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ESSENTIALS OF LIVER IMAGING

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ESSENTIALS OF LIVER IMAGING

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    1. ESSENTIALS OF LIVER IMAGING

    2. Website: http://brighamrad.harvard.edu/rsna2003/course995/ E-mail Addresses: pros@partners.org valarie.vilgrain@bin.ap-hop-paris.fr kmortele@partners.org

    3. ESSENTIALS OF LIVER IMAGING: WHAT YOU NEED TO KNOW

    4. ESSENTIALS OF LIVER IMAGING: WHAT YOU NEED TO KNOW

    5. FOCAL LIVER LESIONS: TECHNIQUE CT Thin sections (ATAP) Multiphasic enhancement (AMAP) MRI T1 and T2 Breathold Gadolinium (almost always) Specific contrast agents (occasionally)

    6. FOCAL LIVER LESIONS: ESSENTIAL PROCESSES (BIG 8) Hemangioma Focal Nodular Hyperplasia (FNH) Hepatocellular Adenoma (HCA) Metastasis Hepatocellular Carcinoma (HCC) Focal fatty change (FFC) Cyst (Bile duct cyst) Abscess

    7. FOCAL LIVER LESIONS: CLINICAL FACTORS - GENDER Female predominance HCA (almost always) FNH (overwhelming predominance) Hemangioma (predominantly) Male predominance HCC Abscess

    8. FOCAL LIVER LESIONS: CLINICAL FACTORS - AGE 60s Cyst, Metastasis, HCC 50s Cyst, Hemangioma, Metastasis, Abscess 40s FNH, Abscess 30s HCA

    9. FOCAL LIVER LESIONS: CLINICAL FACTORS - SYMPTOMS Symptomatic HCC HCA Metastasis (primary) Abscess Asymptomatic (incidentaloma) Hemangioma Cyst FNH FFC

    10. FOCAL LIVER LESIONS: CHARACTERISTIC FINDINGS HEMANGIOMA Enhancement pattern (CT and MRI) Peripheral Nodular Same attenuation than aorta Delayed, slow filling Morphology Well defined (sharp margins) Lobulated Normal liver contour Signal Intensity T2 (light bulb sign)

    11. FOCAL LIVER LESIONS: CHARACTERISTIC FINDINGS FNH Reticuloendothelial system (RES) activity Uptake ferumoxides, sulfur colloid Homogeneous Central scar Low attenuation, high signal (T2) Vessels No calcification Enhancement Rapid fill in (bright, arterial phase) Rapid washout (disappears, venous phase) Delayed enhancement of scar

    12. FOCAL LIVER LESIONS: CHARACTERISTIC FINDINGS HCA Only if hemorrhagic Large size Heterogeneous Hemosiderin rings Other findings Fat content Multiple Fatty liver Women, OC

    13. FOCAL LIVER LESIONS: CHARACTERISTIC FINDINGS HCC Cirrhosis - Malignant Nodules Arterial enhancement High signal (T2), no hemosiderin Cirrhosis background Multiple No cirrhosis Single, large Encapsulated Fat Vascular invasion

    14. FOCAL LIVER LESIONS: CHARACTERISTIC FINDINGS METASTASIS Multiple Known malignancy Peripheral halo Enhancement Hypovascular If hypervascular, rapid washout Calcification

    15. FOCAL LIVER LESIONS: CHARACTERISTIC FINDINGS FOCAL FAT Low attenuation Well demarcated Straight margins Normal liver contour Normal vasculature Typical locations (periportal, falciform ligament)

    16. FOCAL LIVER LESIONS: CHARACTERISTIC FINDINGS CYST (BDC) Smooth wall Water density No enhancement No septa

    17. FOCAL LIVER LESIONS: CHARACTERISTIC FINDINGS ABSCESS Low attenuation Heterogeneous Multiseptated Clustered satellite lesions Rim enhancement Air Clinical picture

    18. ESSENTIALS OF LIVER IMAGING

    19. DIFFUSE LIVER DISEASE: CT TECHNIQUE

    20. DIFFUSE LIVER DISEASE: MRI TECHNIQUE FAT: T1 fat saturation water selection in and opposed phase imaging IRON: T2 and T2*

    21. STEATOSIS Accumulation of lipid within the cytoplasm of hepatocytes Alcohol, obesity, diabetes mellitus, hepatitis, drugs, hyperalimentation ? steatohepatitis NASH ballooning degeneration inflammation and fibrosis

    22. STEATOSIS US: increased echogenicity and sound attenuation Non contrast CT: liver-spleen attenuation difference > 10 HU

    23. STEATOSIS

    24. IRON OVERLOAD Hepatic parenchymal deposition of iron Hereditary hemochromatosis, cirrhosis and hemolysis Reticuloendothelial deposition Transfusion-related iron overload states

    25. IRON OVERLOAD Non CE CT increased density (> 75 HU) MR imaging T2-: decreased SI T2*-W GE: most sensitive liver/spinal muscles SI

    26. CIRRHOSIS Extensive fibrosis and regenerative nodules Micro or macronodular pattern Main causes alcohol ingestion chronic hepatitis C chronic hepatitis B hemochromatosis Wilson disease

    27. CIRRHOSIS Morphologic criteria Hypertrophy of caudate lobe Atrophy of segment 4 Atrophy of the right liver

    28. CIRRHOSIS Other signs Expanded gallbladder fossa Enlargment of hilar periportal space Enlargment of the spleen Ascitis Portocaval collaterals

    29. CIRRHOSIS Score Surface, parenchymal texture, hepatic vessels + spleen length Se 83% Sp 80% Surface nodularity + mean portal velocity Se 87% Sp 98% Spleen length accuracy 84% + mean portal velocity Lin. JCU 1993 Gaiani. J Hepatol 1997 Aub. J Hepatol 1999

    30. HEPATOSPLENIC SCHISTOSOMIASIS Schistosoma mansoni presinusoidal PHT Granulomatous reaction in the periportal zones +fibrosis Grade 1 Grade 2 Grade 3 Schistosoma japonicum Richter. Radiology 1992

    31. HEPATIC VENOOCCLUSIVE DISEASE Early complication of: intensive chemotherapy radiation therapy Lesions of the endothelium, hepatocyte damage US: score based on morphologic and Doppler criteria CT and MR: portal hypertension Lassau. Radiology 1994

    32. CONGENITAL HEPATIC FIBROSIS Periportal fibrosis and irregularly shaped proliferating bile ducts Caroli disease may be associated Imaging: morphologic changes of the liver PTH

    33. PRIMARY BILIARY CIRRHOSIS Chronic progressive cholestatic liver disease destruction of small intrahepatic bile ducts Inflammation progressive scarring Most common in middle-aged woman Imaging: enlarged or normal liver smooth contour fibrosis and regenerative nodules portal hypertension lymphadenopathy Blachar. Radiology 2001

    34. BUDD-CHIARI SYNDROME Hepatic venous outflow obstruction due to thrombosis of the main hepatic veins in patients with hypercoagulable states Imaging: abnormalities of the main hepatic veins hepatic venous collaterals enlargment of the caudate lobe peripheral patchy enhancement

    35. HEPATIC CONGESTION Elevated hepatic venous pressure Decreased hepatic blood flow fibrosis Imaging dilatation of IVC and hepatic veins Patchy enhancement

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