastic shield is placed over the abdomen and pelvis to protect the sterile field to avoid dislodgement of the intranodal cannula and to lift the weight of the anterior coil off of the patient. C, The anterior component of the coil is placed over the shield. This setup provides a large field of view from the lower neck to the inguinal regions.
A precontrast mask is acquired that is used for subtraction. The images are acquired every minute from the start of intranodal injection of contrast until it reaches the venous angle between left subclavian and left internal jugular veins.
The dynamic images are reformatted using maximum intensity projection.
Variable morphology of cisterna chyli. (A) Coronal T2-weighted image of the abdomen in a 17-year-old boy with nonspecific abdominal pain shows a usual slightly bulbous cisterna chyli (arrow). (B) Coronal T2-weighted MRCP image in a 10-year-old child with history of choledochal cyst resection demonstrates an irregular cisterna chyli (arrow) joined by lumbar trunks. (C) Coronal T2-weighted MRCP image in another 15-year-old child with choledocholithiasis demonstrates a thin tubular cisterna chyli (arrow).
It demonstrates normal central con-ducting lymphatics. Coronal 3D T1-weighted images at 4 minutes (A), 5 minutes (B), 6 minutes (C), 7 minutes (D), and 8 minutes (E) after injection of contrast demonstrate progressive passage of the contrast (arrows) up to the venous angle (arrowhead).
A–E, Selective thick-slab maximum intensity
projections at different time-points after intranodal contrast material injection. contrast material appears in the retroperitoneal lymphatics within 2 minutes (arrow in B)and in the thoracic duct (thick white arrow in C and D) and venous angle within 4–8 minutes (thin white arrow in D). Depending on the volume of injection, contrast material washes out of the CCL in 15–20 minutes. Transient stasis or pooling of contrast material proximal to the venous angle insertion (thin white arrow in C and D)is considered a normal finding related to bolus injection of contrast material in the CCL. There is progressive accumulation of contrast material in the renal collecting system on the delayed images consistent with venous entry of contrast material.
DCMRL therefore playsan important role in planning of the embolization treatment in these patients. Elevated CVP in TCPC results in increased lymph production, mainly by the liver as well as increased impedance to lymphatic drainage. This causes congestion in the central lymphatic system, and in the presence of PLPS, it can result in overflow of lymph into the lung parenchyma and/or into the airways, resulting in protein leakage into the airways. This may be mediated by a potential inflammatory component, as evidenced by presence of fibrin and inflammatory cells in bronchial casts of Fontan patients with plastic bronchitis.
Chest plain radiograph demonstrate consolidation and atelectasis at the right lobe.
Chest CT shows multifocal consolidation, atelectasis, airway stenosisand mucus plug.
The MRI scan demonstrated the presence of a dilated right-sided peribronchial lymphatic network supplied by retrograde lymphatic flow through a large collateral lymphatic vessel originating from the thoracic duct.
Selective embolisation
Plastic bronchitis in a 4-year-old child with Fontan surgery. Coronal 3D T1-weighted images with thin maximum intensity projection (MIP) reconstruction at 8 minutes (A), 10 minutes (B), and 16 minutes (C) after injection of contrast demonstrate an abnormal ectatic lymphatic duct extending from retroperitoneum to the left side of superior mediastinum (arrows), lymphangiectasia in retroperitoneum (arrowheads) and mediastinum (arrowheads),and extensive and progressive chylolymphatic reflux into left supraclavicular and axillary lymph nodes. There is also chylolymphatic reflux into the lungs (dashed arrows).
Time lapse DCMRL in plastic bronchitis
Congenital left chylothorax in a 7-week-old baby. Coronal 3D T1-weighted images precontrast (A) and18 minutes after injection of contrast (B) demonstrate left pleural effusion with opacification on postcontrast image suggesting lymphatic leak (dashed arrows). A thin MIP reconstruction image (C) shows abnormal tortuous CCL (arrowheads) without a single normal looking thoracic duct and chylolymphatic reflux into left pleural cavity(arrows).
Congenital chyloperitoneum in an 8-week-old baby from chyle leak. Coronal T2-weighted (A), and post nodal injection coronal 3D T1-weighted images at 3 minutes (B) and 15 minutes (C) after injection of contrast
demonstrate contrast leakage from retroperitoneal lymphatic channel (arrow on B) with progressive opacification of ascites on left side of the abdomen.
Chylolymphatic reflux and pulmonary lymphangiectasia in a 13-year-old girl with recurrent chylopericardium and chylothorax. A, B, Rapid opacification of normal pelvic and retroperitoneal lymphatics. C, D, The cisterna chyli and thoracic duct appear at 7–8 minutes; there is apparent narrowing at the junction
of the middle and superior thirds of the thoracic duct (arrow), but no obstruction to transit of contrast material. At 8–9 minutes, there is chylolymphatic reflux (arrows in F, G, I, K) from the thoracic duct into dysplastic lymphatic channels in the mediastinum, left lower lobe, and pleura, which progresses over the next 10 minutes(E–L). M, Delayed 40-minute image shows pooling of contrast material within the pericardial (thick arrow) and pleural (thin arrow in L and M) spaces with washout of contrast material from the CCL.
Protein losing enteropathy (PLE) in a 23-month-old child. Axial T2-weighted images of the abdomen (A,B) demonstrate mild ascites, mesenteric edema, and diffuse bowel wall thickening in keeping with PLE. This child
had normal CCL as demonstrated
14-year-old male with ahistory of hypoplastic left heartsyndrome post Fontan palliation who presents with protein-losingenteropathy (PLE). a Coronalplane of T2-weighted imaging ofthe abdomen and chest in a patient b with PLE showing the duodenum(arrow) with minimal fluid and no significant T2 signal. b In a coronalplane at the same location , a high-resolution contrast-enhancedT1 sequence shows enhancement of the duodenum(arrow) consistent with PLE
22-year-old female with a history of hypoplastic left heart syndromepost Fontan palliation who presents with protein-losing enteropathy(PLE). a–f Time series of intrahepatic dynamic contrast magneticresonance lymphangiography (IH-DCMRL) showing coronal maximum intensity projections of the abdomen and chest. a At the time of the start of injection (t = 0) showing the site of injection (arrow). b At 2 min afteri njection demonstrating contrast moving along the hepatic lymphatic system(arrow) and exiting into the hepatic hilum (arrowhead). c At 3 minafter injection showing contrast beginning to leak into the duodenum(arrow) and opacifying the thoracic duct (TD) (arrowhead). d At4.5 min after injection demonstrating further filling of the duodenumand hilar lymphatic channels (arrow). e At 8.5 min after injection where there is complete filling of the first portion of the duodenum (arrow) aswell as hepatic, hilar, retroperitoneal lymphatics, and the TD. f A more
delayed coronal image obtained 12 min after injection shows enhancementof the duodenal wall (arrowhead) and filling of the duodenal lumenwith contrast. h Confirmation of the MRI findings was demonstrated by intrahepatic injection of blue dye with endoscopy showing a leak into the duodenal lumen
Magnetic resonance enterography image showing a thickened lymphangiectatic duodenal loop (arrow) corresponding to loss of lymph throughout the duodenal loop.
Selective intranodal magnetic resonance lymphangiogram recorded prior to embolization showing enhanced contrast medium uptake by the lymphatic system and retrograde flow into the intestinal lymphatics from the intestinal lymphatic trunk, confirming a duodenal obstruction.
Selective glue embolization of the refluxing and leaking intestinal lymphatic trunk with n-butyl-2-cyanoacrylate (n-BCA) liquid embolic system (Trufill; Cordis Neurovascular, Miami Lakes, FL, USA) resulted in rapid reversal of the PLE over just a few weeks after the procedure
Gastrointestinal endoscopy image showing chylous lymphangiectasia localized to the duodenal loop (A, B) and complete resolution after the procedure (C, D).
MRI lymphangiography. (A) Unenhanced coronal T2 MRI sequence of the abdomen demonstrates multiple large T2 hyperintense lymphatic masses (black stars). (B) Coronal MR sequence following injection of contrast through bilateral inguinal lymph nodes demonstrates only partial opacification of these masses (black stars). her diarrhea
Fluoroscopic image of n-BCA glue injection into the periduodenal mass (white arrowhead) through 25 G needle (black arrow). Note the contrast in the duodenum (black stars).cessation of her diarrhea, and two days after the procedure she was discharged to home. Two weeks later, she reported near complete resolution of soft tissue edema, relief of abdominal pressure and return of regular bowel movements. Her weight decreased from 135 lbs. to 116 lbs. and her albumin increased from 1.7 g/dL to 2.7 g/dL.
Retroperitoneal lymphangiectasia in a 29-year-old woman with chronic lymphedema of the left lower extremity, with multiple large cysts in the inguinal region and retroperitoneum, after repeated surgical excisions of lymphatic cysts and sclerotherapy .Because of progression of the cystic collections and lower extremity edema, dynamic MR lymphangiographic imaging was performed to evaluate the integrity of the CCL and to determine if lymphatic dysplasia, rather than lymphatic malformation, was the origin of the cystic collections. A, There is severe left lower extremity edema with soft-tissue overgrowth. B, C, D, Short t inversion recovery images demonstrate large cystic collections in the inguinal
region that extend into the left retroperitoneum (arrow in B) and subcutaneous edema of the left lower extremity (C) and lateral abdominal wall (D),which may be collateral pathways for lymphatic flow from the lower extremities. E, F, After a right-sided inguinal nodal injection, there is reflux of contrast material from the right-sided retroperitoneal channels into aneurysmal dysplastic lymphatic channels in the left side of the retroperitoneum and pelvis (arrows in E, F). The thoracic duct was not visible, even on delayed images, because of pooling of injected contrast material within the dysplastic lymphatics and resultant poor antegrade transit of contrast material.
DCRML imaging of the patient with GLA and bilateral pleural effusion demonstrates normal size TD (white arrow) and abnormal pulmonary lymphatic perfusion that originates in the left retroperitoneum and extends into the mediastinum and left pleural cavity (black arrowheads).
DCRML imaging of the patient with GLA, and progressive deterioration of pulmonary function and hemoptysis demonstrated dilated TD (white arrow) and abnormal pulmonary lymphatic perfusion that originates in the distal TD toward lung parenchyma (white arrowheads).