Hjr Radiology T11 Iss1

ISSN 2529-0568 2654-1629 JANUARY - MARCH 2026 | VOLUME 11, ISSUE 1

J

90 ΧΡΟΝΙΑ

Quarterly Publication by the Hellenic Radiological Society

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ΑΓΚΦΑ-ΓΚΕΒΕΡΤ Μον/πη ΑΕΒΕ

Αχαρνών 481, 143 43 Ν. Χαλκηδόνα

Τηλ.: 210.5706565 Fax: 210.5706600

e-mail: athanasios.tsegkos@agfa.com

ΠΕΡΙΛΗΨΗ ΤΩΝ ΧΑΡΑΚΤΗΡΙΣΤΙΚΩΝ ΤΟΥ ΠΡΟΙΟΝΤΟΣ

1. ΟΝΟΜΑΣΙΑ ΤΟΥ ΦΑΡΜΑΚΕΥΤΙΚΟΥ ΠΡΟΙΟΝΤΟΣ Ultravist® 300, Ενέσιμο διάλυμα, 62,34% (30% ιώδιο). Ultravist® 370, Ενέσιμο διάλυμα,

76,9% (37% ιώδιο). 2. ΠΟΙΟΤΙΚΗ ΚΑΙ ΠΟΣΟΤΙΚΗ ΣΥΝΘΕΣΗ Ultravist 300: 1 ml περιέχει 623,4 mg ιοπρομίδης (αντιστοιχεί σε 300 mg ιωδίου),

Ultravist 370: 1 ml περιέχει 768,86 mg ιοπρομίδης (αντιστοιχεί σε 370 mg ιωδίου), Έκδοχο: Κάθε ml περιέχει 0,01109 mmol (αντιστοιχεί σε

0,2549 mg) νατρίου (βλ. Παράρτημα 1), Για τον πλήρη κατάλογο των εκδόχων βλ. παράγραφο 6.1. 3. ΦΑΡΜΑΚΟΤΕΧΝΙΚΗ ΜΟΡΦΗ Ενέσιμο

διάλυμα, Διαυγές, άχρωμο έως υποκίτρινο διάλυμα. Οι φυσικο-χημικές ιδιότητες του Ultravist στις διαφορετικές συγκεντρώσεις είναι οι εξής:

Συγκέντρωση ιωδίου (mg/ml) 300 370

Ωσμωτική γραμμομοριακή περιεκτικότητα (οsm/kg H2O) σε 37°C 0,59 0,77

Ιξώδες (mPa·S)

σε 20°C

σε 37°C

Πυκνότητα (g/ml)

σε 20°C

σε 37°C

8,9

4,7

1,328

1,322

22,0

10,0

1,409

1,399

Τιμή pH 6,5-8,0 6,5-8,0

4. ΚΛΙΝΙΚΕΣ ΠΛΗΡΟΦΟΡΙΕΣ 4.1 Θεραπευτικές ενδείξεις Αυτό το προϊόν είναι μόνο για διαγνωστική χρήση. Για ενίσχυση της σκιαγραφικής

αντίθεσης. Για ενδοαγγειακή χρήση και χρήση σε κοιλότητες του σώματος. Ultravist 300: Eνδοφλέβια πυελογραφία, Αγγειογραφία σπλάχνων,

Αγγειογραφία εγκεφάλου, Αγγειογραφία άκρων, Αξονική τομογραφία, Ψηφιακή αφαιρετική αγγειογραφία, Σκιαγράφηση κοιλοτήτων (με

εξαίρεση τη μυελογραφία, την κοιλιογραφία και την ακτινογραφία των κοιλιών του εγκεφάλου). Για χρήση σε ενήλικες γυναίκες σε ψηφιακή

μαστογραφία με έγχυση σκιαγραφικού για την αξιολόγηση και την ανίχνευση γνωστών ή ύποπτων βλαβών του μαστού, ως συμπληρωματική

εξέταση στη μαστογραφία (με ή χωρίς υπέρηχο) ή ως εναλλακτική της μαγνητικής τομογραφίας (MRI) όταν η μαγνητική τομογραφία αντενδείκνυται

ή δεν είναι διαθέσιμη. Ultravist 370: Eνδοφλέβια πυελογραφία, Αγγειοκαρδιογραφία, Αξονική τομογραφία, Ψηφιακή αφαιρετική

αγγειογραφία, Σκιαγράφηση κοιλοτήτων (με εξαίρεση τη μυελογραφία, την κοιλιογραφία και την ακτινογραφία των κοιλιών του εγκεφάλου).

Για χρήση σε ενήλικες γυναίκες σε ψηφιακή μαστογραφία με έγχυση σκιαγραφικού για την αξιολόγηση και την ανίχνευση γνωστών ή ύποπτων

βλαβών του μαστού, ως συμπληρωματική εξέταση στη μαστογραφία (με ή χωρίς υπέρηχο) ή ως εναλλακτική της μαγνητικής τομογραφίας

(MRI) όταν η μαγνητική τομογραφία αντενδείκνυται ή δεν είναι διαθέσιμη. Το Ultravist δεν ενδείκνυται για ενδοραχιαία χρήση. 4.3 Αντενδείξεις

Δεν υπάρχουν απόλυτες αντενδείξεις για τη χρήση του Ultravist. 4.4 Ειδικές προειδοποιήσεις και προφυλάξεις κατά τη χρήση Για όλες

τις ενδείξεις • Αντιδράσεις υπερευαισθησίας: Το Ultravist μπορεί να συσχετιστεί με αναφυλακτοειδείς αντιδράσεις / αντιδράσεις υπερευαισθησίας

ή άλλες ιδιοσυγκρασιακές αντιδράσεις χαρακτηριζόμενες από καρδιοαγγειακές, αναπνευστικές και δερματικές εκδηλώσεις. Αντιδράσεις

αλλεργικού τύπου που κυμαίνονται από ήπιες έως σοβαρές, συμπεριλαμβανομένου του σοκ, είναι πιθανές (βλ. παράγραφο 4.8 «Ανεπιθύμητες

Ενέργειες»). Οι περισσότερες από αυτές τις αντιδράσεις εμφανίζονται μέσα σε 30 λεπτά από τη χορήγηση. Ωστόσο, μπορεί να

εμφανιστούν όψιμες αντιδράσεις (μετά από ώρες έως μέρες). Ο κίνδυνος για αντιδράσεις υπερευαισθησίας είναι υψηλότερος στην περίπτωση:

- Προηγούμενης αντίδρασης σε σκιαγραφικό μέσο - Ιστορικό βρογχικού άσθματος ή άλλων αλλεργικών διαταραχών. Ιδιαίτερα σε ασθενείς

με γνωστή υπερευαισθησία στο Ultravist ή σε οποιοδήποτε από τα έκδοχά του ή με ιστορικό προηγούμενης αντίδρασης υπερευαισθησίας

σε οποιοδήποτε άλλο ιωδιούχο σκιαγραφικό μέσο, απαιτείται προσεκτική αξιολόγηση της σχέσης κινδύνου/οφέλους, λόγω του αυξημένου

κινδύνου εμφάνισης αντιδράσεων υπερευαισθησίας (συμπεριλαμβανομένων σοβαρών αντιδράσεων). Ωστόσο, οι αντιδράσεις αυτές δεν εμφανίζονται

με σταθερό ρυθμό και η φύση τους δεν μπορεί να προβλεφθεί. Ασθενείς που εμφανίζουν παρόμοιες αντιδράσεις ενόσω λαμβάνουν

αποκλειστές των β-υποδοχέων μπορεί να παρουσιάσουν ανθεκτικότητα στη θεραπευτική αγωγή με αγωνιστές των β-υποδοχέων (βλ.

επίσης παράγραφο 4.5 «Ειδικές προειδοποιήσεις και προφυλάξεις κατά τη χρήση»). Σε περίπτωση σοβαρής αντίδρασης υπερευαισθησίας, οι

ασθενείς με καρδιαγγειακή νόσο είναι περισσότερο επιρρεπείς σε μια σοβαρή ή ακόμα και θανατηφόρο έκβαση. Λόγω της πιθανότητας εμφάνισης

σοβαρών αντιδράσεων υπερευαισθησίας μετά τη χορήγηση, συνιστάται παρακολούθηση του ασθενούς μετά την εξέταση. Πρέπει

να υπάρχει ετοιμότητα για την εφαρμογή επειγόντων μέτρων για όλους τους ασθενείς. Σε ασθενείς με αυξημένο κίνδυνο οξέων αντιδράσεων

αλλεργικού τύπου, και ασθενείς με ιστορικό μετρίας ή σοβαρής οξείας αντίδρασης, άσθματος ή αλλεργίας που απαίτησε ιατρική αντιμετώπιση,

μπορεί να ληφθεί υπόψη μια προφυλακτική αγωγή με κορτικοστεροειδή. • Δυσλειτουργία του θυρεοειδούς. Ιδιαίτερα προσεκτική εκτίμηση

της σχέσης κινδύνου/οφέλους είναι απαραίτητη σε ασθενείς με γνωστό ή πιθανολογούμενο υπερθυρεοειδισμό ή βρογχοκήλη, καθώς τα

ιωδιούχα σκιαγραφικά μέσα μπορεί να προκαλέσουν υπερθυρεοειδισμό και θυρεοτοξική κρίση σε αυτούς τους ασθενείς. Ο έλεγχος της λειτουργίας

του θυρεοειδή πριν από τη χορήγηση του Ultravist και/ή προληπτική φαρμακευτική αγωγή με αντιθυρεοειδικά μπορεί να ληφθούν

υπόψη στους ασθενείς με γνωστό ή πιθανολογούμενο υπερθυρεοειδισμό. Έχουν αναφερθεί δοκιμές λειτουργίας του θυρεοειδούς ενδεικτικές

του υποθυρεοειδισμού ή παροδικής καταστολής του θυρεοειδούς μετά από χορήγηση ιωδιούχου σκιαγραφικού μέσου σε ενήλικες και παιδιατρικούς

ασθενείς. Αξιολογήστε τον πιθανό κίνδυνο υποθυρεοειδισμού σε ασθενείς με γνωστές ή ύποπτες ασθένειες του θυρεοειδούς πριν

από τη χρήση ιωδιούχων σκιαγραφικών μέσων. Παιδιατρικός πληθυσμός Θυροειδική δυσλειτουργία χαρακτηριζόμενη από υποθυρεοειδισμό

ή παροδική θυρεοειδική καταστολή έχει αναφερθεί τόσο μετά από εφάπαξ όσο και μετά από πολλαπλές εκθέσεις σε ιωδιούχα σκιαγραφικά

μέσα (ICM) σε παιδιατρικούς ασθενείς ηλικίας κάτω των 3 ετών. Η συχνότητα εμφάνισης έχει αναφερθεί μεταξύ 1% και 15% ανάλογα με την

ηλικία των ατόμων και τη δόση του ιωδιούχου σκιαγραφικού και παρατηρείται πιο συχνά σε νεογνά και πρόωρα βρέφη. Τα νεογνά μπορεί

επίσης να εκτεθούν μέσω της μητέρας κατά τη διάρκεια της εγκυμοσύνης. Μικρότερη ηλικία, πολύ χαμηλό βάρος γέννησης, προωρότητα,

υποκείμενες ιατρικές παθήσεις που επηρεάζουν τη λειτουργία του θυρεοειδούς, εισαγωγή σε μονάδες εντατικής θεραπείας νεογνών ή παίδων

και συγγενείς καρδιακές παθήσεις σχετίζονται με αυξημένο κίνδυνο υποθυρεοειδισμού μετά από έκθεση σε ICM. Οι παιδιατρικοί ασθενείς με

συγγενείς καρδιακές παθήσεις ενδέχεται να διατρέχουν τον μεγαλύτερο κίνδυνο, δεδομένου ότι συχνά απαιτούν υψηλές δόσεις σκιαγραφικού

κατά τις επεμβατικές καρδιακές διαδικασίες. Ένας υπολειτουργικός θυρεοειδής κατά την πρώιμη ζωή μπορεί να είναι επιβλαβής για τη

γνωστική και νευρολογική ανάπτυξη και μπορεί να απαιτεί θεραπεία υποκατάστασης θυρεοειδικών ορμονών. • Μετά την έκθεση σε ICM,

εξατομικεύστε την παρακολούθηση της λειτουργίας του θυρεοειδούς με βάση τους υποκείμενους παράγοντες κινδύνου, ειδικά στα τελειόμηνα

και πρόωρα νεογνά. Παθήσεις του ΚΝΣ. Ασθενείς με ιστορικό διαταραχών του ΚΝΣ μπορεί να διατρέχουν αυξημένο κίνδυνο εμφάνισης

νευρολογικών επιπλοκών σχετιζόμενων με τη χορήγηση του Ultravist. Οι νευρολογικές επιπλοκές εμφανίζονται συχνότερα στην εγκεφαλική

αγγειογραφία και ανάλογες διαδικασίες. Έχει αναφερθεί εγκεφαλοπάθεια με τη χρήση ιοπρομίδης (βλ. παράγραφο 4.8). Η εγκεφαλοπάθεια

οφειλόμενη σε σκιαγραφικό μπορεί να εκδηλωθεί με συμπτώματα και σημεία νευρολογικής δυσλειτουργίας όπως κεφαλαλγία, διαταραχή

της όρασης, φλοιώδη τύφλωση, σύγχυση, επιληπτικές κρίσεις, απώλεια συντονισμού, ημιπάρεση, αφασία, απώλεια συνείδησης, κώμα και

εγκεφαλικό οίδημα. Τα συμπτώματα συνήθως εμφανίζονται εντός λεπτών έως ωρών μετά τη χορήγηση ιοπρομίδης και γενικά υποχωρούν

πλήρως εντός ημερών. Θα πρέπει να δίνεται προσοχή σε καταστάσεις κατά τις οποίες μπορεί να υπάρχει μειωμένος ουδός ως προς την εμφάνιση

επιληπτικών κρίσεων, όπως προηγούμενο ιστορικό επιληπτικών κρίσεων και χρήση ορισμένων συγχορηγούμενων φαρμάκων. Παράγοντες

που αυξάνουν τη διαπερατότητα του αιματοεγκεφαλικού φραγμού διευκολύνουν τη δίοδο του σκιαγραφικού μέσου στον εγκεφαλικό

ιστό, γεγονός που πιθανόν να οδηγήσει σε αντιδράσεις από το ΚΝΣ, για παράδειγμα εγκεφαλοπάθεια. Εάν πιθανολογείται εγκεφαλοπάθεια

οφειλόμενη σε σκιαγραφικό, θα πρέπει να αρχίζει κατάλληλη ιατρική διαχείριση και η χορήγηση ιοπρομίδης δεν πρέπει να επαναληφθεί. •

Ενυδάτωση: Πρέπει να διασφαλιστεί επαρκής κατάσταση ενυδάτωσης σε όλους τους ασθενείς, πριν από ενδοαγγειακή χορήγηση του

Ultravist, (βλ. επίσης υποπαράγραφο «Οξεία νεφρική βλάβη»). Αυτό ισχύει ιδιαίτερα για τους ασθενείς με πολλαπλό μυέλωμα, σακχαρώδη

διαβήτη, πολυουρία, ολιγουρία, υπερουριχαιμία, καθώς επίσης και σε νεογνά, βρέφη, μικρά παιδιά και ηλικιωμένους ασθενείς. Η επαρκής

κατάσταση ενυδάτωσης πρέπει να διασφαλίζεται σε ασθενείς με νεφρική δυσλειτουργία. Ωστόσο, η προφυλακτική ενδοφλέβια ενυδάτωση

σε ασθενείς με μέτρια νεφρική δυσλειτουργία (eGFR 30 – 59 ml / min / 1,73 m2) δεν συνιστάται, καθώς δεν έχουν τεκμηριωθεί πρόσθετα

οφέλη για την νεφρική ασφάλεια. Σε ασθενείς με σοβαρή νεφρική δυσλειτουργία (eGFR <30 ml / min / 1,73 m2) και συνοδές καρδιακές παθήσεις,

η προφυλακτική ενδοφλέβια ενυδάτωση μπορεί να οδηγήσει σε αυξημένες σοβαρές καρδιακές επιπλοκές. Ανατρέξτε στις υποπαραγράφους

«Οξεία νεφρική βλάβη», «Καρδιαγγειακή νόσος», «Κατάλογος των ανεπιθύμητων ενεργειών σε μορφή πίνακα». • Ανησυχία: Έντονες

καταστάσεις έξαψης, ανησυχίας και πόνου μπορεί να αυξήσουν τον κίνδυνο ανεπιθύμητων ενεργειών ή να εντείνουν τις αντιδράσεις που

σχετίζονται με τα σκιαγραφικά μέσα. Πρέπει να λαμβάνεται μέριμνα για την ελαχιστοποίηση της κατάσταση άγχους σε αυτούς τους ασθενείς.

• Προκαταρτικός έλεγχος: Δεν συνιστάται η δοκιμή ευαισθησίας χρησιμοποιώντας μία μικρή δοκιμαστική δόση του σκιαγραφικού μέσου

καθώς δεν έχει προγνωστική αξία. Επιπρόσθετα, οι ίδιες οι δοκιμές ευαισθησίας έχουν οδηγήσει περιστασιακά σε σοβαρές ή ακόμα και θανατηφόρες

αντιδράσεις υπερευαισθησίας. • Σοβαρές δερματικές ανεπιθύμητες ενέργειες (SCARs): Σοβαρές δερματικές ανεπιθύμητες ενέργειες

(SCARs) που συμπεριλαμβάνουν σύνδρομο Stevens-Johnson (SJS), τοξική επιδερμική νεκρόλυση (TEN), αντίδραση στο φάρμακο με ηωσινοφιλία

και συστηματικά συμπτώματα (DRESS) και οξεία γενικευμένη εξανθηματική φλυκταίνωση (AGEP), οι οποίες μπορεί να είναι απειλητικές

για τη ζωή ή θανατηφόρες, έχουν αναφερθεί με συχνότητα μη γνωστή σε συνδυασμό με τη χορήγηση ιοπρομίδης. Οι ασθενείς θα πρέπει να

λαμβάνουν συμβουλές σχετικά με τα σημεία και συμπτώματα και να παρακολουθούνται στενά για δερματικές αντιδράσεις. Στα παιδιά, η

αρχική παρουσίαση εξανθήματος μπορεί να εκληφθεί εσφαλμένα ως λοίμωξη, και οι ιατροί θα πρέπει να εξετάζουν την πιθανότητα αντίδρασης

στην ιοπρομίδη στα παιδιά τα οποία αναπτύσσουν σημεία εξανθήματος και πυρετού. Οι περισσότερες από αυτές τις αντιδράσεις εμφανίστηκαν

εντός 8 εβδομάδων (AGEP 1 12 ημέρες, DRESS 2 8 εβδομάδες, SJS/TEN 5 ημέρες έως 8 εβδομάδες). Εάν ο ασθενής έχει αναπτύξει μια

σοβαρή αντίδραση όπως SJS, TEN, AGEP ή DRESS με τη χρήση ιοπρομίδης, δεν πρέπει ποτέ να επαναχορηγηθεί ιοπρομίδη σε αυτόν τον

ασθενή. Ενδοαγγειακή χρήση • Οξεία νεφρική βλάβη. Μετά την ενδοαγγειακή χορήγηση του Ultravist μπορεί να εμφανιστεί οξεία νεφρική

βλάβη που οφείλεται στη χορήγηση του σκιαγραφικού μέσου (Post-Contrast Acute Kidney Injury – PC-AKI), η οποία εμφανίζεται ως παροδική

έκπτωση της νεφρικής λειτουργίας. Σε μερικές περιπτώσεις μπορεί να εμφανιστεί οξεία νεφρική ανεπάρκεια. Στους παράγοντες κινδύνου

περιλαμβάνονται ενδεικτικά: - προϋπάρχουσα μειωμένη νεφρική λειτουργία (βλ. υποπαράγραφο «Ασθενείς με νεφρική ανεπάρκεια»), - αφυδάτωση

(βλ. υποπαράγραφο «Ενυδάτωση»), - σακχαρώδης διαβήτης, - πολλαπλό μυέλωμα/παραπρωτεϊναιμία - επαναλαμβανόμενες και/ή

υψηλές δόσεις Ultravist. Ασθενείς με μέτρια έως σοβαρή (eGFR 44 – 30 ml / min / 1,73 m2) ή σοβαρή νεφρική δυσλειτουργία (eGFR <30 ml /

min / 1,73 m2) διατρέχουν αυξημένο κίνδυνο εμφάνισης οξείας νεφρικής βλάβης που οφείλεται στη χορήγηση του σκιαγραφικού μέσου

(PC-AKI) μετά την ενδοαρτηριακή χορήγηση του μέσου αντίθεσης με νεφρική έκθεση σε πρώτο χρόνο (first pass renal exposure). Οι ασθενείς

με σοβαρή νεφρική δυσλειτουργία (eGFR <30 ml / min / 1,73 m2) διατρέχουν αυξημένο κίνδυνο PC-AKI μετά την ενδοφλέβια ή ενδοαρτηριακή

χορήγηση του μέσου αντίθεσης με νεφρική έκθεση σε δεύτερο χρόνο (second pass renal exposure) (βλ. υποπαράγραφο «Ενυδάτωση»). Οι

ασθενείς που υποβάλλονται σε αιμοκάθαρση, ακόμα και αν δεν παρουσιάζουν υπολειμματική νεφρική λειτουργία, μπορούν να λάβουν

Ultravist για τη διεξαγωγή ακτινολογικών εξετάσεων, διότι τα ιωδιούχα σκιαγραφικά μέσα απεκκρίνονται μέσω της διαδικασίας της αιμοκάθαρσης.

• Καρδιαγγειακή νόσος: Ασθενείς με σημαντική καρδιακή νόσο ή στεφανιαία νόσο βρίσκονται σε αυξημένο κίνδυνο να αναπτύξουν

κλινικά σημαντικές αιμοδυναμικές μεταβολές και αρρυθμία. Η ενδοαγγειακή ένεση Ultravist μπορεί να οδηγήσει σε πνευμονικό οίδημα σε

ασθενείς με καρδιακή ανεπάρκεια. • Φαιοχρωμοκύττωμα: Ασθενείς με φαιοχρωματοκύττωμα μπορεί να βρίσκονται σε αυξημένο κίνδυνο να

αναπτύξουν υπερτασική κρίση. • Μυασθένια Gravis: Η χορήγηση Ultravist μπορεί να επιδεινώσει τα συμπτώματα της μυασθένιας Gravis. •

Θρομβοεμβολικά συμβάματα: Μία από τις ιδιότητες των μη ιονικών σκιαγραφικών μέσων είναι η μικρή επίδρασή τους στις φυσιολογικές

λειτουργίες του οργανισμού. Συνεπώς, τα μη ιονικά σκιαγραφικά μέσα έχουν μικρότερη αντιπηκτική δράση in vitro από τα ιονικά. Πολλοί

παράγοντες επιπρόσθετα στα σκιαγραφικά μέσα, συμπεριλαμβανομένης της διάρκειας της διαδικασίας, του αριθμού των ενέσεων, του υλικού

του καθετήρα και της σύριγγας, της υποκείμενης νόσου, και της ταυτόχρονης φαρμακευτικής αγωγής, μπορούν να συμβάλλουν στην

εμφάνιση θρομβοεμβολικών επεισοδίων. Αυτό πρέπει να λαμβάνεται υπόψη κατά την εφαρμογή τεχνικών με φλεβοκαθετήρα και να δίνεται

ιδιαίτερη προσοχή στην τεχνική της αγγειογραφίας και στο συχνό πλύσιμο των καθετήρων με φυσιολογικό ορό (εφόσον είναι απαραίτητο με

προσθήκη ηπαρίνης) ενώ ο χρόνος της εξέτασης να μειώνεται στο ελάχιστο, ώστε να ελαχιστοποιείται ο κίνδυνος θρομβώσεων και εμβολών

που συνδέονται με τη διαδικασία. Ψηφιακή μαστογραφία με έγχυση σκιαγραφικού (CEM) Η Ψηφιακή μαστογραφία με έγχυση σκιαγραφικού

έχει ως αποτέλεσμα μεγαλύτερη έκθεση του ασθενούς σε ιονίζουσα ακτινοβολία από την τυπική μαστογραφία. Η δόση ακτινοβολίας

εξαρτάται από το πάχος του μαστού, τον τύπο και τις ρυθμίσεις συστήματος της συσκευής. Η συνολική δόση ακτινοβολίας CEM παραμένει

κάτω από το όριο που ορίζεται από τις διεθνείς οδηγίες για τη μαστογραφία (κάτω από 3 mGy). 4.8 Ανεπιθύμητες ενέργειες Περίληψη του

προφίλ ασφαλείας Το συνολικό προφίλ ασφαλείας του Ultravist βασίζεται σε δεδομένα που λήφθηκαν σε μελέτες πριν από την κυκλοφορία

του προϊόντος σε περισσότερους από 3.900 ασθενείς και σε μελέτες μετά την κυκλοφορία του προϊόντος σε περισσότερους από 74.000

ασθενείς, καθώς επίσης και σε δεδομένα από αυθόρμητες αναφορές και τη βιβλιογραφία. Οι πιο συχνά αναφερόμενες ανεπιθύμητες ενέργειες

(≥4 %) σε ασθενείς που λαμβάνουν Ultravist είναι κεφαλαλγία, ναυτία και αγγειοδιαστολή. Οι πιο σοβαρές ανεπιθύμητες ενέργειες σε

ασθενείς που λαμβάνουν Ultravist είναι αναφυλακτικό σοκ, αναπνευστική ανακοπή, βρογχoσπασμός, λαρυγγικό οίδημα, φαρυγγικό οίδημα,

άσθμα, κώμα, εγκεφαλικό έμφρακτο, εγκεφαλικό επεισόδιο, εγκεφαλικό οίδημα, σπασμοί, αρρυθμία, καρδιακή ανακοπή, μυοκαρδιακή ισχαιμία,

έμφραγμα του μυοκαρδίου, καρδιακή ανεπάρκεια, βραδυκαρδία, κυάνωση, υπόταση, καταπληξία, δύσπνοια, πνευμονικό οίδημα, αναπνευστική

ανεπάρκεια και αναρρόφηση. Κατάλογος των ανεπιθύμητων ενεργειών σε μορφή πίνακα Οι ανεπιθύμητες ενέργειες που παρατηρήθηκαν

με το Ultravist παρουσιάζονται στον παρακάτω πίνακα. Κατηγοριοποιούνται σύμφωνα με το Οργανικό Σύστημα κατά MedDRA

(έκδοση 13.0). Ο πιο κατάλληλος όρος MedDRΑ χρησιμοποιείται για να περιγράψει μία συγκεκριμένη κατάσταση καθώς επίσης και τα συνώνυμά

της και σχετιζόμενες καταστάσεις. Οι ανεπιθύμητες ενέργειες από τις κλινικές μελέτες κατηγοριοποιούνται σύμφωνα με τις συχνότητές

τους. Οι ομαδοποιήσεις των συχνοτήτων ορίζονται σύμφωνα με την εξής σύμβαση: Συχνές (≥1/100 έως <1/10), Όχι συχνές (≥1/1.000 έως

<1/100), Σπάνιες (≥1/10.000 έως <1/1.000). Οι ανεπιθύμητες ενέργειες που αναγνωρίστηκαν μόνο κατά τη διάρκεια της παρακολούθησης του

προϊόντος μετά την κυκλοφορία του και για τις οποίες η συχνότητα δεν μπορούσε να εκτιμηθεί, παρατίθενται στην κατηγορία «μη γνωστές».

Πίνακας 1: Ανεπιθύμητες ενέργειες που αναφέρθηκαν σε κλινικές μελέτες ή κατά την παρακολούθηση του προϊόντος μετά την κυκλοφορία

του σε ασθενείς που έλαβαν Ultravist. Οργανικό σύστημα: Διαταραχές του ανοσοποιητικού συστήματος, Όχι συχνές: ΑΑντιδράσεις

υπερευαισθησίας/ αναφυλακτοειδείς αντιδράσεις (αναφυλακτικό σοκ §) *), αναπνευστική ανακοπή §) *), βρογχοσπασμός *), λαρυγγικό

*)/ φαρυγγικό*) οίδημα, οίδημα προσώπου, οίδημα γλώσσας §), λαρυγγικός /φαρυγγικός σπασμός §), άσθμα §) *),, επιπεφυκίτιδα §),

δακρύρροια §), πταρμός, βήχας, οίδημα βλεννογόνων, ρινίτιδα §), βράγχος §), ερεθισμός λαιμού §), κνίδωση, κνησμός, αγγειοοίδημα).

Οργανικό σύστημα: Διαταραχές του ενδοκρινικού συστήματος, Μη γνωστές: Θυρεοτοξική κρίση, Διαταραχή της θυρεοειδικής λειτουργίας.

Οργανικό σύστημα: Ψυχιατρικές διαταραχές, Σπάνιες: Ανησυχία. Οργανικό σύστημα: Διαταραχές του νευρικού συστήματος, Συχνές:

Ζάλη, Πονοκέφαλος, Δυσγευσία, Όχι συχνές: Βαγοτονία, Κατάσταση σύγχυσης, Νευρικότητα, Παραισθησία/Υπαισθησία, Αϋπνία,

Μη γνωστές: Κώμα*), Εγκεφαλική ισχαιμία/ έμφρακτο *), Εγκεφαλικό επεισόδιο *), Εγκεφαλικό οίδημα α) *), Σπασμοί *), Παροδική

φλοιώδης τύφλωση α), Απώλεια συνείδησης, Διέγερση, Αμνησία, Τρόμος, Διαταραχές ομιλίας, Πάρεση/παράλυσηΕγκεφαλοπάθεια

οφειλόμενη σε σκιαγραφικό. Οργανικό σύστημα: Οφθαλμικές διαταραχές, Συχνές: Θολή/ διαταραγμένη όραση Οργανικό σύστημα:

Διαταραχές του ωτός και του λαβυρίνθο, Μη γνωστές: Διαταραχές της ακοής. Οργανικό σύστημα: Καρδιακές διαταραχές, Συχνές:

Πόνος / στο στήθος/δυσφορία, Όχι συχνές: Αρρυθμία *) , Σπάνιες: Καρδιακή ανακοπή *) , Μυοκαρδιακή ισχαιμία, Αίσθημα παλμών, Μη

γνωστές: Έμφραγμα του μυοκαρδίου *) , Καρδιακή ανεπάρκεια *) , Βραδυκαρδία *) , Ταχυκαρδία, Κυάνωση *) Οργανικό σύστημα: Αγγειακές

διαταραχές Συχνές: Υπέρταση Αγγειοδιαστολή Όχι συχνές: Υπόταση *) Μη γνωστές: Καταπληξία *) , Θρομβοεμβολικά συμβάντα α) , Αγγειόσπασμος

α) Οργανικό σύστημα: Διαταραχές του αναπνευστικού συστήματος, του θώρακα και του μεσοθωράκιου Όχι συχνές: Δύσπνοια

*)

Μη γνωστές: Πνευμονικό οίδημα *) , Αναπνευστική ανεπάρκεια *) , Αναρρόφηση *) Οργανικό σύστημα: Διαταραχές του γαστρεντερικού,

Συχνές: Έμετος, Ναυτία, Όχι συχνές: Κοιλιακό άλγος, Μη γνωστές: Δυσφαγία, Μεγέθυνση των σιελογόνων αδένων, Διάρροια. Οργανικό

σύστημα: Διαταραχές του δέρματος και του υποδόριου ιστού Μη γνωστές: Πομφολυγώδεις δερματοπάθειες (π.χ. σύνδρομο Stevens-

Johnson ή σύνδρομο Lyell), Εξάνθημα, Ερύθημα, Υπερίδρωση, Οξεία γενικευμένη εξανθηματική φλυκταίνωση, Αντίδραση στο φάρμακο

με ηωσινοφιλία και συστηματικά συμπτώματα. Οργανικό σύστημα: Διαταραχές του μυοσκελετικού συστήματος και του συνδετικού

ιστού, Μη γνωστές: Σύνδρομο διαμερισματοποίησης σε περίπτωση εξαγγείωσης α) Οργανικό σύστημα: Διαταραχές των νεφρών και των

ουροφόρων οδών, Μη γνωστές: Μειωμένη νεφρική λειτουργία α) , Οξεία νεφρική ανεπάρκεια α) Οργανικό σύστημα: Γενικές διαταραχές

και καταστάσεις της οδού χορήγησης Συχνές: ΠόνοςΑντίδραση στο σημείο της ένεσης (ποικίλλων ειδών, π.χ. πόνος, θερμότητα §) , οίδημα

§)

, φλεγμονή §) και κάκωση των μαλακών μορίων §) σε περίπτωση εξαγγείωσης), Αίσθημα θερμότητας Όχι συχνές: Οίδημα, Μη γνωστές:

Αδιαθεσία, Ρίγη, Ωχρότητα. Οργανικό σύστημα: Παρακλινικές εξετάσεις, Μη γνωστές: Διακυμάνσεις στη θερμοκρασία του σώματος. *)

έχουν αναφερθεί απειλητικές για τη ζωή και/ή μοιραίες περιπτώσεις, α) μόνο σε ενδοαγγειακή χρήση, §) αναγνωρίστηκαν μόνο κατά την παρακολούθηση

του προϊόντος μετά την κυκλοφορία του (συχνότητα μη γνωστή). Η πλειοψηφία των αντιδράσεων μετά από μυελογραφία ή χρήση

σε σωματικές κοιλότητες, εμφανίζονται μερικές ώρες μετά τη χορήγηση. Εκτός από τις προαναφερθείσες ανεπιθύμητες ενέργειες, μπορεί να

εμφανιστούν και οι ακόλουθες με τη χρήση σε ERCP: αύξηση των επιπέδων των ενζύμων του παγκρέατος και παγκρεατίτιδα σε μη γνωστή

συχνότητα. Αναφορά πιθανολογούμενων ανεπιθύμητων ενεργειών: Η αναφορά πιθανολογούμενων ανεπιθύμητων ενεργειών μετά από τη

χορήγηση άδειας κυκλοφορίας του φαρμακευτικού προϊόντος είναι σημαντική. Επιτρέπει τη συνεχή παρακολούθηση της σχέσης οφέλους-κινδύνου

του φαρμακευτικού προϊόντος. Ζητείται από τους επαγγελματίες υγείας να αναφέρουν οποιεσδήποτε πιθανολογούμενες ανεπιθύμητες

ενέργειες μέσω: Ελλάδα: Εθνικός Οργανισμός Φαρμάκων, Μεσογείων 284, GR-15562 Χολαργός, Αθήνα, Τηλ: + 30 21 32040337, Ιστότοπος:

http://www.eof.gr, http://www.kitrinikarta.gr, Κύπρος: Φαρμακευτικές Υπηρεσίες, Υπουργείο Υγείας, CY-1475 Λευκωσία, Τηλ: +357 22608607,

Φαξ: + 357 22608669, Ιστότοπος: www.moh.gov.cy/phs 6. ΦΑΡΜΑΚΕΥΤΙΚΕΣ ΠΛΗΡΟΦΟΡΙΕΣ 6.1 Κατάλογος εκδόχων Νατριούχο εδετικό

ασβέστιο, τρομεταμόλη, υδροχλωρικό οξύ 10% (για ρύθμιση του pH), υδροξείδιο του νατρίου (για ρύθμιση του pH), ενέσιμο ύδωρ. 6.2 Ασυμβατότητες

To Ultravist δεν πρέπει να αναμειγνύεται με άλλα φάρμακα, ώστε να αποφευχθεί ο κίνδυνος πιθανής ασυμβατότητας. 6.3 Διάρκεια

ζωής 3 χρόνια. Μετά το άνοιγμα του περιέκτη, το Ultravist συνιστάται να χρησιμοποιείται εντός 10 ωρών. 6.4 Ιδιαίτερες προφυλάξεις κατά

τη φύλαξη του προϊόντος Να φυλάσσεται σε θερμοκρασία έως 25° C και να μην εκτίθεται στο φως και την ακτινοβολία. Διατηρείτε τα φάρμακα

προσεκτικά και μακριά από τα παιδιά. 6.5 Φύση και συστατικά του περιέκτη Φιάλες από γυαλί τύπου ΙΙ, Φιαλίδια από γυαλί τύπου Ι,

Πώμα από καουτσούκ: ελαστομερές χλωροβουτύλιο ή βρωμοβουτύλιο, γκρι. Ultravist 300 Ελλάδα: φιαλίδια των 20 ml, 50 ml, 100 ml και

φιάλες των 200 ml, 500 ml, 1000 ml, Κύπρος: φιαλίδια των 50 ml, 100 ml και φιάλες των 200 ml Ultravist 370

Ελλάδα: φιαλίδια των 50 ml, 100 ml και φιάλες των 150 ml, 200 ml και 500 ml, 1000 ml, Κύπρος: φιαλίδια των 50 ml, 100 ml και φιάλες των

150 ml, 200 ml και 500 ml, 1000 ml, Μπορεί να μη κυκλοφορούν όλες οι συσκευασίες. 6.6 Ιδιαίτερες προφυλάξεις απόρριψης και άλλος

χειρισμός Οπτικός έλεγχος. Πριν τη χρήση των σκιαγραφικών μέσων πρέπει να διενεργείται οπτικός έλεγχος και δεν θα πρέπει αυτά να χρησιμοποιούνται

σε περίπτωση αποχρωματισμού, ούτε επί παρουσίας σωματιδίων (περιλαμβανομένων των κρυστάλλων) ή ελαττωματικού περιέκτη.

Επειδή το Ultravist είναι ένα υψηλής συγκέντρωσης διάλυμα, πολύ σπάνια μπορεί να εμφανισθεί κρυσταλλοποίηση (γαλακτώδης – θολερή

εμφάνιση και/ή ίζημα στον πυθμένα ή αιωρούμενοι κρύσταλλοι). • Φιαλίδια: Το διάλυμα του σκιαγραφικού δεν πρέπει να αναρροφάται στη

σύριγγα ή στον ορό της συσκευής έγχυσης, παρά μόνο αμέσως πριν τη χορήγησή του. Το ελαστικό πώμα πρέπει να διατρυπάται μία μόνο φορά,

ώστε να αποφεύγεται η εισροή μικροσωματιδίων από το πώμα στο διάλυμα. Συνιστάται για τη διάτρηση του ελαστικού πώματος και για την

αναρρόφηση του σκιαγραφικού να χρησιμοποιούνται βελόνες με μακρά λοξή κοπή και με διάμετρο κατά μέγιστο 18G (ιδιαίτερα κατάλληλες

είναι γνήσιες βελόνες παρακέντησης με πλάγιo άνοιγμα π.χ. βελόνες Nocore-Admix). Διάλυμα σκιαγραφικού που δεν καταναλώθηκε σε μια

εξέταση για ένα συγκεκριμένο ασθενή πρέπει να απορρίπτεται. • Περιέκτες μεγάλου όγκου (μόνο για ενδοαγγειακή χορήγηση): Οι ακόλουθες

οδηγίες πρέπει να ακολουθούνται για την πολλαπλή αφαίρεση σκιαγραφικού από τις συσκευασίες των 200 ml και άνω: Η πολλαπλή αφαίρεση

σκιαγραφικού πρέπει να γίνεται με τη χρήση ιατροτεχνολογικών βοηθημάτων, τα οποία έχουν εγκριθεί για πολλαπλή χρήση. Το ελαστικό πώμα

πρέπει να διατρυπάται μία μόνο φορά, ώστε να αποφεύγεται η εισροή μικροσωματιδίων από το πώμα στο διάλυμα. Το σκιαγραφικό μέσο

πρέπει να χορηγείται με τη βοήθεια ενός αυτόματου εγχυτή ή οποιασδήποτε άλλης διαδικασίας, η οποία μπορεί να εξασφαλίσει τη στειρότητα

του σκιαγραφικού μέσου. Ο σωλήνας που οδηγεί από τον εγχυτή στον ασθενή (σωλήνας του ασθενούς) πρέπει να αλλάζει μετά από κάθε

εξέταση, διότι μολύνεται με το αίμα του ασθενούς. Οι σωλήνες και όλα τα εξαρτήματα μίας χρήσης του εγχυτή πρέπει να απορρίπτονται, όταν

αδειάζει η φιάλη ή 10 ώρες μετά το πρώτο άνοιγμα του περιέκτη. Το σκιαγραφικό που μένει μέσα σε ανοιγμένη φιάλη, πρέπει να απορρίπτεται

δέκα ώρες μετά το πρώτο άνοιγμα του περιέκτη. Επίσης, πρέπει να ακολουθούνται πιστά οι οποιεσδήποτε πρόσθετες οδηγίες που έχουν δοθεί

από τον παρασκευαστή του αντίστοιχου εξοπλισμού. 7. ΚΑΤΟΧΟΣ ΑΔΕΙΑΣ ΚΥΚΛΟΦΟΡΙΑΣ ΚΑΤΟΧΟΣ ΑΔΕΙΑΣ ΚΥΚΛΟΦΟΡΙΑΣ ΣΤΗΝ ΕΛΛΑΔΑ ΚΑΙ

ΣΤΗΝ ΚΥΠΡΟ Bayer Ελλάς ΑΒΕΕ, Αγησιλάου 6-8, 151 23 Μαρούσι, Αττική, Ελλάδα, Τηλ: +30 210 6187500 Τοπικός αντιπρόσωπος στην Κύπρο

Novagem Ltd Τηλ: +357 22483858. 8. ΑΡΙΘΜΟΣ ΑΔΕΙΑΣ ΚΥΚΛΟΦΟΡΙΑΣ ΕΛΛΑΔΑ: Ultravist 300: 39944/4-11-2009, Ultravist 370: 39946/4-

11-2009 ΚΥΠΡΟΣ: Ultravist 300: 023211, Ultravist 370: 18966 9. ΗΜΕΡΟΜΗΝΙΑ ΤΗΣ ΠΡΩΤΗΣ ΕΓΚΡΙΣΗΣ/ΑΝΑΝΕΩΣΗΣ ΤΗΣ ΑΔΕΙΑΣ ΕΛΛΑΔΑ:

Ultravist® 300: 06.02.1989 / 4.11.2009 (επ’ αόριστον), Ultravist® 370: 06.02.1989 / 4.11.2009 (επ’ αόριστον) ΚΥΠΡΟΣ: Ultravist® 300: 07.10.2020

/ 13 Μαρτίου 2025, Ultravist® 370: 11.07.2000 / 14.9.2011 (επ’ αόριστον). 10. ΗΜΕΡΟΜΗΝΙΑ ΑΝΑΘΕΩΡΗΣΗΣ ΤΟΥ ΚΕΙΜΕΝΟΥ Ελλάδα: Μάρτιος

2025, Κύπρος: 13/03/2025.

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iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial. Lancet. 2017 Apr 1;389(10076):1312-1322. 3. Chen JY, Liu Y,

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P, Bostelamm S, Lengsfeld P. Safety and tolerability of iopromide intravascular use: a pooled analysis of three no-interventional studies in 132,012 patients. Acta Radiologica 2014;55(6):707-714 5. Endrikat J, Chernova J, Gerlinger C, et

al. Risk of Hypersensitivity Reactions to Iopromide in Children and Elderly: An Analysis of 132,850 Patients From 4 Observational Studies and Pharmacovigilance Covering >288 Million Administrations. Invest Radiol. 2022;57(5):318-326

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H JR

Hellenic Journal of Radiology

Editorial Board

Editor-in-Chief

Athanasios Chalazonitis, Athens/GR

Associate Editor

Anastasios Gyftopoulos, Athens/GR

Assistant Editors

Konstantinos Stefanidis, Athens/GR

Aikaterini Tavernaraki, Athens/GR

Junior Assistant Editors

Alexandros Letsos, Athens/GR

Antigoni Logotheti, Athens/GR

Kalliopi Parlamenti, Athens/GR

Ioannis Raftopoulos, Athens/GR

Stavroula Tzamouri, Athens/GR

Section Editors

Neuro/Head and Neck Radiology

Petros Zampakis, Patras/GR

Georgios Karas, Amsterdam/NL

Spyridon Kollias, Athens/GR

Stavroula Lyra, Athens/GR

Ekaterini Solomou, Patras/GR

Thoracic and Cardiovascular Imaging

Alexandros Kalifatidis, Thessaloniki/GR

Theodoros Kratimenos, Athens/GR

Renata Mastorakou, Athens/GR

Marousa Ntouskou, Liverpool/UK

Abdominal Imaging

Evaggelos Alexiou, Larissa/GR

Anastasios Leukopoulos, Thessaloniki/GR

Chrysovalantis Vergadis, Athens/GR

Konstantinos Revenas, Athens/GR

Oncologic Imaging

Efthymios Andriotis, Athens/GR

Christina Kalogeropoulou, Patras/GR

Myrsini Stassinopoulou, Athens/GR

Kostas Tsilikas, Athens/GR

Dimitris Tsitsimelis, Athens/GR

Paediatric Radiology

Ioannis Nikas, Athens/GR

Marina Papadaki, Athens/GR

Marina Vakaki, Athens/GR

Musculoskeletal Imaging

Alexia Balanika, Athens/GR

Georgios Delimpasis, Bern/CH

Marianna Vlychou, Larissa/GR

Interventional Radiology

Ioannis Ioannidis, Larissa/GR

Georgios Karydas, Athens/GR

Konstantinos Papadopoulos, Athens/GR

Christos Rountas, Larissa/GR

Breast Imaging

Irini Georgiou, Athens/GR

Polytimi Leonardou, Athens/GR

Vasilis Tataridas, Athens/GR

Aikaterini Vassiou, Larissa/GR

Molecular and Hybrid Imaging

Maria Gavra, Athens/GR

Ioannis Pantazis, Athens/GR

Konstantinos Stefanidis, Athens/GR

Cited in: • Scopus • Index Copernicus International • Google Scholar

Visit the journal website www.hjradiology.org

Published by: SPEG Consulting

Ippokratous 44-46, 106 80, Athens, Greece

Tel.: +30 210 5238777, E - mail: info@speg.gr

ΕΙΔΙΚΗ

ΠΡΟΣΦΟΡΑ

ΕΩΣ 30/4/2026

ΔΩΡΑ:

1. Ο Ηλεκτρονικός υπολογιστής

της Hewlett Packard.

2. Tο πρόγραμμα 3D AI SEGMENTATION

προσφέρει αυτόματο σχεδιασμό του

φατνιακού με αναφορά στο μήκος του,

μετρήσεις διαμέτρου για endo,

σχεδιασμό εμφυτευμάτων κτλ.

με τη βοήθεια Τεχνητής

Νοημοσύνης

H JR


Editorial Board

Editorial Board Members

Andreas Adam, London/UK - Interventional Radiology

Gina Allen, Oxford/UK - Musculoskeletal Radiology

Luis Marti Bonmati, Valencia/ES - Neuroradiology

Efstathios Boviatsis, Athens/GR - Neurosurgery

Roberto Cannella, Palermo/IT - Abdominal and Gastrointestinal Imaging

Elias Brountzos, Athens/GR - Interventional Radiology

Achilles Chatziioannou, Athens/GR - Interventional Radiology

Sofia Chatziioannou, Athens/GR - Nuclear Medicine

Ioannis Datseris, Athens/GR - Nuclear Medicine

Athanasios Gouliamos, Athens/GR - Neuroradiology

Giuseppe Guglielmi, Foggia/IT - Musculoskeletal Radiology

Thomas Helmberger, Munich/DE - Abdominal Imaging

Vasiliki Kamenopoulou, Vienna/AT - Radiation Physics

Dimitrios Kardamakis, Patras/GR - Radiation Oncology

Dimitrios Karnabatidis, Patras/GR - Interventional Radiology

Ioannis Koutsikos, Athens/GR - Nuclear Medicine

Andrea Laghi, Rome/IT - Abdominal and Gastrointestinal Imaging

Paul Nikolaidis, Chicago/USA - Body Imaging

Sotirios Oikonomidis, Athens/GR - Radiation Physics

Nikos Papanicolaou, Philadelphia/USA - Genitourinary Imaging

Georgios Pissakas, Athens/GR - Radiation Oncology

Spyridon Pneumatikos, Athens/GR - Orthopedics

Marios Psychogios, Basel/CH - Interventional Neuroradiolgy

Vassilios Raptopoulos, Boston/USA -Abdominal Radiology

Hans Peter Schlemmer, Heidelberg/DE - Oncologic Imaging

Nikolaos Tentolouris, Athens/GR - Internal Medicine

David Wilson, Oxford/UK - Musculoskeletal Radiology

Giulia Zamboni, Verona/IT - Abdominal Imaging

Anastasia Zikou, Ioannina/GR - Neuroradiology

H JR


90 ΧΡΟΝΙΑ

Official Journal of the

HELLENIC RADIOLOGICAL

SOCIETY

Board of the Society

President

Athanasios Chalazonitis

Honorary President

Prof. Kyriakos Strigaris

Vice President A'

Stylianos Benakis

Vice President B'

Antonio Tsanis

Secretary General

Kyriaki Tavernaraki

Treasurer

Konstantinos Tsilikas

Members

Orestis Kavvadas

Penelope Lampropoulou

Christos Mpaltas

Fotios Takis

Secretary Specialists

Vassiliki Bizimi

Ioanna Staikidou

The Hellenic Radiological Society is the formal scientific and educational Society of Greek Radiolgists. It was founded in 1933

and aims to develop the highest Radiological standards, as well as to exchange scientific informationin all fields of Imaging

through training and research.

Hellenic Radiological Society, 21, P. Kiriakou str., 11521 Athens, Greece

E-mail: info@helrad.org, Tel.: (+30) 210 6451489, Fax: (+30) 210 6453092

ΠΡΟΣΤΑΤΕΥΣΤΕ ΤΟΝ

ΕΓΚΕΦΑΛΟ ΣΑΣ

Μείωση σκεδάζουσας

ακτινοβολίας έως 97% 1

H JR


Contents

original article

Comparative Study of Radiation Dose Levels in Automatic and Manual Slice Thickness Selection

in Contrast Enhanced Computed Tomography Abdomen

Akhil Raj, Amita Digambar Dabholkar, Adithya G. Rao, Amal Shaji 22-30

Quantitative Assessments For Phase-Sensitive Inversion Recovery

Post Gadolinium Based Contrast Enhancement

Hamza Arjah, Noor Diyana Osman, Hussein ALMasri, Sawsan E. Abusharkh,

Mustafa Hammad, Mohammad Nofal, Omarah Abdelqader 31-37

Assessment of Anatomical Variations and Cerebral Vessel Diameters in Ischemic Stroke Patients

Using CT Angiography Examination

Zeliha Cosgun MD, Ozgur Senol MD, Bekir Enes Demiryurek MD, Emine Dagistan MD,

Yasar Dagistan MD, Oya Kalaycioglu, Melike Elif Kalfaoglu MD 38-47

Distinguishing between low-grade and high-grade brainstem glioma using standard MRI pulse sequences

Nguyen Duy Hung, Ta Van Lam, Do Viet Anh, Nguyen Thu Minh Chau,

Bui Huyen Trang, Nguyen Minh Duc 48-59

Morphometric Analysis of Hard Palate Using Cone Beam Computed Tomography for Sex Estimation

Karthikeya Patil, Mahima V Guledgud, Sanjay Chikkarasinakere Jogigowda,

Varusha Sharon Christopher, Akash Saha, Ritu Basavarajappa 60-67

Clinical Case - Test Yourself

72-Year-Old Male with Chronic Untreated Pain and Incidental Radiographic Findings

Prasanna Srinivas Deshpand, Karthikeya Patil, Meera Theenathayalan 68-72

Acute Shoulder Pain with Inflammatory Imaging Features: A Diagnostic Challenge

Evangelia Kalaitzidou, Aikaterini Tavernaraki, Dimitrios Exarchos 74-76

GUIDELINES FOR AUTHORS 77-80

21

H R J


in Contrast Enhanced Computed Tomography Abdomen, p. 22-30

VOLUME 11 | ISSUE 1

Original Article

Physics

Comparative Study of Radiation

Dose Levels in Automatic and Manual

Slice Thickness Selection

in Contrast Enhanced Computed

Tomography Abdomen

Akhil Raj, Amita Digambar Dabholkar, Adithya G. Rao, Amal Shaji

Department of Medical Imaging Technology, Yenepoya School of Allied Health Sciences

(Yenepoya deemed to be University)

SUBMISSION: 23/07/2024 | ACCEPTANCE: 12/01/2025

Abstract

Purpose: To compare the radiation dose in automatic

and manual slice thickness selection in Contrast Enhanced

Computed Tomography (CECT) Abdomen.

Material and Methods: In the department of Radiodiagnosis

and Medical Imaging, this prospective study

involved 52 participants who were referred for CECT

Abdomen scan with 128 slice CT scanner (GE Revolution

EVO). The study involved 26 participants in the automatic

slice selection group and another 26 participants

in the manual slice thickness based on the participants

co-operation while scanning. Intravascular (IV) contrast

material was administered to the patient during

Key words

Computed Tomography, Contrast Enhanced Computed Tomography,

Automatic slice thickness, Manual slice thickness, Dose Length

product, Radiation dose, Plain scan, Arterial phase, Venous phase.

Corresponding

Author,

Guarantor

Miss. Amita Digambar Dabholkar, Assistant Professor, Department: Medical

Imaging Technology, Yenepoya School of Allied Health Sciences (Yenepoya

Deemed to be University) Mangaluru - 575018, Karnataka, India

Email: dabholkaramita99@gmail.com

22



VOLUME 11 | ISSUE 1

H R J

a CECT Abdomen scan. After the scan, the dose report

was measured based on the slice thickness with the help

of DLP to compare the radiation dose between the automatic

and manual slice thickness selection methods.

Results: There was a significant difference in DLP between

the automatic slice thickness (AST) and manual

slice thickness (MST) groups (p value <0.001). The mean

DLP in the automatic slice thickness group was 1152.54

mGy-cm, while in the manual slice thickness group it

was notably lower at 802.69 mGy-cm. In the automatic

slice thickness and manual slice thickness group, we

observed a statistically significant difference in mean

DLP between the arterial and venous phase (p value

<0.001). Pearson’s correlation was used to compare the

correlation among the variables, and we found that, in

AST, the arterial and venous phases are closely related,

with a correlation of 0.852 (p value <0.0001). In MST,

similarly, the arterial and venous phases are strongly

related with a correlation of 0.920 (p value <0.0001).

Conclusion: This study's findings demonstrated that

manual slice thickness was the most effective approach

for reducing radiation dose in dual-phase CECT Abdomen

scans compared to automatic slice thickness selection.

Introduction

Abdominal and pelvic imaging is among the medical

diagnostics that have been transformed by Computed

Tomography (CT). It has proven to be a vital tool for

the diagnosis and treatment of numerous illnesses due

to its capacity to provide intricate cross-sectional views

of internal organs. From the creation of multi-detector

CT scanners to the incorporation of advanced software

that improves image quality and minimises motion

artefacts, the development of CT technology has been

characterised by notable breakthroughs. Notwithstanding

these developments, there are still serious

worries about the radiation dosages to patients from

CT scans [1,2].

The possible CT radiation risk, which could increase

a person's lifetime risk of acquiring cancer, is a growing

source of concern [3]. Due to rising CT usage and

widespread worries about the risk of radiation exposure

from medical imaging, the precise radiation dose

to each patient from a CT scan is infamously difficult

to measure. Due to this, dosage monitoring devices

are now more frequently used in clinical settings [4,5].

By using CT as an imaging modality sparingly, dosage

reduction can be accomplished. There are several parameters

that affect the radiation dose, including tube

current (mA), product of the tube current-time (mAs),

tube voltage (kVp), time per rotation, collimation, scan

length, pitch, and slice thickness [6]. The CT parameters

are important in calculating the radiation dose. Slice

thickness is a crucial parameter that needs to be optimized

based on clinical demands. The slice thickness

values range from 1mm to 10mm [7]. A CT scan's slice

thickness influences the radiation dose that a patient is

exposed to. In CT imaging, the link between slice thickness

and collimation width is crucial since both factors

affect the radiation dose, quality, and resolution of a

CT scan. With a single rotation of the CT gantry, many

slices can be acquired concurrently with multi-slice CT

scanners because multiple detectors are stacked in parallel.

The collimation width and the quantity of slices

obtained per rotation both affect the slice thickness. In

multi-slice CT scanners, slice thickness can be changed

apart from collimation. However, the detector system's

architecture and the collimation's width typically limit

the shortest slice thickness that can be achieved. It is

possible to choose the slice thickness as a percentage

of the collimated width. Depending on the clinical requirements,

the slice thickness and collimation width

of contemporary CT scanners can be independently

changed. This adaptability enables personalised imaging

techniques that strike a compromise between radiation

dose, scan time, and resolution [8].

Thicker slices yield higher SNR images with shorter

scan times than thinner slices. In certain instances,

it could be advantageous to use thinner, more closely

spaced slices to detect the existence of tiny regions of

bone sequestration. Using thicker slices is advantageous

if the imaging features are more gross, like seeing

thick curvilinear interior septae. Therefore, patient

safety and accurate diagnosis, a balance between radiation

and image quality is essential [9]. Recently, CT

technology and software have been merged to provide

both automatic and manual slice thickness selection.

Slice thickness is set at 7.5 mm for manual slice selection

and 5 mm for automatic slice thickness. Compared

to 7.5 mm slices, 5 mm slices offer superior spatial resolution

and image quality, making it possible to scan

finer features, lesions, and smaller structures more

clearly. This is very helpful for spotting mild diseases or

23

H R J



VOLUME 11 | ISSUE 1

smaller structures. Another benefit is that, in contrast

to 7.5 mm slices, the partial volume effect is less noticeable.

Because each slice catches finer information and

distinguishes tissues more clearly, the image can more

properly depict the boundaries of various tissues. Additionally,

the improved spatial resolution makes it possible

to perform more comprehensive reconstructions in

several planes, which is crucial for accurate anatomical

localisation in Multi-Planar Reconstruction (MPR). Because

more data must be collected to cover the same

space, one of the primary drawbacks is a longer scan

time compared to 7.5 mm slices. In some populations,

the patient may have to remain motionless for an extended

amount of time, which can be difficult. For situations

where speed is more crucial than fine detail, a 7.5

mm slice thickness is appropriate. Helpful for patients

who struggle to stay motionless or in emergency situations,

it is useful for imaging the abdomen, chest, and

pelvis, particularly when high-resolution detail is not

the main need. [10,11]

The CT scanner uses a routine to automatically determine

a slice thickness; it does not take the patients'

age or Body Mass Index (BMI) into account. The selected

thickness is the same for every patient. While most

radiographers use automatic slice selection, manual

slice thickness selection necessitates the radiographer

selecting a slice thickness. Regardless of the patient's

age, the main disadvantage of automatic slice

selection is that it will expose kids to more radiation.

Automatic slice thickness selection enhances the efficiency

of imaging by automatically selecting the slice

thickness. Benefits of automatic slice selection include

reduced workload for the radiographer and increased

consistency and accuracy in slice selection. Automatic

slice selection achieves higher resolution images,

more slices are needed, and thus more X-ray exposure

is required, leading to an increased radiation dose to

the patient. The skill and judgement of the technologist

play a crucial role in manual slice thickness selection.

Under these conditions, using the manual slice thickness

selection will provide patients a reduced radiation

dose while still producing an image with a good level of

diagnostic quality. The CT dose report shows the current

radiation dose output from the CT scanner after

patient imaging in terms of the Dose Length Product

(DLP) and volume CT dose index (CTDI vol). DLP offers

a highly practical means of comparing the dosages administered

by various scan protocols [12].

With this background, the current study aims to compare

the radiation dose in automatic and manual selection

of slice thickness in CECT abdomen.

Material and Methods

Study population

This descriptive cross-sectional study was conducted

in the department of Radiodiagnosis and Medical Imaging,

Yenepoya Medical College Hospital, Mangalore,

between July 2023 and January 2024. The study approval

was obtained from Yenepoya Ethical Committee after

approval from the Scientific Review Board.

The study enrolled 52 participants with ages ranging

from 20 to 80 years who satisfied the inclusion and exclusion

criteria, including those undergoing dual-phase

CECT Abdomen with normal BMI (18.5-24.9 kg/m2).

Participants with a history of contrast allergy, severe

heart disease, creatinine levels exceeding 1.3mg/dl,

and pregnant women were excluded from the study.

After explaining the procedure to the patient, written

informed consent was obtained. The CT scan was

conducted using a 128-slice General Electronics (GE)

Revolution Evo scanner. The 52 participants were categorized

into two groups, the automatic slice thickness

selection group and the manual slice thickness selection

group, using a simple random selection method,

with each group consisting of 26 participants.

Imaging Protocol and Analysis

A non-ionic contrast media, Iohexol, with an iodine

content of 350mgI/ml, was used in this study. Using a

sterile technique, 70ml of contrast was given at the rate

of 2-3ml/s by a pressure injector controlled by the technologist,

which was the same for both automatic slice

selection and manual slice selection. Adult patients

underwent contrast-enhanced abdominal dual-phase

scans with normal BMI and were classified into two

groups based on their cooperation during scanning.

Participants who readily cooperated during scanning

were categorized in automatic slice thickness selection

(group 1), while participants who were less cooperative

were categorized in manual slice thickness selection

(group 2).

A 7.5 mm was chosen for manual slice thickness and

5 mm for automatic. The CT system automatically presets

the 5 mm slice thickness, which is why it is utilised

24



VOLUME 11 | ISSUE 1

H R J

for automatic slice selection. A 7.5 mm slice thickness

works well in scenarios where speed is more important

than fine detail. beneficial for patients who have trouble

remaining still; for this reason, it was used for the

manual selection.

A plain abdominal scan was conducted, which was

identical for both groups. Following the initial scan

(plain), participants who adhered to breathing instructions

and remained motionless during the scan were included

in group 1. Participants who moved and did not

follow breathing instructions were included in group 2.

In group 1, a plain abdominal scan was taken with a

10 mm slice thickness. After the plain scan, participants

were scanned for the arterial and venous phases with

a 5 mm slice thickness using automatic slice selection.

After the completion of the scan, the radiation dose was

measured based on the slice thickness using the DLP

from the dose report.

In group 2, a plain abdominal scan was taken with a

10 mm slice thickness. After the plain scan, participants

were scanned for the arterial and venous phases with

a 7.5 mm slice thickness using manual slice selection.

After the completion of the scan, the radiation dose was

measured based on the slice thickness using DLP from

the dose report. Group 1 and Group 2 were compared

based on the total DLP value.

Table 1. CECT Abdomen protocol.

Patient position

Scan type

Scano/Scout

Area coverage

Scan direction

Start location

End location

Slice thickness

Supine feet first

Helical

AP/Lateral

Domes of diaphragm to

pubic symphysis

Cranio caudal

Domes of diaphragm

Pubic symphysis

5mm (AST)

7.5mm (MST)

kVp/mAs 120/250

Gantry angle 0°

Resolution

Standard

Pitch 1.375:1

Rotation time

0.75 second

Table 1. CECT Abdomen protocol.

FOV

350mm

Matrix 512 x 512

Collimation 64 x 0.625

Contrast

Reconstruction

Volume: 70ml

Flow rate: 2-3ml/s

Locator/tracker:

Abdominal aorta

Threshold: 80 HU

MPR

3mm

Statistical analysis

For statistical analysis, the data were analysed in

SPSS version 21.0 in descriptive statistics. Mean and

standard deviation for continuous variable, frequency

and percentage for categorical variable. Paired t-test

was used to compare the automatic and manual slice

thickness selection, and the independent sample t-test

was used to compare the arterial and venous phase.

Results

The selection of slice thickness has a major influence

on radiation exposure in CECT examinations. DLP between

arterial and venous phases within both groups,

as well as between automatic and manual slice thickness

selections, showed a significant difference.

As shown in Table 2 and illustrated in Figure 1, the

Paired sample t-test revealed a statistically significant

difference (p < 0.0001) between the mean DLP values of

the automatic slice thickness (AST) and manual slice

thickness (MST) groups in CECT abdomen scans. The

mean DLP in the AST group was 1152.54 mGy-cm, while

in the MST group, it was notably lower at 802.69 mGy-cm.

In the AST group, in plain scan, the mean DLP was

186.6496 mGy-cm (SD=3.5209). The mean DLP of the

arterial scan was 509.1481 mGy-cm (SD=57.7907), in

the venous scan, the mean DLP was 456.7404 mGy-cm

(SD=50.0578) (Figure 2).

In the MST group, the mean DLP of plain scan was

185.6062 mGy-cm (SD=3.5084). In arterial and venous

scans, the mean DLP was 320.8504 mGy-cm (SD=22.4191)

and 295.8742 mGy-cm (SD=23.2704), respectively (Figure

3).

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Table 2. Paired t-test to compare the DLP between AST and MST.

Total DLP

in AST

Total DLP in

MST

Mean Std Deviation t p Value

1152.54 105.54

802.69 44.53

15.433 <0.0001* 303.16

95% Confidence Interval

of the Difference

Lower

396.53

Upper

(* significant)

Figure 1: Comparison of total DLP between AST and MST.

Figure 2: Comparison of DLP between arterial and

venous phase in AST.

Figure 3: Comparison of DLP between arterial and

venous phase in MST.

The DLP of arterial and venous phases between the

two groups was compared using an Independent sample

t-test. Table 3 indicates a statistically significant difference

between automatic and manual slice thickness

in the arterial phase and venous phase, with a p-value

of <0.001 (Figure 4 and Figure 5). No significant difference

in DLP was noted between automatic and manual

slice thickness in plain scan, with the mean difference

of 1.0435 mGy-cm (p-value >0.05).

Table 3. Comparison of the radiation dose between Arterial and Venous phase.

Variables Group Mean

Plain

Arterial

Venous

Std.

Deviation

AST 186.6496 3.5209

MST 185.6062 3.5084

AST 509.1481 57.7907

MST 320.8504 22.4191

AST 456.7404 50.0578

MST 295.8742 23.2704

Test

Statistics

p value

Mean

difference

95% Confidence Interval

of the Difference

Lower

Upper

1.0704 0.2896 1.0435 -0.9145 3.0014

15.4893 <0.001* 188.2977 163.8804 212.7150

14.8591 <0.001* 160.8662 139.1214 182.6110

(* significant)

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H R J

Figure 4: Comparison of DLP between AST and MST in

arterial phase.

Figure 5: Comparison of DLP between AST and MST in

venous phase.

Table 4. Pearson correlation among the

variables for AST.

Variables correlation p value

Plain

(* significant)

Arterial 0.517 0.007*

Venous 0.452 0.021*

Arterial Venous 0.852 <0.0001*

Table 5. Pearson correlation among the

variables for MST.

Variables correlation p value

Plain

(* significant)

Arterial -0.122 0.552

Venous -0.132 0.521

Arterial Venous 0.920 <0.0001*

The correlation between the variables was examined

using the Pearson correlation test. Table 4 shows how

different phases of the CECT scan relate to each other. A

correlation value of 0.517 between the plain and arterial

phases (p-value 0.007) means they are slightly related.

The plain and venous phases have a correlation of

0.452 (p-value 0.021), showing a moderate connection.

The arterial and venous phases are closely related, with

a correlation of 0.852 (p-value <0.0001). These numbers

tell us that the arterial and venous phases are strongly

related, while the plain phase is less related to the other

two in AST group.

In the present study we found that there was a correlation

between plain and arterial (p value is 0.007),

plain and venous (p value is 0.021), arterial and venous

(p value <0.0001), which is statistically significant.

Table 5 shows how different phases of the CECT scan

are related for MST. The plain phase doesn't have a

strong relationship with the arterial phase (correlation

-0.122, p-value 0.552) or the venous phase (correlation

-0.132, p-value 0.521). This means changes in

the plain phase don't match changes in the arterial or

venous phases. However, the arterial and venous phases

are closely related (correlation 0.920, p-value less

than 0.0001). This means that when the arterial phase

changes, the venous phase changes in a similar way. So,

the plain phase is not related to the other phases, but

the arterial and venous phases are strongly related.

The Pearson correlation test was used to compare the

correlation among the variables. In the present study,

we found that there was a correlation between arterial

and venous (p value <0.0001), which is a statically significant.

No significant difference between the plain and arterial

(p value 0.552), as well as plain and venous (p value

0.521) was found. Hence, they were not correlated with

each other.

Discussion

The exact radiation dose that each patient received

from a CT scan was notoriously difficult to estimate due

to the growing use of CT scans and general concerns

about the risk of radiation exposure from medical imaging

[4].

Dosage monitoring systems are therefore being employed

in clinical settings more frequently [5]. Reduction

in the dose can be achieved by using different dose

reduction techniques and also by altering the protocol.

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The tube current (mA) regulates how much radiation

the X-ray tube emits. Although they increase the radiation

exposure, higher mA settings typically result in better

image quality.

Tube voltage (kV) affects both the penetration depth

and the X-rays' energy level. Larger patients may require

higher kV settings to guarantee sufficient penetration,

although doing so may result in an increase in dosage.

The ratio of slice thickness to table movement per

rotation is known as pitch. By reducing the overlap of

the slices, a greater pitch can lower the radiation dose,

but image quality may suffer. Collimation refers to the

process of shaping and limiting the x-ray beam so that it

only exposes the area of interest. Collimation lowers radiation

exposure to non-imaged regions and minimises

scatter radiation, which happens when the X-ray beam

strikes tissues outside the target region. In addition to

contributing to needless radiation exposure, scatter radiation

can deteriorate image quality.

In order to maximise the balance between radiation

exposure and image quality, Automatic Exposure Control

(AEC) systems that automatically modify collimation

and tube current are frequently included in modern CT

scanners. The scan length impacts the total radiation

dose, the dose increases as more body areas are scanned.

Exposure can be decreased by reducing the scan area or

length. Rotation time is the amount of time it takes the

CT scanner to go around the patient one full rotation.

Shorter rotation durations may need more radiation to

produce high-quality images, but they can lessen motion

artefacts [8,13,14].

The thickness of a CT scan's slices determines the radiation

dose to which a patient is exposed. It is a critical

metric that must be optimized for clinical use [9].

With the recent merger of CT technology and software,

slice thickness selection can now be performed automatically

and manually. The thickness that is automatically

set for each patient is the same regardless of their age or

BMI, which results in a high radiation dosage. However,

an adequate diagnostic quality image can be produced

with a lower radiation dose when the slice thickness is

manually adjusted by the radiographer, specifically by

increasing the slice thickness slightly. In terms of image

quality, automated slice thickness adjustment is superior

[12].

In our study, we compared the radiation dose in automatic

and manual slice thickness selection group in

CECT Abdomen. For manual and automatic slice thickness,

7.5 mm and 5 mm, respectively, were selected. Because

of the predefined thickness value for the CECT abdominal

scan protocol, a 5mm slice thickness is chosen

as the automatic slice selection. A 7.5mm is adjacent to

the 5mm slice thickness in our CT system; it was chosen

as the manual slice thickness.

The reason we are not regarded as having the thinner

slice thickness for manual slice selection is that

the participants who underwent manual slice selection

in CECT abdomen scan did not follow the breathing instructions

and movement during the scan; in those cases,

choosing the thinnest slice thickness will take more

scan time, affect image quality, and produce artefacts. In

order to overcome that, we chose a slice thickness of 7.5

mm, which falls between 10 and 5 mm, offers a balanced

image quality, and enables faster data collection, which

reduces the amount of time required to finish the scan.

This can help patients who might have trouble staying

still or in emergency situations.

Paired t-test (p value <0.001) was used to compare

the automatic and manual slice thickness selection. We

found that there was a significant difference in radiation

dose between automatic and manual slice thickness

selection, with a mean DLP of 1152.54 mGy-cm, 802.69

mGy-cm, respectively. An increased radiation dose was

seen in automatic slice thickness selection with a slice

thickness of 5mm compared to manual slice thickness

selection with a slice thickness of 7.5 mm. It revealed

that an increased slice thickness led to reduced radiation

dose. In a study conducted by N. Hirasawa et al.

(2010) where they compared 1mm and 3mm slice thickness,

they found that a CT scan acquired using 3mm slice

thickness was optimal with a reduced radiation dose

compared to a 1mm slice thickness, which was similar

to our study. CT scans acquired using thinner slices are

considered to increase radiation exposure [15].

In the present study, we compared the radiation dose

in automatic and manual slice selection in the arterial

and venous phase by using the independent sample

t-test (p value <0.001). We found that there was a significant

difference in mean DLP between the arterial and

venous phases in both automatic and manual slice thickness

selection. Pearson’s correlation shows that there

was a significant correlation between DLP of arterial and

venous phase in both groups (p value <0.001) using Pearson’s

correlation test.

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VOLUME 11 | ISSUE 1

H R J

Compared to the venous phase, the arterial phase has

more contrast deposition, which leads to more radiation

in the arterial phase.

Because faster image acquisition is required to capture

the rapid passage of contrast via the arteries, the arterial

phase frequently necessitates a greater radiation

dose. To distinguish between surrounding tissues and

high-contrast arterial arteries, a greater radiation level

is required for sufficient resolution.

Compared to the arterial phase, the venous phase often

requires less radiation. This is because, because contrast

moves through the veins more slowly in the venous

phase. Hence, in our study, we found that the radiation

dose was higher in the arterial phase of the CECT Abdomen

scan compared to the venous phase in both automatic

and manual slice thickness selection. In automatic

slice thickness selection, the mean DLP of the arterial

phase was 509.1481 mGy-cm, and the mean DLP of the

venous phase was 456.7404 mGy-cm. In manual slice

thickness selection, the mean DLP of the arterial and

venous phase was 320.8504 mGy-cm and 295.8742 mGycm,

respectively. In a similar study conducted by Kostas

Perisinakis et al., (2018) found that administration of

iodinated contrast media considerably increases radiation

dose to tissue from CT exposure. These observations

support our study [16].

There are no further studies similar to the present

study. Our study concluded that manual slice thickness

selection provides efficient dose reduction in CECT abdomen

examination compared to automatic slice thickness

selection. There was a significant difference in radiation

dose between the arterial and venous phases in both

groups; the arterial phase always had more radiation

dose compared to the venous phase due to its greater

contrast deposition. Also, there was a positive correlation

between the arterial and venous phases.

In AST, the arterial and venous phases are closely

related with a correlation of 0.852 (p value <0.0001). In

MST, the arterial and venous phases are closely related

with a correlation of 0.920 (p value <0.0001). Pearson’s

correlation admits that the arterial and venous phases

are strongly related in both groups. In plain scan, there

was no significant difference between AST and MST, due

to the same slice thickness of 10mm in the plain scan

in both groups. Compared to arterial and venous scans,

plain scans provided a reduced radiation dose due to the

thicker slice thickness and absence of contrast media.

The null hypothesis stated that manual selection of

slice thickness will not provide a reduction of radiation

dose in CECT Abdomen, which is not true, whereas the

alternate hypothesis stated that manual selection of

slice thickness will provide a better reduction of radiation

dose. Through our study, we found a reduced radiation

dose in the manual slice thickness group.

Our research findings indicate that using MST with a

7.5mm slice thickness in CECT Abdomen examinations

resulted in a decreased radiation dose compared to AST

with a 5mm slice thickness. This highlights that thinner

slice thicknesses typically entail higher radiation doses

than thicker slices. Expanding the future scope of this

study involves increasing the sample size and conducting

it across multiple centers in a multicenter study setting.

R

Limitation

One limitation of this study is that the automatic slice

thickness was only compared with a single manually selected

slice thickness of 7.5mm.

Conclusion

In CECT examinations, the choice of slice thickness

significantly impacts radiation dose.

A significant difference was observed in DLP between

automatic and manual slice thickness selections, as

well as DLP between arterial and venous phases within

both groups. Our findings revealed that, automatic slice

thickness selection resulted in a higher radiation dose

with a thinner slice thickness compared to thicker slice

of manual slice thickness.

Therefore, we conclude that manually selecting slice

thickness is an effective approach for reducing radiation

exposure in CECT Abdomen scans while maintaining

good diagnostic image quality.

Funding

This project did not receive any specific funding.

Ethical Approval

“The Institutional Review Board of Yenepoya Deemed

to be University approved informed consent form due to

the prospective nature of the study”.

Conflict Of Interest

There is no conflict of Interest in this study.

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Ready - Made

Citation

Akhil Raj, Amita Digambar Dabholkar, Adithya G. Rao, Amal Shaji.

Comparative Study of Radiation Dose Levels in Automatic and Manual Slice

Thickness Selection in Contrast Enhanced Computed Tomography Abdomen,

Hell J Radiol 2026; 11(1): 22-30.

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Post Gadolinium Based Contrast Enhancement, p. 31-37

VOLUME 11 | ISSUE 1

Neuroradiology

H R J

Original Article

Quantitative Assessments For

Phase-Sensitive Inversion Recovery

Post Gadolinium Based Contrast

Enhancement

Hamza Arjah 1,2 , Noor Diyana Osman 1 , Hussein ALMasri 3 , Sawsan E. Abusharkh 4 ,

Mustafa Hammad 5 , Mohammad Nofal 6 , Omarah Abdelqader 2

1

Advanced Medical and Dental Institute, Universiti Sains Malaysia, Kepala Batas, Penang, Malaysia

2

Radiology Department, Allmed Medical Center, Ramallah, Palestine

3

Medical Imaging Department, Faculty of Health Professions, Al-Quds University, Abu dis, Jerusalem, Palestine

4

Physiology and pharmacology department, Faculty of Medicine, Al-Quds University, Abu dis, Jerusalem, Palestine

5

Neurology clinic, Allmed Medical Center, Ramallah, Palestine

6

Al-Salihi Radiology Center, Ramallah, Palestine


Abstract

Purpose: The T1-weighted Magnetization Prepared

Rapid Acquisition Gradient Echo (T1 MPRAGE) sequence

is widely adopted for gadolinium-based contrast enhancement

(GBCE) for brain lesions, but researchers

still inspect other sequences for GBCE to achieve more

accurate diagnostic images. This study aimed to evaluate

the effectiveness of Phase Sensitive Inversion Recovery

(PSIR) in evaluating brain lesions post-GBCE.

Key words

PSIR, MRI contrast, Brain MRI, contrast-to-noise ratio (CNR), GBCE

Corresponding

Author,

Guarantor

Hamza Arjah, Advanced Medical and Dental Institute, Universiti Sains Malaysia,

Kepala Batas, Penang, Malaysia - Radiology Department, Allmed Medical Center,

Ramallah, Palestine

Email: hamza.arejeh@gmail.com

Tel: 00972597266724

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Material and Methods: Retrospective data collection

from one radiology unit included 44 patients with

Brain lesions. The patients underwent brain Magnetic

Resonance Imaging (MRI) with GBCE using a 1.5 Tesla

MRI scanner. GBCE analysis on MPRAGE and PSIR sequences

involved quantitative assessments based on

the contrast ratio (CR), contrast enhancement (CE), and

contrast-to-noise ratio (CNR) for MPRAGE.

Results: PSIR CNR was slightly higher than T1-

MPRAGE, while T1-MPRAGE was more effective in

CE and CR. The average lesion CNR was 38.4 for T1-

MPRAGE, and increased to 41.3 for PSIR without a significant

difference p-value > 0.05. For CE, the average

lesion CE in T1-MPRAGE was 0.75, and significantly decreased

to 0.36 for the PSIR sequence p-value < 0.001.

The CR in T1-MPRAGE exhibited an average value of

1.2, while PSIR's average value significantly decreased

to 0.67, p-value < 0.001. However, the CR and CE were

higher in PSIR for some lesions.

Conclusion: Although PSIR post-GBCE imaging can

enhance the visualisation of certain brain lesions, in

some cases, it cannot replace T1 MPRAGE for routine

clinical use. However, PSIR post-GBCE can be combined

with T1-MPRAGE to improve lesion evaluation.

Introduction

MRI is widely recognised for its superior soft tissue

contrast and non-invasive capabilities, making it a critical

diagnostic tool for brain lesion detection. PSIR is an

MRI sequence that has drawn attention for its potential

to enhance lesion visibility. PSIR offers improved CNR

and reduces artefacts, which can help in the identification

of subtle pathological changes in brain tissue [1].

PSIR imaging benefits from its phase-sensitive nature,

which allows for precise tissue differentiation

and improved lesion conspicuity compared to MPRAGE.

The ability of PSIR to detect low signal intensity (SI) lesions

or differentiate complex structures could provide

a diagnostic advantage in challenging cases, such as

multiple sclerosis (MS), gliomas, and metastases [2] [3]

[4] [5]. The GBCE is essential for some pathologies [6].

And it should be administered according to the clinical

needs [7]. However, different works employed different

sequences post-GBCE, such as susceptibility-weighted

imaging (SWI) [8], Fluid-Attenuated Inversion Recovery

(FLAIR) [9] and PSIR [10]. Each work achieved different

benefits and limitations, so selecting a new sequence

post-GBCE can sometimes add benefits.

Ping Hou et al. mentioned in their work that the

PSIR sequence can detect GBCE enhancement in Brain

lesions [10]. No work in our literature has evaluated

brain lesions for PSIR post-GBCE compared to standard

T1 post-GBCE for different Brain lesions. This study addresses

this challenge by comparing the diagnostic performance

of PSIR post-GBCE imaging with T1 MPRAGE

sequences for brain lesion evaluation and characterisation.

This work employs quantitative assessment for

lesions, including CE, CR, and CNR.

Methods

Scanner, Patients and Sequences

MRI scans were performed using a Siemens MAG-

NETOM ESSENZA 1.5 Tesla system equipped with PSIR

and MPRAGE sequences. A head-and-neck 16-channel

coil was used for all scans. Retrospective data collection

achieved ethical approval from the institutional

research and ethics review committee (413/REC/2024).

Data collection included 44 patients diagnosed with

various brain lesions; among these patients, 27 underwent

PSIR pre-GBCE and post-GBCE imaging, while

17 received only PSIR post-GBCE. All 44 patients were

scanned using T1 MPRAGE pre-GBCE and post-GBCE sequences.

Quantitative analysis

Region-of-interest (ROI) analyses were employed for

both PSIR and T1-MPRAGE; lesion size and region were

accounted for during analysis, with ROI placement specific

to each lesion and other ROI in surrounding normal

tissue. Mean signal intensity (SI) and the standard

deviation (SD) values were recorded for post-GBCE and

pre-GBCE sequences. The following metrics were used

for quantitative analysis:

Contrast Ratio (CR)

CR was calculated according to Equation 1, and the

calculation was performed on PSIR and MPRAGE post-

GBCE images [11]:

Equation 1

Where S lesion

is the mean signal intensity within the

lesion, S normal

is the mean signal intensity (SI) in the

surrounding normal tissue [12].

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Contrast Enhancement (CE)

CE was defined by Equation 2; the CE measurements

require pre-GBCE and post-GBCE to be achieved [13].

Equation 2

Where S Ipost

is the SI of lesion post-GBCE, and SI pre

is

the SI of lesion pre-GBCE brain [13]. This calculation

was performed for 27 patients only on PSIR due to the

absence of PSIR pre-GBCE.

Contrast-to-Noise Ratio (CNR)

CNR measure two tissues or object's differentiation

and the effect of noise on the differentiation; CNR was

calculated according to Equation 3 on post-GBCE sequences

[11].

Equation 3

Where SD background

is the standard deviation (SD) of the

SI in a region outside the brain (typically in air) [14],

and SI lesion

and SI normal

are the SI values of the lesion and

surrounding normal tissue, respectively. The work

published by Qing Fu et al. employed the white matter

(WM) as normal tissue (SInormal), and in their second

measurement, they employed the grey matter (GM) as

normal tissue [5]. In this work, we used WM as SInormal

only because WM appears bright on T1, and contrast

media also appears bright. We aim to measure CNR between

two bright tissues.

Quantitative measurements were carried out using

RADIANT DICOM viewer software, with ROIs placed

over lesion, background, and normal WM as depicted

in Figure 1. The ROIs placed on lesions varied according

to lesion size to minimise variability in SI due to different

compositions and to avoid including normal tissue.

At the same time, ROIs placed on normal tissue were

placed on nearby WM tissue. The background noise or

SD was measured using ROIs placed between bone and

image border, with appropriate size to eliminate SD

fluctuations within the measured areas.

The measured SI and SD of different lesions on both

sequences were arranged in Microsoft Excel, and the SI

and SD were employed to measure CR, CE, and CNR according

to the suggested equations. A statistical t-test

was performed to compare CR, CE, and CNR of both sequences,

with a p-value of 0.001 considered a significant

difference.

Results

Contrast ratio (CR)

The CR for the MPRAGE sequence was significantly

higher compared to the PSIR sequence (p < 0.001). The

CR values for PSIR ranged from 1.2 to 0.18, with an average

of 0.67, while the CR values for MPRAGE ranged

from 0.88 to 3.4, with an average of 1.7.

Figure 1: Regions of interest (ROIs) in different imaging

sequences: (A) T1 MPRAGE pre-GBCE illustrating the lesion;

(B) T1 MPRAGE post-GBCE displaying enhancement of the

lesion; (C) PSIR pre-GBCE image; (D) PSIR post-GBCE image

demonstrating slight lesion enhancement and prominent

wall enhancement.

Figure 2: The contrast ratio (CR) for the lesion, comparing

values obtained from the MPRAGE and PSIR sequences.

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VOLUME 11 | ISSUE 1

Contrast enhancement (CE)

MPRAGE also demonstrated significantly higher contrast

enhancement (CE) compared to PSIR (p < 0.001).

MPRAGE CE values ranged from 0.0 to 2.4, with an average

of 0.75, while PSIR CE values ranged from 0.00 to

0.81, with an average of 0.36.

Figure 3: Contrast enhancement (CE) for the lesion, as

observed in both the MPRAGE and PSIR sequences.

Contrast to noise ratio (CNR)

There was no significant difference between MPRAGE

and PSIR in terms of the CNR (p > 0.05). MPRAGE CNR

values ranged from 1.5 to 264.6, with an average of 38.3,

while PSIR CNR values ranged from 3.1 to 170.8, with an

average of 41.5.

for enhanced lesions by GBCE to stand out more distinctly

[15]. This aligns with existing literature, where

T1-weighted post-GBCE sequences like MPRAGE are

routinely used for their ability to highlight GBCE that

accumulate in lesions [16] [17].

However, the assessments reveal that PSIR has worsened

specific scenarios. For example, in vestibular

schwannomas, the bright bone hides the enhanced lesion

that extends from the auditory nerve. In contrast,

in some cases of MS lesions, PSIR provided better lesion

border delineation and higher CR. In some cases, the

differentiation between active and inactive MS lesions

was more pronounced in PSIR images, as shown in Figure

5. However, the differentiation between active and

inactive MS is a clinical concern [7], [18], and researchers

are still developing new techniques to differentiate

between active and inactive MS [2], [19], [20]. The obtained

results in this work add benefits in distinguishing

between active and inactive MS.

Contrast Ratio (CR)

Overall, the CR was higher for MPRAGE, indicating

superior lesion GBCE. However, in certain MS cases,

Figure 4: Figure 4 Contrast to noise ratio (CNR) for the

lesion, the results from the MPRAGE and PSIR sequences

post-GBCE.

Discussion

The findings of this study demonstrate that MPRAGE

post-GBCE imaging generally provides better CE and

lesion visibility than PSIR for most brain lesions. The

superiority of MPRAGE can be attributed to its dark

background and dark bone signals, as shown in Figures

5, 6, and 7. The dark background and bone allow

Figure 5: Displays an MS case with imaging across four

sequences: (A) PSIR pre-GBCE, (B) PSIR post-GBCE, (C)

MPRAGE pre-GBCE, and (D) MPRAGE post-GBCE.

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H R J

presented in Figure 5, the visualisation of active MS

enhanced by GBCE is more evident in PSIR than in

MPRAGE.

This finding suggests that it may be more effective

in visualising active MS lesions in some cases. However,

PSIR’s efficiency in detecting MS lesions without

GBCE is conducted by different works [3], [21], [22]. Our

results showed the ability of PSIR to differentiate between

active and inactive MS lesions in PSIR post-GBCE.

Previous research has also noted the strong correlation

between contrast enhancement and clinical outcomes

[15], and the Improvement of diagnostic precision is essential

in MS [23].

Contrast Enhancement (CE)

The enhanced conspicuity of GBCE in MPRAGE sequences

allows for more precise differentiation of lesion

components, which is particularly important in

assessing lesion vascularity [24] [25]. Ping Hou et al.

concluded that the PSIR sequence is less sensitive to

small T1 values such as GBCE [10], their work results

support our findings, and the detection of contrast enhancement

using PSIR is less than T1 MPRAGE. MPRAGE

outperformed PSIR for most lesion types, except for

some lesions. As shown in Figure 6, the lesion in the

PSIR sequence displays better contrast enhancement

than the MPRAGE sequence. Figure 6 demonstrates that

the lesion is brighter with a higher signal.

noise index (SD). In contrast, the SI of enhanced lesions

in T1-MPRAGE was higher. However, the final results of

Equation 3 indicate a higher CNR for PSIR compared to

T1 MPRAGE. The PSIR sequence suppresses the oedematous

tissue beside the lesion. The lesion visibility and

CNR are enhanced due to more signal differences between

the suppressed dark area around the enhanced

tissue by GBCE, as shown in Figure 7.

PSIR suppresses oedematous tissues surrounding lesions

while enhancing lesion borders, making it particularly

valuable in some instances, such as glioblastomas

(GBM) and cystic schwannomas. However, the

visualisation of brain oedema is critical [26] because

oedematous tissue can be treated and become healthy

after neurosurgery [27].

The suppressed oedematous tissue and enhanced lesion

spots-GBCE are expected to help the neurosurgeon

in the surgery plan for brain lesions. In addition, PSIR

enhances differentiation between WM and GM, which is

essential in identifying brain anatomy [3].

Figure 7: Comparative imaging of glioblastomas (GBM)

using two post-GBCE sequences: (A) MPRAGE post-GBCE,

which provides a conventional representation of the lesion,

and (B) PSIR post-GBCE, which offers an alternative GBCEenhanced

view for better delineation of tumour margins.

Figure 6: Comparison of an enhanced lesion imaged using

two sequences: (A) MPRAGE post-GBCE, and (B) PSIR post-

GBCE.

Contrast-to-Noise Ratio (CNR)

The WM to GM CNR was higher in PSIR compared to

other T1 sequences without GBCE [10]. In this work, lesion

CNR in PSIR post-GBCE was higher due to a lower

The diagnostic limitations of PSIR were evident when

evaluating tumours near bright structures, such as

bone. The bright signal from the bone in PSIR images

often obscured the lesion, making it challenging to differentiate

between the lesion, the bone, and the background.

The lesion should be intra-axial to avoid these

limitations. MPRAGE, with its dark background, provided

superior visualisation of particular lesions, such

as vestibular schwannomas extending into the internal

auditory canal, which was more easily visualised on

MPRAGE compared to PSIR, where the dark bone signal

did not interfere with lesion visibility.

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This study's primary limitation is the relatively small

sample size of 44 patients, which may not fully represent

all brain lesion types.

Additionally, not all patients underwent PSIR pre-

GBCE, so CE in 17 cases was not assessed. Further studies

with larger patient populations and complete imaging

datasets will be necessary to fully validate these findings

and explore the complementary roles of MPRAGE

and PSIR in clinical practice.

Also, we recommend including histopathology lap results

with classification of CR, CE, and CNR according to

pathology, as well as qualitative assessments by boarded

radiologists to offer better background knowledge

about PSIR post-GBCE.

Conclusion

While MPRAGE post-GBCE remains the superior sequence

for most lesions, PSIR shows promise as a supplementary

tool for specific lesion types like MS, cystic

Schwannoma, and GBM, particularly in cases where

lesion background is suppressed, and precise border

delineation is crucial. Combining both sequences could

offer clinicians a more comprehensive diagnostic approach,

improving lesion detection and characterisation

in various brain pathologies. R

Acknowledgments

All authors thank Allmed Medical Center for their

collaboration in data collection.

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Ready - Made

Citation

Hamza Arjah, Noor Diyana Osman, Hussein ALMasri, Sawsan E. Abusharkh,

Mustafa Hammad, Mohammad Nofal, Omarah Abdelqader. Quantitative

Assessments For Phase-Sensitive Inversion Recovery Post Gadolinium Based

Contrast Enhancement, Hell J Radiol 2026; 11(1): 31-37.

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Original Article

Assessment of Anatomical Variations and Cerebral Vessel Diameters

in Ischemic Stroke Patients Using CT Angiography Examination, p. 38-47

Neuroradiology

VOLUME 11 | ISSUE 1

Assessment of Anatomical Variations

and Cerebral Vessel Diameters in

Ischemic Stroke Patients Using CT

Angiography Examination

Zeliha Cosgun MD¹, Ozgur Senol MD², Bekir Enes Demiryurek MD³, Emine Dagistan MD¹,

Yasar Dagistan MD², Oya Kalaycioglu 4 , Melike Elif Kalfaoglu MD¹

1

Abant Izzet Baysal University Hospital, Department of Radiology, Bolu, Turkey

2

Abant Izzet Baysal University Hospital, Department of Neurosurgery, Bolu, Turkey

3

Abant Izzet Baysal University Hospital, Department of Neurology, Bolu, Turkey

4

Abant Izzet Baysal University, Faculty of Medicine, Department of Bioistatistics and Medical Informatics, Bolu, Turkey


Abstract

Background: Willis Polygon (WP), cerebral circulation,

and brain function are closely linked. Anatomical

variations may contribute to cerebrovascular diseases,

making their understanding vital for assessing stroke

risk. Exploring the relationship between WP variations

and vessel diameters holds clinical significance. The

aim of this study was to investigate different anatomic

variations and dimensions of WP in patients with ischemic

stroke.

Methods: This observational, descriptive, and retrospective

study evaluated CW anatomy in 132 ischemic

stroke patients and 130 controls using CT angiography.

WP arterial diameters were measured, and variations

recorded.

Results: In the ischemic stroke patient group, anterior

system variation was 48.9% and posterior system

variation was 51%, with no significant difference compared

to controls (p=0.5).

Diameters of right and left internal carotid arteries

(ICA), A1 segment, and middle cerebral artery (MCA)

were significantly lower in the study group. However,

no significant differences were found in diameters of

Corresponding

Author,

Guarantor

Zeliha Cosgun, M.D. Specialist in Radiology, Department of Radiology Bolu

Abant İzzet Baysal University, Izzet Baysal Training and Research Hospital,

Bolu/Turkey.

Email: zeliha44@gmail.com

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H R J

the basilar artery and the P1 segment of the right and

left posterior cerebral arteries between groups.

Conclusion: In our study, no significant differences

were found in WP variation and basilar artery and P1

segment of posterior cerebral arteries between ischemic

stroke patients and the normal population.

However, arterial diameters (bilateral ICA, A1, MCA)

were significantly lower in the ischemic stroke group

compared to controls. In conclusion, arterial calibrations

forming the anterior circulation of the Willis

polygon were notably lower in patients with anterior

circulation infarction, suggesting a significant role of

decreased arterial diameters in ischemic stroke pathophysiology.

Key words

Willis Polygon, ischemic stroke, variations, arterial diameter, CT angiography,

anterior system variation

Introduction:

Willis Polygon, situated at the base of the skull within

the interpeduncular fossa, serves as a pivotal vascular

network regulating cerebral circulation. It comprises

various arteries and connections, with the anterior

segment primarily constituted by the anterior cerebral

artery (ACA), while the anterior communicating artery

(AcomA) serves to connect the right and left ACAs. The

posterior division involves the bifurcation of the basilar

artery into the right and left posterior cerebral arteries

(PCAs), each establishing connections with the bilateral

internal carotid arteries (ICAs) via the posterior communicating

arteries (PcomAs) [1].

Functionally, the WP plays a crucial role in safeguarding

the brain against ischemia by ensuring a consistent

and regulated supply of arterial blood [2]. Despite its

relatively small mass, the brain commands a significant

share of resources, necessitating a substantial portion

of the cardiac output and oxygen supply [3]. Arteriogenesis,

representing a multifaceted embryological

process, can lead to various anatomical variations within

the WP [4].

In situations of significant occlusion in cerebral arteries,

collateral vessels, including the WP, assume a critical

role in preserving essential blood circulation [5]. Ischemic

stroke, comprising various subtypes, accounts for over

eighty-seven percent of all stroke cases [6]. Structural

variations within the WP, influenced by genetic and

hemodynamic factors, often do not substantially affect

brain function due to collateral circulations [7].

Nevertheless, WP variations may disrupt cerebral

hemodynamic, potentially leading to diverse cerebrovascular

diseases, such as cerebral aneurysms and ischemic

stroke [8]. Individuals with efficient collateral

circulations demonstrate a reduced risk of developing

ischemic stroke compared to those with less effective

collateral circulations [9]. Understanding intracranial

artery variations is crucial, as they may increase susceptibility

to aneurysms and impact cerebral blood

flow [10].

WP variations hold significant clinical relevance, influencing

the risk of ischemic stroke [11]. While most

normal variations typically have minimal clinical impact,

they are crucial considerations for surgical and

interventional procedures [12]. Arterial diameters

serve as vital predictors of vascular health, with larger

diameters potentially associated with vascular events

[13]. Clinicians routinely rely on arterial diameters for

assessing vascular health, utilizing observations such

as focal luminal narrowing in coronary arteries and

lumen reductions at the carotid bifurcation and focal

points within intracranial arteries to stratify stroke

risk [14,15].

Therefore, the objective of our study was to assess the

relationship between Circle of Willis variations and vessel

diameters concerning ischemic stroke.

Materials and Methods:

Study Design and Patient Selection

In our study, a total of 428 patients aged 45 and over

who presented to the emergency department or neurology

outpatient clinic with symptoms of acute ischemic

stroke (AIS) between February 01, 2019, and

February 01, 2020, were included. After admission,

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VOLUME 11 | ISSUE 1

these patients underwent diffusion-weighted magnetic

resonance imaging (DW-MRI) and cerebral CT angiography

(CTA) at the radiology department. Patients

who consented to participate in the study were further

evaluated based on their radiological findings, clinical

characteristics (including symptoms and the presence

of concomitant diseases such as hypertension, diabetes,

and coronary artery disease), and laboratory data

(including total cholesterol, triglycerides, HDL, and LDL

cholesterol). The data were retrospectively collected

from our hospital's PACS system. Ethical approval for

the study was obtained from the BAIBU Ethics Committee

(ethics committee number:2020/114). Patients with

posterior circulation infarctions (n=138), cerebral hemorrhage

(n=16), and those with missing laboratory data

(n=12) identified during the DW-MRI examination were

excluded from the study. Consequently, a total of 132

patients with complete clinical, radiological, and laboratory

data, who had anterior circulation infarctions,

were included in the study. In order to detect a difference

between the groups with an anticipated small to

medium effect size of d=0.35, we needed at least 260

participants in total (alpha = 0.05 and power = 80%).

Therefore, along with the 132 patients in the study

group, we included 130 age and gender-matched control

subjects. The control group comprised individuals

who presented with suspected acute infarction but had

normal findings on non-contrast brain CT and diffusion-weighted

MRI examinations. The flowchart of our

study is shown in Figure 1.

Radiological Examination: The patients underwent

diffusion-weighted MRI examination using a 1.5

Tesla MRI machine (Symphony; Siemens, Erlangen,

Germany) located in our radiology department. The

diffusion-weighted MRI examination was performed

to assess the presence or absence of infarction and, if

present, to determine its localization. For the cerebral

CT angiography (CTA) examination, a 64-slice CT angiography

machine was employed (General Electric Revolution

EVO, 64 slices).

The CTA examination was utilized to evaluate WP anterior

system variations in both the patient and control

groups. The classification system for WP variations, as

used in previous similar studies, was adopted as a reference

for categorizing these variations [16]. According

to this classification system, the anterior system was

categorized (figure 2) as follows: (a) complete anterior

system, (b) two or more AcomA, (c) the origin of

the corpus callosum median artery from AcomA, (d)

short-segment fusion of the ACA, (e) division of the ACA

into two branches distally after a common trunk, (f) the

MCA originating from two separate vessels from the

ICA, (g) hypoplasia or absence of AcomA, (h) unilateral

hypoplasia or aplasia of the A1 segment with the other

A2 segment originating from the existing A1 segment,

(i) hypoplasia or absence of one ICA, and (j) hypoplasia/aplasia

of AcomA with accompanying MCA arising as

two separate branches.

In the study of anatomical variations of the posterior

part of the WP, various configurations were observed

Figure 1: The flowchart of our study is shown in Figure 1.

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H R J

(figure 3). (a) Bilateral PcomAs are present, (b) PCA originates

predominantly from the ICA. This variant is known

as a unilateral fetal type PCA; the PcomA on the other

side is patent. Bilateral fetal PCA variation was not observed

in our population (c) Bilateral fetal type PCAs with

both pre-communicating segments of the PCAs patent.

(d) Unilateral PcomA present. (e) Hypoplasia or absence

of both PcomAs and isolation of the anterior and posterior

parts of the circle at this level. (f) Unilateral fetal

type PCA and hypoplasia or absence of the pre-communicating

segment of the PCA. (g) Unilateral fetal type PCA

and hypoplasia or absence of the contralateral PcomA.

(h) Unilateral fetal type PCA and hypoplasia or absence

of both pre-communicating segment of the PCA and the

PcomA. (i) Bilateral fetal type PCAs with hypoplasia or

absence of bothpre-communicating segments of the

PCAs. (j) Bilateral fetal type PCAs with hypoplasia or absence

of the pre-communicating segment of either PCA.

The maximum arterial diameter was measured bilaterally

in the supraclinoid internal carotid artery (ICA),

anterior cerebral artery (ACA) A1 segment, middle cerebral

artery (MCA) M1 segment, basilar artery, posterior

cerebral artery (PCA) P1 and P2 segments from the

proximal 5 mm portion. Vessel diameters were meas-

Figure 2: Complete anterior system (a), two or more AcomA (b, arrow and star), the origin of the corpus callosum

median artery from AcomA(c), short-segment fusion of the ACA(d), division of the ACA into two branches distally after

a common trunk(e), the MCA originating from two separate vessels from the ICA(f), hypoplasia or absence of AcomA(g),

unilateral hypoplasia or aplasia of the A1 segment with the other A2 segment originating from the existing A1 segment (h),

hypoplasia or absence of one ICA(i), and hypoplasia/aplasia of AcomA with accompanying MCA arising as two separate

branches(j).

Figure 3: a) Bilateral PcomAs present,(c) Bilateral fetal type PCAs, both pre-communicating segments patent, (d)

Unilateral PcomA present(e) Hypoplasia or absence of both PcomAs, isolation of anterior and posterior parts of circle, (f)

Unilateral fetal type PCA, hypoplasia or absence of pre-communicating segment, (g) Unilateral fetal type PCA, hypoplasia

or absence of contralateral PcomA, (h) Unilateral fetal type PCA, hypoplasia or absence of both pre-communicating

segment and PcomA, (i) Bilateral fetal type PCAs, hypoplasia or absence of both pre-communicating segments, (j) Bilateral

fetal type PCAs, hypoplasia or absence of pre-communicating segment in either PCA

41

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ured by non-contrast enhanced CT and CT angiography

in stroke patients.

Arterial diameter measurements were performed axial

section, from the anterior wall to the posterior wall,

with measurements taken from more proximal areas

where luminal plaques were present as well as from

normal segments.

The presence of accompanying aneurysms or vascular

malformations was also noted. Radiological data

were jointly evaluated by two radiologists with 14 and

16 years of experience in a consensus manner, ensuring

the reliability of the findings.

Figure 4: ROC curve analysis for ICA, A1 and MCA

diameters for classifying infarct

Statistical Analysis: Descriptive data are presented

as number (percentages) or median and interquartile

ranges (25th - 75th percentiles) or mean ± standard deviation.

Independent samples t-tests or non-parametric

Mann-Whitney U-tests were used for the comparison of

continuous variables between two groups. Pearson’s

chi-square or Fisher’s exact tests were used for the categorical

variables. Receiver operating characteristic

(ROC) curve analysis was used to determine the optimal

cutoff for points for measurements distinguishing between

patients with and without infarct, and the area

under the ROC curve (AUC), sensitivity and specificity

were calculated. Multivariate logistic regression analyses

were carried out to identify the predictors associated

with infarct, with calculation of odds ratios (ORs)

and 95% confidence intervals (95%CI). The analyses

were performed using the Statistical Package for Social

Sciences 25.0 for Windows (SPSS Inc., Chicago, Illinois,

USA). The results were considered to be significant at a

level of p < 0.05.

Results:

A total of 262 patients were included in the study,

comprising 132 patients in the study group and 130 patients

in the control group. The mean age of patients in

the study group was 70.54±12.24, while in the control

group, it was 68.69±12.01, with no significant difference

observed between the two groups. In the study group,

72 patients (54.5%) were male, and in the control group,

83 patients (63.8%) were male, with no significant difference

in gender distribution between the two groups.

When evaluating the study and control groups for cardiovascular

risk factors such as hypertension, coronary

artery disease, diabetes, and hyperlipidemia, no significant

differences were found between the two groups.

The univariate analysis of the characteristics for the

patients in control and study groups were presented in

Table 1.

Among the 262 patients included in the study, 134

(51.1%) had a complete WP anterior system without any

variations. In the study group, 67 patients (50.8%) had

WP variations, while in the control group, 61 patients

(46.9%) had WP variations, resulting in a total of 128 patients

(48.9%) with WP variations in the combined dataset.

There was no statistically significant difference in

the frequency of WP variations between the study and

control groups (p=0.5). Among the 128 patients with WP

variations, the following distribution of variation types

was observed: 6 patients (4.6%) had Type B, 1 patient

(0.8%) had Type C, 48 patients (37.7%) had Type D, 3

patients (2.3%) had Type E, 1 patient (0.8%) had Type

F, 13 patients (10.0%) had Type G, 47 patients (36.9%)

had Type H, 2 patients (1.5%) had Type I, and 7 patients

(5.4%) had Type J variations (Table 2). The types of variations

in the patient and control groups are detailed

in Table 2.

Among the 262 patients included in the study, 19

(7.3%) had a complete WP posterior system without any

variations. In the study group, 124 patients (93.9%) had

WP variations, while in the control group, 119 patients

(91.5%) had WP variations, resulting in a total of 243 pa-

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Table 1. Demographics, cardiovascular risk factors and degrees of control and study groups.

Demographics

Total (n=262) Study Group (n=132) Control Group (n=130) P

Age (years) 69.19±12.15 70.54±12.24 68.69±12.01 0.219

Gender, male 155 (59.2%) 72 (54.5%) 83 (63.8%) 0.126

Cardiovascular risk

factors

Hypertension 129 (49.2%) 66 (50.0%) 63 (48.5%) 0.803

Coronary artery

disease

51 (19.5%) 26 (19.7%) 25 (19.2%) 0.924

Diabetes 77 (29.4%) 38 (28.8%) 39 (30.0%) 0.830

Hyperlipidemia 102 (38.9%) 53 (40.2%) 49 (37.7%) 0.683

Values are expressed as n (%) or means ± SD. For categorical variables Pearson’s chi-square or Fisher’s exact test are used. For continuous variables, p-values

are calculated using independent samples t-test. Bold p-values indicate statistical significance at a<0.05.

Table 2. Comparisons of diameters of right and left ICA, A1 and MCA between control and study groups.

Total (n=262) Study Group (n=132) Control Group (n=130) P

Right ICA (mm) 4.23±0.77 3.97±0.70 4.50±0.74 <0.001

Left ICA (mm) 4.27±0.86 3.97±0.75 4.56±0.86 <0.001

Right A1 (mm) 2.0 (1.6-2.4) 2.2 (2.0-2.5) 2.8 (2.5-3.0) <0.001

Left A1 (mm) 2.1 (1.8-2.4) 2.6 (2.3-2.9) 2.9 (2.6-3.2) <0.001

Right MCA (mm) 2.53±0.54 2.23±0.46 2.83±0.43 <0.001

Left MCA (mm) 2.77±0.47 2.62±0.46 2.93±0.43 <0.001

Aneurism 17 (6.5%) 6 (4.5%) 11 (8.5%) 0.198

Anterior WP variation 128 (48.9%) 67 (50.8%) 61 (46.9%) 0.535

Anterior WP

variation type

0.911

1 (type B variation) 6 (4.6%) 3 (4.2%) 3 (5.1%)

2 (type C) 1 (0.8%) 1 (1.4%) 0 (0.0%)

3 (type D) 48 (37.7%) 28 (42.3%) 20 (32.2%)

4 (type E) 3 (2.3%) 2 (2.8%) 1 (1.7%)

5 (type F) 1 (0.8%) 0 (0.0%) 1 (1.7%)

6 (type G) 13 (10.0%) 7 (9.9%) 6 (10.2%)

7 (type H) 47 (36.9%) 22 (32.4%) 25 (42.3%)

8 (type I) 2 (1.5%) 1 (1.4%) 1 (1.7%)

9 (type J) 7 (5.4%) 4 (5.6%) 3 (5.1%)

Values are expressed as n (%), means ± SD or median (25 th – 75 th percentile). For categorical variables Pearson’s chi-square or Fisher’s exact test are used. For

continuous variables, if values are reported in means, p-values are calculated using independent samples t-test; if values are given in medians, p-values are

calculated using Mann Whitney U test. Bold p-values indicate statistical significance at a<0.05. ICA = Internal carotid artery CCA: Common carotid artery

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VOLUME 11 | ISSUE 1

tients (92.7%) with WP variations in the combined dataset.

There was no statistically significant difference in

the frequency of WP variations between the study and

control groups (p=0.5). Among the 243 patients with WP

variations, the following distribution of variation types

was observed: 14 patient (5.3%) had Type C, 57 patients

(21.8%) had Type D, 128 patients (48.9%) had Type E, 4

patient (1.5%) had Type F, 2 patients (0,8%) had Type

G, 24 patients (9.2%) had Type H, 7 patients (2.7%) had

Type I, and 7 patients (2.7%) had Type J variations.

The presence of accompanying aneurysms was noted

in 6 patients in the study group and 11 patients in the

control group, with no statistically significant difference

observed between the two groups (p=0.1) (Table

2).

The diameters of right and left ICA, A1 and MCA were

significantly higher in the control group, compared to

the study group (p<0.001) (Table 2).

ROC curve analysis (Figure 3) revealed that the diameters

right and left of ICA, Anterior cerebral artery A1

segment and middle cerebral artery M1 segment have

the ability to detect infarct with high accuracy rates.

Table 3 juxtaposes characteristics of the predictive

power of the ROC curve analysis. For ICA, an accuracy

of 0.700 (95%CI: 0.637-0.762, p<0.001) and 0.720 (95%CI:

0.659-0.782, p<0.001) for right and left ICAs were obtained,

respectively. Optimum cut-off values for the

right and left ICA diameters of ≤4.5 mm and ≤3.95 mm

were found as the optimal cutoffs for infarct, respectively.

When A1 diameters considered, we found that a

right diameter of ≤2.05 mm and a left diameter of ≤2.25

mm were optimal cutoffs for identifying patients with

infarct (area under the curve of 0.755 (95%CI: 0.694-

0.816, p<0.001) and 0.782 (95%CI: 0.726-0.839, p<0.001),

respectively). Calculation of the MCA revealed that the

optimal cutoff values for right diameter is ≤2.65 mm

Table 3. Performance of ICA, A1 and MCA diameters for classifying infarct.

Diameters

Optimum

cut-off

AUC 95% CI p a Sensitivity Specificity

Right ICA (mm) 4.55 0.700 0.637-0.762 <0.001 48.5% 80.3%

Left ICA (mm) 3.95 0.720 0.659-0.782 <0.001 51.5% 83.8%

Right A1 (mm) 2.05 0.755 0.694-0.816 <0.001 79.5% 70.0%

Left A1 (mm) 2.25 0.782 0.726-0.839 <0.001 62.3% 84.1%

Right MCA (mm) 2.65 0.838 0.791-0.886 <0.001 86.4% 64.6%

Left MCA (mm) 2.85 0.691 0.627-0.754 <0.001 70.5% 60.0%

ICA: Internal carotid artery, Anterior cerebral arteryy A1 segment, Middle cerebral artery M1 segment, AUC: Area under the curve, CI: Confidence Interval,

a

Hypothesis test for H 0

:AUC=0.5

Table 4. Comparisons of diameters of basilar artery and the posterior cerebral artery's P1 and P2

segment between control and study groups.

Study Group (n=132) Control Group (n=130) p

Basilary artery (mm) 3.36±0.81 3.27±0.74 0.345

Left P1 (mm) 1.96±0.75 1.94±0.75 0.864

Right P1 (mm) 1.88±0.78 1.96±0.63 0.363

Left P2 (mm) 1.98±0.36 1.93±0.35 0.113

Right P2 (mm) 2.00±0.34 1.94±0.38 0.476

Values are expressed as n(%), means ± SD or median (25 th – 75 th percentile).

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H R J

and a left diameter is ≤2.85 mm with the accuracies of

0.838 (95%CI: 0.791-0.886, p<0.001) and 0.691 (95%CI:

0.627-0.754, p<0.001), respectively.

The diameter measurements of left A1 (OR: 0.306;

95%CI: 0.160-0.586; p<0.001), right MCA (OR: 0.027;

95%CI: 0.007-0.098; p<0.001) and left MCA (OR: 4.575;

95%CI: 1.340-15.613; p=0.015) were also identified as

statistically significant predictors of infarct. Although

the diameters of Right and Left ICA, and Right A1 found

statistically significantly difference between the two

groups in the univariate analysis, these measurements

lost their significant in the multivariate analysis.

Measurements of diameter from the basilar artery

and the posterior cerebral artery's P1 and P2 segment

revealed no significant difference between the two

groups (p > 0.05) (Table 4).

Discussion:

The most significant finding of our study, which indicates

the lack of a significant difference in WP variations

between the ischemic stroke patient group and

the comparison group. The results of studies examining

the relationship between WP variations and infarcts

are conflicting in the literature. In numerous studies,

it has also been demonstrated that there is no significant

association between WP variations and the risk

of ischemic stroke, consistent with our findings [17-

19]. However, in another studies were observed that

some Willis polygon variations were more prevalent

in ischemic stroke patients compared to the control

group [20-22]. These contradictory results emphasize

the need for further research to better understand the

relationship between Willis polygon variations and the

risk of infarcts.

Another result of our study is that the most frequently

observed variation in the anterior system among the

infarct group was Type D (short-segment fusion of the

ACA) in 28 patients, followed by Type H in 22 patients.

Conversely, the most common posterior system variation

in both the infarct and control groups was Type E

(Hypoplasia or absence of both PcomAs and isolation

of the anterior and posterior parts of the circle at this

level.

Another important finding of our study is the decrease

in diameter observed in the ICA, A1, and M1

segments in the ischemic stroke patient group. In our

study, only anterior circulation infarctions were included,

and while arterial diameters in the anterior system

were found to be significantly lower, no significant

difference was found in the arterial diameters forming

the posterior system. Arterial diameter measurements

were performed axially, from the anterior wall to the

posterior wall, with measurements taken from more

proximal areas where luminal plaques were present as

well as from normal segments. Based on this, we believe

that the arteries being of a smaller caliber than normal

may be a contributing factor to the development

of infarction. The scarcity of arterial calibrations in the

Willis polygon can be pathophysiologically linked to

atherosclerosis and susceptibility to infarction. For instance,

Jebarı-benslaıman, Shifa et al. [23] demonstrated

that atherosclerosis is associated with vascular wall

damage and plaque accumulation, which can lead to a

reduction in arterial calibrations. Additionally, Wijesinghe

et al. [24] suggested that the decrease in arterial

diameters in the Willis polygon may increase the risk

of infarction due to flow restrictions caused by atherosclerotic

plaques. These findings indicate that the scarcity

of arterial calibrations in the Willis polygon may

contribute to the development of atherosclerosis and

subsequently increase the risk of infarction. Therefore,

understanding the relationship between the scarcity of

arterial calibrations and susceptibility to atherosclerosis

and infarction plays a crucial role in elucidating the

underlying pathophysiological mechanisms.

Various studies suggest that the reduction in arterial

diameters forming the Willis polygon is associated with

cerebrovascular diseases. For instance, studies concerning

white matter changes indicate that these reductions

are linked with hyperintensities in the white

matter, emphasizing the long-term effects of inadequate

cerebral blood flow [25]. Therefore, the reduction

in arterial diameters may play a significant role in the

pathophysiology of ischemic stroke, consistent with

our study findings, underscoring the need for further

research in this area.

One of the primary limitations of our study is its

single-center, retrospective design, and the relatively

small sample size. A larger-scale, multicenter investigation

would be needed to provide a more comprehensive

understanding of the frequency of variations and

vascular diameters in this patient population.

In conclusion, as a result of increased awareness regarding

the relationship between decreased arterial

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VOLUME 11 | ISSUE 1

diameters, Willis polygon variations, and stroke, we

believe that incorporating detailed information such as

arterial diameters and variations related to the Willis

polygon in the reports of patients undergoing imaging

due to stroke risk will provide additional contributions

to patient management. Additionally, we are of

the opinion that detailed mapping of the Willis polygon

(including variations and arterial diameters) before

endovascular thrombectomy, which is an important

treatment option for this patient group, could provide

additional information facilitating the interventional

procedure prior to the endovascular thrombectomy,

we believe that detailed mapping of the Willis polygon

(including variations and arterial diameters) before

endovascular thrombectomy, which is an important

treatment option for this patient group, could provide

additional information facilitating the interventional

procedure. R

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Ready - Made

Citation

Zeliha Cosgun MD, Ozgur Senol MD, Bekir Enes Demiryurek MD,

Emine Dagistan MD, Yasar Dagistan MD², Oya Kalaycioglu, Melike Elif

Kalfaoglu MD. Assessment of Anatomical Variations and Cerebral Vessel

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Hell J Radiol 2026; 11(1): 38-47.

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H R J

Distinguishing between low-grade and high-grade brainstem glioma using standard MRI pulse sequences, p. 48-59

VOLUME 11 | ISSUE 1

Original Article

Neuroradiology

Distinguishing between low-grade and

high-grade brainstem glioma using

standard MRI pulse sequences

Nguyen Duy Hung 1,2 , Ta Van Lam 1 , Do Viet Anh 1,2 , Nguyen Thu Minh Chau 1,2 ,

Bui Huyen Trang 1,2 , Nguyen Minh Duc 3

1

Department of Radiology, Viet Duc Hospital, Hanoi, Vietnam

2

Department of Radiology, Hanoi Medical University, Hanoi, Vietnam

3

Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam


Abstract

Purpose: This retrospective study employs a quantitative

analysis of signal intensities derived from standard

MRI pulse sequences to differentiate between lowgrade

and high-grade brainstem gliomas (BSGs).

Material and Methods: Forty-three patients with

histopathologically confirmed BSGs underwent gadolinium-enhanced

brain MRI. Quantitative parameters,

including mean, median, standard deviation, maximum,

minimum, and lesion-to-normal tissue ratios,

were extracted from volumes of interest (VOIs) placed

on pre- and post-contrast T1-weighted, fluid-attenuated

inversion recovery (FLAIR), and apparent diffusion

coefficient (ADC) maps. Receiver operating characteristic

curve analysis was performed to assess the diagnostic

performance of each parameter.

Results: Quantitative analysis of T1-weighted and

FLAIR sequences revealed that mean T1 signal intensity

(T1_mean), median T1 signal intensity (T1_medi-

Key words

grading brainstem glioma; conventional MR; diffusion-weighted imaging;

quantitative.

Corresponding

Author,

Guarantor

Nguyen Minh Duc, MD, Department of Radiology, Pham Ngoc Thach

University of Medicine, 2 Duong Quang Trung Ward 12 District 10 Ho Chi

Minh City, Vietnam

Email: bsnguyenminhduc@pnt.edu.vn

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[8]. Therefore, it is crucial to develop effective minimally

or non-invasive methods for differential diagnosis,

which can assist in prognosis and guide the selection of

the appropriate treatment approach.

Magnetic resonance imaging (MRI), with its advantageous

characteristics of high spatial and tissue resolution,

non-invasiveness, and absence of ionizing radiation,

has become the preferred imaging modality

for the diagnosis, surgical planning, and post-treatment

monitoring of BSGs [9]. While conventional MRI

sequences have demonstrated value in assessing BSG

grade, their diagnostic performance remains limited.

Previous studies have reported sensitivity and specificity

values of 62.5% and 46.6%, respectively, for diagnosing

low-grade BSGs, and 58.3% and 61.7%, respectively,

for diagnosing high-grade BSGs [10]. To enhance

diagnostic accuracy, advanced MRI techniques, such as

diffusion kurtosis imaging (DKI), diffusion tensor imaging

(DTI), perfusion-weighted imaging, and magnetic

resonance spectroscopy (MRS), have been employed.

However, these advanced sequences often prolong acquisition

time and require specialized expertise for image

processing and interpretation. Quantitative analysis

of advanced diffusion metrics has shown promise

in differentiating BSG genotypes, with a combined DKI

and DTI histogram model achieving an area under the

curve (AUC) of 0.931 for predicting isocitrate dehydrogenase

(IDH) mutation status [11]. Similarly, MRS

and perfusion-weighted imaging have demonstrated

high discriminatory value for BSG grading, with the

choline/N-acetylaspartate (Cho/NAA) ratio from MRS

yielding an AUC of 0.944 and relative cerebral blood

flow (rCBF) from perfusion-weighted imaging achieving

an AUC of 0.917 [12].

Qualitative analyses of BSGs using standard MRI sequences

have demonstrated limited utility in differentiating

tumor grade, as these tumors typically exhibit

similar signal characteristics, such as hyperintensity on

T2-weighted images and hypointensity on T1-weighted

images. Furthermore, features such as necrosis, hemorrhage,

and brainstem invasion are not reliably distinctive

between low-grade and high-grade BSGs. While

quantitative analyses of T1-weighted and T2-weighted

signal intensities have been explored in tentorial gliomas,

their application to BSGs remains limited [13,14].

Quantitative analysis of the apparent diffusion coefficient

(ADC) map, derived from diffusion-weighted iman),

and minimum FLAIR signal intensity (FLAIR_min)

were significant discriminators between low-grade and

high-grade BSGs. Optimal cut-off values, sensitivities,

and specificities for these parameters were as follows:

559.5 (87.5%, 65.5%) for T1_mean, 576.5 (78.6%, 69%)

for T1_median, and 349 (79.3%, 64.3%) for FLAIR_min.

Analysis of the solid tumor component on ADC maps

identified minimum ADC (ADCs_min) and the ratio of

mean ADC to normal white matter ADC (rADCs_mean)

as significant discriminators, with optimal cut-off values,

sensitivities, and specificities of 862.5 x 10 -6 mm²/s

(42.9%, 93.1%) and 1.4785 (92.9%, 48.3%), respectively.

Conclusion: Quantitative signal intensity analysis of

conventional MRI sequences, particularly T1-weighted

and FLAIR, can effectively differentiate between lowgrade

and high-grade brainstem gliomas (BSGs). Furthermore,

analysis of the solid tumor component on

ADC maps provides valuable discriminatory information.

Introduction

In contrast to tentorial gliomas, brainstem gliomas

(BSGs) are relatively uncommon, with an incidence of

approximately 0.311 per 100,000 individuals. BSGs exhibit

a predilection for the pediatric population, accounting

for 10-20% of all intracranial tumors in children,

with a peak incidence between 5 and 9 years of

age. In adults, BSGs are less frequent, comprising only

1-2% of intracranial tumors [1-4]. Histopathological assessment

remains the gold standard for differentiating

gliomas from other brainstem lesions and for grading

tumor aggressiveness. The World Health Organization

(WHO) classifies gliomas into four grades, with grades

1 and 2 designated as low-grade and grades 3 and 4 as

high-grade [5,6]. However, obtaining tissue for histopathological

analysis necessitates invasive procedures,

such as biopsy or surgical resection, which carry inherent

risks, including a mortality rate of approximately

2.5-3.8% [9-13]. The prognosis and survival outcomes

for patients with BSGs vary significantly depending on

tumor grade and patient age. In children, high-grade

BSGs are associated with a dismal prognosis, with an average

survival time of only 9-13 months, whereas lowgrade

BSGs have an average survival exceeding 5 years

[7]. In adults, the disparity is less pronounced, with

average survival times of approximately 26 months for

low-grade BSGs and 10-13 months for high-grade BSGs

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VOLUME 11 | ISSUE 1

aging, has gained traction due to its standardized nature

and quantitative metrics, such as mean, maximum,

minimum, and standard deviation, which provide a

more nuanced characterization of tumor heterogeneity

[13,14]. Histogram analysis of ADC maps, which assesses

the distribution of ADC values within the tumor,

has further enhanced the ability to evaluate tumor

heterogeneity and infer underlying biological characteristics

[15]. However, challenges remain in defining

the optimal volume of interest (VOI) for ADC histogram

analysis. Encompassing the entire tumor volume may

introduce confounding effects from cystic or necrotic

regions, while restricting the VOI to the solid tumor

component may not fully capture the tumor's heterogeneity

[14,16,17].

While these VOI placement strategies have been investigated

in tentorial gliomas, their application to

BSGs remains unexplored. Therefore, this study aimed

to evaluate the utility of quantitative signal intensity

analysis, including histogram analysis of ADC maps,

in differentiating between low-grade and high-grade

BSGs using standard MRI sequences.

Methods

Data collection

This retrospective cross-sectional study was conducted

at the Imaging Diagnosis Center of Viet Duc Friendship

Hospital. Patient data were collected between

January 2021 and January 2025. The study included 43

patients with histopathologically confirmed brainstem

gliomas who underwent preoperative 3.0 Tesla MRI of

the brain with gadolinium contrast enhancement. Patients

with a prior history of biopsy or treatment (radiotherapy,

chemotherapy, or tumor resection) were

excluded, as were those with MRI images degraded by

artifacts or inadequate imaging parameters. This study

was conducted in accordance with the Declaration of

Helsinki (2013).

Technique

All patients underwent MRI using a 3.0 Tesla scanner

(SIGNA Pioneer; GE Healthcare, USA) with gadolinium-based

contrast enhancement. A standardized imaging

protocol was employed for all examinations, as

detailed in Table 1.

Table 1: Parameters of sequences

Parameters

Sequences

Plane TR (msec) TE (msec)

Slide thickness

(mm)

FOV

Matrix

T1-FLAIR axial, sagittal 2000-2300 20-25 5 240-260 192x320

T2-FLAIR FS axial 7500-8500 110-120 5 230-240 200x320

T2 TSE

axial, sagittal,

coronal

3900-4700 100-105 4 210-220 256x384

T2 GRE axial 250-360 8-10 4 210-220 256x384

DWI/ADC axial 4000-4700 75-80 5 230-240 192x192

T1 3D CE + axial, sagittal 5.3-6.3 2.0-2.5 1 240 240x300

TR: Repetition time; TE: Echo time; FOV: Field of view

T1-FLAIR: T1-weighted fluid-attenuated inversion recovery

T2-FLAIR FS: T2-weighted fluid-attenuated inversion recovery fat-saturated

T2 TSE : T2-weighted turbo spin-echo

T2 GRE: T2-weighted gradient-echo or T2*

T1 3D CE+: 3D IR-prepped fast SPGR high-resolution T1-weighted (“BRAVO”); CE+: a single dose of intravenous contrast agent injection (Gadolinium-DTPA

1ml/kg, the injection rate of 5 mL/s)

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Image analysis

MRI images, stored in DICOM format, were analyzed

using the Medical Imaging Interaction Toolkit software

(MITK Workbench v2023.12; Division of Medical Image

Computing, German Cancer Research Center, Heidelberg,

Germany) [18]. An experienced neuroradiologist

performed all image analyses.

Lesion characterization was conducted manually

based on the following criteria: [16]

• Whole Tumor: On T2W and FLAIR images, the

whole tumor was defined as the region encompassing

all abnormal signal intensity, including edema,

solid components (enhancing and non-enhancing),

and necrosis, demarcated by normal brain tissue or

cerebrospinal fluid.

• Tumor Core and Edema: The tumor core, comprising

the solid and necrotic portions, was identified as

the central area of heterogeneous signal intensity

on T2W and FLAIR images, surrounded by vasogenic

edema with homogenous high signal intensity. Edema

was defined as the region of high signal intensity

extending beyond the tumor core. (Fig. 1A-B)

• Enhancing, Necrotic, and Non-Enhancing Solid

Components: On post-contrast T1W images, the enhancing

solid component, necrotic areas, and hemorrhagic

components were identified. Necrotic areas

were defined as central regions without contrast

enhancement, surrounded by enhancing solid tumor.

Hemorrhagic components were identified by

signal increase on pre-contrast T1 images or signal

decrease on T2*-weighted gradient-echo (T2* GRE)

images. Homogenous cystic areas with cerebrospinal

fluid signal characteristics on T2W and FLAIR

images were also classified as necrotic. (Fig. 1C-H)

The non-enhancing solid component was defined as

the residual tumor volume after subtracting the enhancing

and necrotic components. (Fig. 1H)

It is important to note that not all tumors exhibited

all of these components (e.g., enhancing component,

edema, necrosis).

Figure 1. (A-J) Lesion segmentation and volume of Interest (VOI) definition. A-B. Axial FLAIR images demonstrating the

delineation of the tumor core (blue VOI) and peritumoral edema (white VOI) within the whole tumor region (red outline).

C-D. Axial T2*-weighted gradient-echo (T2* GRE) images showing the hypointense hemorrhagic component included within

the necrotic region (orange VOI). E-F. Axial T1-weighted (T1W) and G-H. axial contrast-enhanced T1-weighted (T1 CE+)

images illustrating the identification of the enhancing tumor component (green VOI) and the central necrotic area (orange

VOI). I. Axial T1 CE+ image and J. corresponding axial apparent diffusion coefficient (ADC) map showing all segmented

tumor components. The pink ROI is placed in normal-appearing white matter to calculate the lesion-to-normal tissue signal

intensity ratio.

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From the identified sections, we proceed to place the

VOI measuring the entire tumor (red outlined VOI) on

the T1 and FLAIR sequences (Fig. 1B, 1F), and to place

the VOI of the entire enhancing region of the tumor

(green VOI) on the T1-weighted sequence after contrast

administration (Fig. 1H). With the ADC map, we place

the VOI using two methods: measuring the ADC value of

the entire tumor region (VOI 1 - corresponding to the

red outlined VOI) and measuring the ADC value of the

entire solid part of the tumor (VOI 2 - corresponding to

the total of the blue and green VOI). (Fig. 1J). We also

proceed to measure an additional ROI in normal white

matter to calculate the ratio of the tumor value to that

of the white matter. (Fig. 1B, 1F, 1H, 1J).

Histopathological Analysis

Histopathological diagnoses were obtained from either

surgical resection or biopsy specimens. All tumors

were classified as low-grade or high-grade BSGs according

to the 2021 WHO Classification of Tumors of the

Central Nervous System.

Statistical Analysis

Statistical analysis was performed using SPSS software

(version 20.0; IBM, Armonk, NY, USA). Descriptive statistics

for quantitative variables were presented as mean ± standard

deviation. The Chi-square test, Fisher's exact test, and

Mann-Whitney U test were used to compare categorical

and quantitative variables between low-grade and highgrade

BSG groups. Receiver operating characteristic (ROC)

curve analysis was conducted to determine optimal cut-off

values, sensitivity, and specificity for each quantitative parameter

in differentiating between the two tumor grades. A

p-value < 0.05 was considered statistically significant.

Results

Patient characteristics

This study included 43 patients with BSGs, consisting

of 22 males and 21 females. Twenty-five patients were

children (<18 years old), and 18 were adults. The cohort

comprised 14 patients with low-grade BSGs and 29 with

high-grade BSGs. The histopathological diagnoses in the

high-grade BSG group were as follows: 10 pilocytic astrocytomas,

1 ganglioglioma, 3 diffuse astrocytomas, 1

anaplastic ependymoma, 7 anaplastic astrocytomas, 20

diffuse midline gliomas, and 1 glioblastoma. There were

no statistically significant differences in age or sex distribution

between the low-grade and high-grade BSG

groups, with p-values of 0.458 and 0.586, respectively.

Quantitative analysis of signal intensities on T1W and

FLAIR sequences was performed for the entire tumor

volume. Comparisons of these quantitative parameters

between the low-grade and high-grade BSG groups are

presented in Table 2.

Table 2: Comparison of signal values of the entire tumor on T1W and FLAIR pulse sequence

Parameters

Low grade BSG

(Mean±SD)

High grade BSG

(Mean±SD)

p (0.05)

T1_mean 615.72 ± 83.00 572.94 ± 118.94 0.049**

T1_median 624.36 ± 85.80 569.31 ± 122.88 0.036**

T1_SD 87.60 ± 40.15 68.81 ± 17.85 0.114**

T1_max 871.79 ± 103.89 836.69 ± 167.23 0.120**

T1_min 322.64 ± 134.42 338.69 ± 99.02 0.938**

r_meanT1 0.7605 ± 0.0927 0.7562 ± 0.0972 0.890*

FLAIR_mean 852.86 ± 120.62 829.92 ± 158.78 0.636*

FLAIR_median 874.42 ± 138.48 823.78 ± 160.98 0.319*

FLAIR_SD 160.98 ± 83.29 97.95 ± 68.20 0.078**

FLAIR_max 1181.29 ± 239.84 1191.00 ± 345.25 0.925*

FLAIR_min 298.50 ± 218.40 444.83 ± 158.75 0.016*

r_meanFLAIR 1.5798 ± 0.1926 1.6677 ± 0.2431 0.243*

* Comparision were performed using the Independent Samples Test

** Comparision were performed using the Mann-Whitney U Test

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On T1-weighted (T1W) images, the mean (T1_mean)

and median (T1_median) signal intensities of the whole

tumor were significantly higher in the low-grade BSG

group compared to the high-grade BSG group (p = 0.049

and p = 0.036, respectively). However, the ratio of mean

tumor signal intensity to normal white matter signal

intensity (r_meanT1) did not differ significantly between

the two groups.

On FLAIR images, the minimum signal intensity

(FLAIR_min) of the whole tumor was significantly lower

in the low-grade BSG group compared to the high-grade

BSG group (p = 0.016). Similar to the T1W findings, the

ratio of mean tumor signal intensity to normal white

matter signal intensity (r_meanFLAIR) did not show a

significant difference between the two groups.

Quantitative analysis of signal intensities within the

enhancing portion of the tumor on post-contrast T1W

images was performed. Comparisons of these quantitative

parameters between the low-grade and high-grade

BSG groups are presented in Table 3. In the low-grade

BSG group, 12 of 14 cases (85.7%) demonstrated contrast

enhancement, whereas 18 of 29 cases (62.1%) in

the high-grade BSG group showed enhancement. However,

there were no statistically significant differences

in any of the quantitative signal intensity parameters

between the two groups.

Table 3: Comparison of signal values of the tumor’s entire enhancing portion of on T1W post-contrast

Parameters

Low grade BSG

(Mean±SD)

N=12

High grade BSG

(Mean±SD)

N=18

p (0.05)

T1C+_mean 2248.36 ± 274.42 2241.28 ± 125.04 0.982*

T1C+_max 4448.33 ± 573.33 3823.56 ± 297.49 0.347*

T1C+_min 900.08 ± 138.12 1188.94 ± 79.17 0.062*

r_meanT1C+ 1.3118 ± 0.0494 1.2047 ± 0.0617 0.222*


Quantitative analysis of signal intensities on ADC

maps was performed using two different VOI placement

methods:

(1) encompassing the entire tumor volume and

(2) encompassing only the solid tumor component,

excluding cystic or necrotic areas. Comparisons of

these quantitative parameters between the low-grade

and high-grade BSGs groups are presented in Table 4.

Table 4: Comparison of the signal value of the tumor on the ADC map followed two methods of VOI

placement: the entire tumor and the entire tumor’s solid part

Parameters

Low grade BSG

(Mean±SD) x10 -6 m 2 /s

High grade BSG

(Mean±SD) x10 -6 m 2 /s

p (0.05)

Entire tumor

ADCa_mean 1358.14 ± 315.20 1277.86 ± 337.96 0.460*

ADCa_median 1286.40 ± 279.06 1243.85 ± 342.56 0.688*

ADCa_SD 324.54 ± 188.54 296.46 ± 180.06 0.586**

ADCa_max 2629.14 ± 949.66 2425.76 ± 756.94 0.452*

ADCa_min 711.14 ± 159.43 583.59 ± 241.59 0.133**

rADCa_mean 1.9662 ± 0.4024 1.7998 ± 0.4772 0.268*

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Table 4: Comparison of the signal value of the tumor on the ADC map followed two methods of VOI

placement: the entire tumor and the entire tumor’s solid part

Parameters

Low grade BSG

(Mean±SD) x10 -6 m 2 /s

High grade BSG

(Mean±SD) x10 -6 m 2 /s

p (0.05)

Entire tumor

ADCs_mean 1294.16 ± 288.79 1114.02 ± 272.93 0.053*

ADCs_median 1269.91 ± 307.28 1101.20 ± 281.70 0.081*

ADCs_SD 224.39 ± 93.35 183.17 ± 90.14 0.172*

ADCs_max 2157.93 ± 589.32 1816.72 ± 585.16 0.081*

ADCs_min 800.64 ± 191.26 689.41 ± 136.17 0.034*

rADCs_mean 1.8749 ± 0.3746 1.5721 ± 0.3970 0.022*


** Comparision were performed using the Mann-Whitney U Test

When encompassing the entire tumor volume in the

VOI, there were no statistically significant differences

in any of the ADC parameters between the low-grade

and high-grade BSG groups. However, when restricting

the VOI to the solid tumor component, the minimum

ADC value (ADCs_min) was significantly higher in the

low-grade BSG group compared to the high-grade BSG

group (p = 0.034). Similarly, the ratio of mean ADC value

within the solid tumor component to the mean ADC

value of normal white matter (rADCs_mean) was significantly

higher in the low-grade BSG group (p = 0.022).

Table 5 summarizes the diagnostic performance of

quantitative MRI parameters that demonstrated significant

discriminatory ability between low-grade and

high-grade BSGs, based on ROC curve analysis (Figures

2 and 3). On T1W images, the median signal intensity

(T1_median) exhibited the highest diagnostic accuracy,

with an area under the curve (AUC) of 0.700, an optimal

cut-off value of 576.5, a sensitivity of 78.6%, and a

specificity of 69%. On FLAIR images, the minimum signal

intensity (FLAIR_min) showed good diagnostic performance,

with an AUC of 0.719, a cut-off value of 349,

a sensitivity of 79.3%, and a specificity of 64.3%. On apparent

diffusion coefficient (ADC) maps, using the VOI

encompassing the solid tumor component, the ratio of

mean ADC value in the solid tumor to that of normal

white matter (rADCs_mean) demonstrated the highest

diagnostic accuracy, with an AUC of 0.714, a cut-off value

of 1.4785, a sensitivity of 92.9%, and a specificity of

48.3%.

Table 5: Significant parameters for distinguishing low-grade and high-grade BSGs on conventional MRI

Parameters Cut-off Se (%) Sp (%) PPV (%) NPV (%) AUC

T1_mean 559.50 87.5 65.5 54.5 90.5 0.687

T1_median 576.5 78.6 69 55.0 87.0 0.700

FLAIR_min* 349.0 79.3 64.3 82.1 60.0 0.719

ADCs_min 862.5 42.9 93.1 75.0 77.1 0.655

rADCs_mean 1.4785 92.9 48.3 46.4 93.3 0.714

* Positive correlation: values exceeding the cut-off point indicate high-grade BSGs, whi values below the cut-off suggest low-grade BSGs.

Discussion

Quantitative analysis of density on computed tomography

(CT) scans, measured in Hounsfield units (HU), is

widely employed in both research and clinical practice.

The absolute nature of HU values ensures consistency

across different CT scanners and manufacturers. In

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Figure 2: ROC curve with negative correlation indices significantly distinguishing low-grade BSGs and high-grade BSGs

Figure 3: ROC curve with FLAIR_min index significantly distinguishing low-grade BSGs and high-grade BSGs

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contrast, quantifying signal intensity on MRI is more

complex, as signal values are influenced by various factors,

including pulse sequence parameters, magnetic

field strength, and tissue volume. Consequently, signal

intensities can vary depending on the scanner model,

manufacturer, and acquisition parameters. Despite

these challenges, numerous studies have explored the

quantification of MRI signal intensity [19-21]. Standardization

techniques are crucial for comparing signal

values between different scanners, particularly in

large-scale multicenter studies or when compiling datasets

for deep learning and artificial intelligence applications.

Foltyn et al. [21] demonstrated that standardized

signal intensity approaches can effectively

minimize inter-scanner variability, even when using

identical imaging protocols.

Quantitative MRI studies commonly involve the placement

of ROIs or VOIs within tumor lesions, often coupled

with the calculation of signal intensity ratios relative

to normal brain parenchyma. A fundamental approach

entails placing an ROI within a solid tumor region based

on radiologist observation. However, this method is susceptible

to interobserver variability, poses challenges

for automated analysis via artificial intelligence, and

may not fully represent the tumor's overall characteristics.

An alternative strategy involves delineating a VOI

encompassing the entire lesion, thereby capturing the

complete spectrum of tumor components. This method

facilitates automated processing and reduces observer

bias. Nevertheless, the inclusion of diverse tumor components

with varying signal properties within a single

VOI can influence the overall VOI value.

For instance, necrotic and cystic regions exhibit

similar MRI characteristics, including hypointensity

on T1W and FLAIR images, hyperintensity on T2W images

(similar to cerebrospinal fluid), lack of contrast

enhancement, restricted diffusion on DWI, and elevated

ADC values due to low cellularity. However, hemorrhagic

components within necrotic areas can alter

ADC values depending on the stage of blood product

degradation [22]. Therefore, a more refined approach

involves segmenting distinct tumor components into

separate VOIs, preserving the unique characteristics of

each region. In this study, we employed two VOI placement

strategies, tailored to the specific pulse sequence:

(1) a VOI encompassing the entire tumor volume, and

(2) VOIs delineating individual tumor components.

While previous studies have rarely employed quantitative

analysis of signal intensities on T1W, FLAIR,

and post-contrast T1W sequences, our investigation

revealed several noteworthy findings. Quantitative assessment

of the entire tumor on T1W images demonstrated

that both the mean (T1_mean) and median (T1_

median) signal intensities were significantly higher in

low-grade BSGs compared to high-grade BSGs (p = 0.049

and p = 0.036, respectively). This highlights the potential

value of quantitative signal analysis on T1W images,

particularly in cases where qualitative assessment

is inconclusive. On FLAIR images, only the FLAIR_min

differed significantly between the two groups, being

lower in low-grade BSGs (p = 0.016). This contrasts with

qualitative FLAIR analysis, which did not demonstrate

discriminatory ability. Quantitative analysis of the enhancing

portion of the tumor on post-contrast T1W images,

including assessment of the lesion-to-normal tissue

signal intensity ratio, did not reveal any significant

differences between low-grade and high-grade BSGs.

Quantitative analysis of DWI, specifically using ADC

maps, has been widely employed in differentiating glioma

grades, both supratentorially and infratentorially

[11,13,14,17,23-28]. In our study, we investigated two

methods for ADC quantification: (1) encompassing the

entire tumor volume in the VOI, and (2) restricting the

VOI to the solid tumor component. When analyzing the

entire tumor volume, we did not observe any significant

differences in ADC parameters between low-grade

and high-grade BSGs, even when incorporating ratios to

normal white matter. This contrasts with the findings

of Kang et al., [26] who reported that the ADCmin was

significantly lower in high-grade gliomas compared to

low-grade gliomas (p < 0.001).

However, when restricting the VOI to the solid tumor

component, we found that the ADCs_min was significantly

higher in low-grade BSGs compared to highgrade

BSGs (p = 0.034), consistent with the observations

of Gihr et al. [23]. Furthermore, the rADCs_mean was

also significantly higher in low-grade BSGs (p = 0.022).

This finding differs from the study by Lee et al. [17],

which reported no significant difference in the mean

ADC ratio between glioma grades. It is important to

note that Lee et al. [17] only included the enhancing

solid component in their analysis, excluding non-enhancing

solid regions. These findings suggest that

quantifying ADC parameters within the solid tumor

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component may be more valuable than analyzing the

entire tumor volume, particularly when assessing BSG

grade. Furthermore, incorporating the ratio of tumor

ADC to normal white matter ADC can enhance the discriminatory

ability of this approach.

This study has several limitations. First, the inclusion

of both pediatric and adult patients may have influenced

the results, as the epidemiological and imaging characteristics

of BSGs can differ significantly between these

two groups. Second, the relatively small sample size may

limit the generalizability of our findings. Finally, lesion

segmentation was performed manually by a single observer,

introducing potential subjectivity. While objective

segmentation methods using advanced software or

artificial intelligence are desirable, they were not feasible

in this study due to technical constraints.

Conclusion

Quantitative signal intensity analysis of conventional

MRI sequences, particularly T1-weighted and FLAIR,

can effectively differentiate between low-grade and

high-grade BSGs. Furthermore, analysis of the solid

tumor component on ADC maps provides valuable discriminatory

information compared to analyzing the

whole tumor volume. R

Ethical approval

Hanoi Medical University's institutional review board

supported this study. This study was conducted according

to the ethical standards of the 1964 Declaration of

Helsinki and its later amendments.

Informed consent

The requirement for informed consent was obtained.

Availability of data and material

The datasets generated and/or analysed during the

current study are not publicly available due to privacy

concerns, but are available from the corresponding author

on reasonable request.

Conflicts of interest

The authors declare no conflict of interest.

Funding

This research received no external funding.

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Ready - Made

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Morphometric Analysis of Hard Palate Using Cone Beam Computed Tomography for Sex Estimation, p. 60-67

VOLUME 11 | ISSUE 1

Original Article

Head Neck

Morphometric Analysis of Hard

Palate Using Cone Beam Computed

Tomography for Sex Estimation


Varusha Sharon Christopher, Akash Saha, Ritu Basavarajappa

Department of Oral Medicine and Radiologym JSS Dental College and Hospital

JSS Academy of Higher Education and Research, Mysuru - 570015 Karnataka, India


Abstract

Background: Sex determination from skeletal remains

is crucial in forensic anthropology. The hard

palate, being resistant to postmortem degradation,

presents a potential indicator for sex estimation. This

study aimed to analyze the hard palate's dimensions

and structure in the South Indian population to assess

its efficacy in sex determination.

Materials and Methods: The study examined 58 subjects

(29 males, 29 females) using cone beam computed

tomography (CBCT). Measurements included maxilla-alveolar

breadth, maxilla-alveolar length, palatal

depth, maxilla-alveolar index, and palatal size. The data

were analyzed using descriptive statistics and independent

sample t-tests, with significance set at p≤0.05.

Key words

Cone Beam Computed Tomography, Hard Palate, Sexual Dimorphism,

Forensics.

Corresponding

Author,

Guarantor

Dr. Mahima V Guledgud , MD, Department of Radiology, Pham Ngoc

Thach University of Medicine, Professor at Department of Oral Medicine

and Radiology, JSS Dental College and Hospital, JSS Academy of Higher

Education and Research, Mysuru - 570015, Karnataka, India

Email ID: dr.mahimavg@jssuni.edu.in

Contact Number: +91 94480 86800

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Results: Significant sexual dimorphism was observed

in maxilla-alveolar breadth (male: 61.46±3.55 mm, female:

67.98±4.00 mm, p<0.001), maxilla-alveolar length

(male: 48.60±3.98 mm, female: 46.13±3.93mm, p = 0.02),

and size of the palate (male: 29.89±3.27 mm, female:

26.80±3.50 mm, p<0.001). The depth of the palate and

maxilla-alveolar index showed no statistically significant

differences between sexes. The intraclass correlation

coefficient demonstrated high reliability for the

measurements.

Conclusion: CBCT analysis of the hard palate revealed

that maxilla-alveolar breadth, length, and palatal

size are reliable indicators for sex determination in

the South Indian population. This non-invasive method

offers potential applications in forensic anthropology

and medical diagnostics, though larger-scale studies

are recommended for validation across different populations.

Introduction

The acquisition and analysis of skull fragments for

sex determination is an essential facet of forensic anthropology.

It is among the most significant aspects of

the biological profile in certain forensic instances. The

determination of the gender of an individual through

their skull bones is not frequently straightforward, and

the relevance of the findings could differ based on several

circumstances. For instance, trauma, faulty preservation,

animal scavenging, or the specifics of the incident

may have provoked damage to or loss of several of

the skeleton's areas that are implemented for figuring

out the sex of an individual. The literature addresses

this issue of qualitative sex differentiation through the

use of various bones. [1,2] There is a certain extent of

sexual dimorphism that exists in almost every component

of the human skeleton. The hard palate is one of

the 14 indicators that Krogman and Iscan reported with

an accuracy of ninety percent, which can help in assessing

the sex of an individual [3].

Palatal structures, alongside dental tissues, are impervious

to postmortem degradation for several days,

which validates the valuable role of forensic dentistry

in human identification [4]. On top of that, the oral cavity

hedges the palatal and dental structures, rendering

them safe from temperature and severe trauma. For

the previous reason, morphometric palatal features for

individual identification and sex estimation impart an

intriguing identification tool in cases involving severe

tissue damage.

Highly detailed three-dimensional visualizations of

the skull's anatomical components are produced by

cone beam computed tomography (CBCT), a contemporary

medical imaging approach. It is a significant alternative

for future forensics since it has transformed

treatment planning and diagnosis in various domains

by allowing practitioners to view complex structures

and abnormalities precisely and non-invasively [5].

Numerous investigations have focused on the linear

dimensions of the hard palate using dry skulls from

various geographical populations, which has led to misinterpretations

and several flawed techniques [6–8].

Only one study has been found in the literature analyzing

the morphometric character of the hard palate

using a similar technique in the Arabian population [9].

Known for its reproducible and standard calibration,

evaluating these hard palate linear measures using this

modality can decrease errors and enhance the reliability

of digital forensics. Therefore, this study is aimed at

assessing the anatomy of the hard palate using CBCT to

ascertain the dimensions and structural variations of

the hard palate.

Material and Methods

The 58 subjects in this descriptive retrospective study

comprised 29 men and 29 women from the Indian South

region. The study samples were monocentric, homogeneous

in origin, and chosen using a straightforward purposive

sampling technique, including individuals aged 18

to 65. The institutional ethics committee granted ethical

approval on 20/05/2023 with approval number 44/2023

with the following inclusion and exclusion criteria:

Inclusion criteria

● Optimally diagnostic quality CBCT images

● CBCT scans that indubitably display the structure

of the skull base

Exclusion criteria

● Image with the presence of any developmental

anomaly/central pathology involving the base of

the skull

● Image with any evidence of previous surgery, fracture,

or healed fracture of the base of the skull

● Nondiagnostic CBCT images, including partial images

or the presence of artefacts at the base of the

skull.

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Radiographs satisfying the inclusion criteria were

subjected to analysis for the following landmarks in

axial and coronal dimensions in Planmeca Romexis

5.3 (3D software, Planmeca Oy, Helsinki, Finland), retrospectively

sourced from the archives of the institution’s

data set.

1. Maxilla-Alveolar length: Prosthion (a point on the

alveolar arch midway between the medial and upper

incisor teeth) and Alveolon (the point where

the mid-sagittal plane of the palate is intersected

by a line connecting the posterior borders of the

alveolar crests) will be taken as landmarks for

length in the coronal plane. [Figure 1A]

2. Maxilla-Alveolar Breadth: The maximum breadth

recorded on the lateral surfaces is at the level of

the second maxillary molars across the maxilla's

alveolar limits in the axial plane. [Figure 1B]

3. Depth of the palate: from the deepest point of the

palate until the imaginary line from prosthion to

alveolon in the coronal plane [Figure 1A]

We will also calculate and analyze the following parameters

after collecting the above-mentioned data:

1. Maxilla-alveolar Index: {Maxilla-alveolar breadth /

Maxilla alveolar length} x 100[10]

2. Size of the palate:{Maxilla-alveolar breadth x Maxilla

alveolar length} / 100 [11]

The same observer, a certified oral and maxillofacial

radiologist well-versed in CBCT, conducted two repetitions

of each of these evaluations at a 15-day interval.

To compensate for intra-examiner variability, an average

of these measurements was adopted.

Statistical Analysis

Following data tabulation and statistical analysis, a

comparison of the sex groups was carried out. An independent

computation of the mean, SD, p, and t values was

performed. The gathered data were subsequently put

through the Kolmogorov-Smirnov test and descriptive

statistics to determine normality. Given the normal distribution

of the data, an independent sample two-tailed

t-test was conducted. A p-value of less than or equal to

0.05 was considered statistically significant. The statistical

analysis was carried out using SPSS version 23.0.

Results

The mean age of the population was 34.5, with a minimum

of 18 years, and the maximum age recorded was

65. Table 1 shows the descriptive data that were used to

estimate the mean, standard deviation, maximum, and

minimum data based on sex.

As demonstrated in Table 1, a two-tailed t-test for

independent samples revealed that the difference between

the sexes in terms of the dependent variables

-maxillo-alveolar length, maxilla-alveolar breadth,

and size of the palate- was statistically significant with

p-values less than 0.05. In contrast, the depth of the

palate and the maxilla-alveolar index did not differ statistically

between the sexes. The intraclass correlation

coefficient (ICC) was 0.86 for maxillo-alveolar breadth,

0.91 for maxillo-alveolar length, and 0.84 for depth of

the hard palate.

The logistic regression analysis presents results for

three predictor variables (maxilla-alveolar breadth,

Figure 1: A. CBCT image showing the Maxilla-alveolar length and Depth of the palate; B. CBCT image showing the maxillaalveolar

breadth

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maxilla-alveolar length, and size of the palate) and one

outcome variable (odds ratio). None of the predictor

variables show statistically significant effects on the

outcome variable at the conventional alpha level of 0.05,

as indicated by their respective p-values being greater

than 0.05. Specifically, the coefficients for maxilla-alveolar

breadth, maxilla-alveolar length, and size of the

palate are 2.159 (p = 0.122), 1.853 (p = 0.100), and -3.402

(p = 0.139), respectively, with corresponding standard

errors, Z-scores, and confidence intervals. The intercept,

representing the log odds of the outcome variable

when all predictor variables are zero, is not statistically

significant (p = 0.087). These findings suggest that,

within the context of this analysis, the included predictor

variables do not significantly influence the outcome

variable. [Table 2]

Discussion

The bony structure in the upper portion of the mouth,

known as the hard palate, is essential for many aspects

of human functionality and the state of health. It is a key

component of speech and articulation because it operates

as a surface on which the tongue strikes in order

to generate specific sounds [12]. Additionally, the hard

Table 1: Descriptive Statistics based on sex with mean, standard deviation, maximum, and minimum

values along with inferential analysis where p<0.05 is considered significant.

Parameters

Sex

Mean

(mm)

Maximum

(mm)

Minimum

(mm)

t

p-value

Maxilla-alveolar

Breadth

Maxilla-alveolar Length

Depth of the Palate

Maxilla-alveolar Index

Size of the Palate

Male 61.46±3.55 68.4 52.8

Female 67.98±4.00 67.6 61.6

Male 48.60±3.98 64.4 40.8

Female 46.13±3.93 64.8 34.8

Male 16.01±2.84 21.6 10.0

Female 14.51±3.99 20.8 3.6

Male 127.22±12.09 168.7 109.2

Female 126.39±12.00 164.3 100.9

Male 29.89±3.27 23.0 36.0

Female 26.80±3.50 19.9 37.0

-3.50 <0.001

-2.37 0.02

-1.64 0.10

-0.46 0.79

-3.48 <0.001

Table 2: The logistic regression results show values for maxilla-alveolar breadth, maxilla-alveolar length,

and size of the palate.

Variable

Regression

Coefficient

Standard

Error

Z

Wald’s

P value

Odd’s Ratio

Confidence Interval

Lower

Upper

Intercept -116.586 68.168 -1.710 0.087 2.33x10-15 -250.193 17.022

Maxillaalveolar

breadth

2.16 1.39 1.546 0.122 6.379 -0.578 4.896

Maxillaalveolar

length

Size of the

Palate

1.85 1.125 1.647 0.100 1.546 -0.352 4.058

-3.40 2.298 -1.481 0.139 -1.481 -7.905 1.102

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palate plays a part in the digestive process by facilitating

food mastication and preliminary digestive breakdown.

Each of them produces substantial shifts in the hard palate's

growth and development, contributing to unique

variations. Given that changes in the hard palate may

impact oral health and orthodontic therapies, its anatomical

features may also be clinically significant [13].

For the purpose of ascertaining the gender of skeletal

remains, one may additionally employ the hard palate.

Owing to its pristine position and anatomy, it has

attracted great interest. According to a study that implemented

three-dimensional geometric morphometric

methods, gender differences in the hard palate can

be used to determine the gender of skeletal remains,

as they are statistically significant [14]. In this study,

men had a higher proportion of accuracy in identifying

sex based on their hard palate. According to Alves et

al., a U-shaped palate is male, but a V-shaped palate is

female [15]. Additionally, at 18 to 20 years old, gender

disparities in the thickness of the bony palate were discovered

in a pilot investigation employing computed

tomography [16].

The techniques used for assessing a person's sex

from their cranium either use specific measurements

of various components of the skull or hinge on visually

discernible descriptive aspects of the skull. Experts

can apply the observational approach with accuracy,

but lay individuals can't employ it without training

and experience, and it becomes inaccurate when misapplied.

Currently, we are using imaging modalities for

more precise analysis due to their standard calibration.

The accuracy of cone beam computed tomography's

(CBCT) sex determination varies depending on the specific

anatomical features and regions being analyzed. In

forensic anthropology, CBCT scans are sometimes used

to examine the craniomaxillofacial region, which can

provide valuable information for sex determination [5].

Many authors have analyzed the morphometry of the

hard palate through dry skull studies [6,8,15].

Numerous investigations have been undertaken

regarding sex prediction using metric and non-metric

hard palate analyses in various populations. For

instance, an analysis of dry skulls from South India

quantified the hard palate with a vernier calliper on 24

male and 18 female skulls. The study discovered that its

findings aligned with another survey of the hard palate

in dry skulls from Central India [14]. The following research

evaluated the dry skulls of 312 adult individuals

of both sexes and concluded that the pyriform aperture

and hard palate, both of which encompass metric and

non-metric features, have significance for sex prediction

[15]. Additionally, palatal dimensions reveal sexual

dimorphism and can be employed as sex predictors under

a morphometric study examining the hard palate

and its significance to dentistry and forensic sciences

[17]. These studies illustrate how the hard palate can

potentially be used to predict sex in a range of demographics.

Maxilla-alveolar Length and Breadth

Skeletal remains can be analyzed for sex using the

length of the maxilla alveolar and the breadth of the

hard palate. According to Sumati et al. [18], in specific

racial groupings, men had longer hard palates and wider

maxilla-alveolar breadths on average than women,

which is also consistent with the research carried out

by Song et al. and Burris et al. [19,20]. The same, however,

cannot be said with certainty about mixed-race

or unidentified-race groups because of their unambiguous

overlap. Similar outcomes were also noted in

the present study, with noteworthy findings indicating

that sexual dimorphism is present in maxilla-alveolar

breadth and length.

Maxilla-alveolar index

The maxilla-alveolar index can be projected using the

linear measures of maxilla-alveolar length and breadth,

providing it with a collective perspective. An osteological

study by Sumati et al. in North Indian communities

revealed that the index was greater in females than in

males [18,21]. Comparably, radiological studies in the

Iraqi population by Abdul Ameer and Fatah discovered

that Iraqi females had a greater maxilla-alveolar index,

which does not correspond to the case in the present

study [22]. The current investigation revealed higher

values in males than in females, which was in contrast

to the findings of other studies. However, the maxilla-alveolar

index was shown to be an unfavorable feature

for sex estimation, as none of the research cited

had any significance with regard to it.

Size of the Palate

Research has presented evidence that the size of the

palate, which was determined using the same linear

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measurements, is a sexually dimorphic characteristic

[18,23-25]. In 1949, Wood conducted research on a wide

range of American populations, including white Americans,

Black Americans, Inuit people, Native Americans,

and Mongolians [23]. Meanwhile, Larnach and

Macintosh examined the coastal New South Wales and

Queensland regions, respectively. All three researchers

demonstrated that men have a much larger palate

[24,25]. Implementing metric measurements, Sumati

et al. revealed that males had larger palates, with a

size categorization accuracy of 70% based on measurements

taken from a community of North Indians [18].

The current study's result, which reveals concurrently

significant outcomes, is supported by all of the studies

mentioned above.

Depth of the Palate

The depth of the palate was another linearly dependent

variable examined in this study. A study on the palatal

vault of primary dentition by Tsai et al. found that the

mean palatal depth was 10.77 mm in males and 10.67 mm

in females, with no statistically significant disparities between

the sexes [26]. According to another study, males

often have a deeper palate than females of the same age,

which also indicates that the depth of the palate grows

with age [6]. Males had greater values than females in

the present analysis. Similar to these studies, the present

study showed a significant positive correlation.

Any investigation based on the dimensions of the

hard palate depends substantially on the community

being studied because a wide range of determinants influence

the size and shape of the palatal bone in different

communities at large. To ensure that the findings

of a study conducted in one demographic cannot be

extrapolated to another, it is recommended that comparable

research be carried out on a more extensive database

and that these constraints be considered when

interpreting the study's findings.

One limitation of the current study is its tiny sample

size. We recommend investigating their role in sex estimation

through larger-scale research.

Another limitation is the use of a particular kind of

CBCT device with a predetermined FOV (field of vision)

and voxel size. Changing study settings or employing

different equipment may have an impact on the image's

resolution, producing results that may vary.

Conclusion

To comprehend the hard palate's structural changes,

dimensions, and their correspondence to the presence

of sexual dimorphism, this study used quantifiable

measures of the hard palate and concluded that

parameters such as maxilla-alveolar length, maxilla-alveolar

breadth, and size of the palate are dependable

and statistically significant sexual indicators. Utilizing

cutting-edge imaging methods, especially CBCT, offers

a more comprehensive knowledge of the diversity of

the hard palate.

The imaging modality not only has relevance in therapeutics,

diagnostics, and craniofacial morphology but

can also be helpful for precise population profiling and

sex determination in forensic anthropology. Overall,

this work lays the groundwork for future investigations

and applications in the fields of craniofacial science and

forensic medicine by highlighting the importance of

morphometric analysis of the hard palate in both clinical

and forensic contexts. R

Funding

None

Conflict of Interest

None

Acknowledgements

None

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Ready - Made

Citation


Varusha Sharon Christopher, Akash Saha, Ritu Basavarajappa. Morphometric

Analysis of Hard Palate Using Cone Beam Computed Tomography for Sex

Estimation, Hell J Radiol 2026; 11(1): 60-67.

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72-Year-Old Male with Chronic Untreated Pain and Incidental Radiographic Findings, p.68-72

VOLUME 11 | ISSUE 1


Head and Neck Imaging

72-Year-Old Male with Chronic

Untreated Pain and Incidental

Radiographic Findings

Prasanna Srinivas Deshpand, Karthikeya Patil, Meera Theenathayalan

Department of Oral Medicine and Radiology, JSS Dental College and Hospital,

JSS ACADEMY OF HIGHER EDUCATION AND RESEARCH


Part A

A 72-year-old male presented with four-month

right upper back tooth pain and intermittent bilateral

neck pain. Initially, the patient ignored symptoms

and self-medicated with over-the-counter analgesics.

Pain progressively worsened, restricting head movement

and mastication, prompting consultation for it.

No trauma history was reported. Past medical history

included twenty years of hypertension managed with

regular medication. On palpation, pain was elicited

during head rotation bilaterally. Mild masseter and

trapezius tenderness were noted on palpation. Intraoral

examination revealed multiple decayed teeth.

Investigation included Digital panoramic radiography

(OPG) [Figure 1] followed by Cone Beam Computed

Tomography (CBCT) [Figure 2A, 2B, 2C] for diagnostic

evaluation.

Key words

Incidental findings, dental imaging, chronic pain, vascular pathology,

interdisciplinary care

Corresponding

Author,

Guarantor

R KARTHIKEYA PATIL, MDS, Professor and Head,Department of Oral

Medicine and Radiology, JSS Dental College and Hospita, JSS ACADEMY

OF HIGHER EDUCATION AND RESEARCH, MYSORE - 570 015

Email: dr.karthikeyapatil@jssuni.edu.in

Phone +91 94498 22498

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H R J

Figure 1: Orthopantomogram demonstrating bilateral elongated styloid processes extending beyond normal anatomical

limits with associated radiopaque calcifications in the carotid regions.

Figure 2A: CBCT 3D reconstruction showing bilateral elongated styloid processes and their spatial relationship to

surrounding anatomical structures.

Figure 2B: CBCT sagittal section (right side) revealing elongated styloid process measuring 64.09 mm with

pseudoarticulated morphology and associated calcifications.

Figure 2C: CBCT sagittal section (left side) demonstrating elongated styloid process measuring 45.98 mm with

uninterrupted configuration and nodular calcification pattern.

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Part B

Diagnosis: Elongated styloid process with multiple

carotid calcification (Stylo-carotid syndrome

- a rare variant of Eagle’s syndrome)

The panoramic radiograph revealed unexpected findings

beyond the anticipated dental pathology, specifically

demonstrating bilateral elongated styloid processes

extending significantly beyond normal anatomical

limits. These processes were accompanied by multiple

radiopaque calcifications in regions corresponding to

the anatomical locations of vascular structures. These

incidental findings prompted immediate concern for

potential vascular pathology, leading to the recommendation

for cone-beam computed tomography to

provide detailed three-dimensional assessment of calicifications

and the styloid processes with their spatial

relationship to critical anatomical structures.

Bilateral styloid process elongation was confirmed by

advanced CBCT imaging, with measurements of 64.09

mm on the right side and 45.98 mm on the left [Figure

3A, 3B], considerably exceeding the typical range of 20-

25 mm.

Morphological classification revealed a pseudoarticulated

pattern on the right side and an uninterrupted

configuration on the left side. According to Langlais classification,

both bilateral regions demonstrated nodular

type calcification patterns [Figure 3A, 3B]. The three-dimensional

reconstruction amply illustrated the close anatomical

proximity of the elongated styloid processes to

Figure 3A & 3B: CBCT measurements confirming bilateral styloid process elongation with morphological classification showing

pseudoarticulated pattern (right) and uninterrupted configuration (left).

Figure 4A: Three-dimensional CBCT reconstruction illustrating close anatomical proximity of elongated styloid processes

with bilateral calcifications at C3-C5 vertebral levels.

Figure 4B: CBCT imaging showing multiple discrete calcifications near hyoid cornu processes, with seven calcified deposits

predominantly at C4-C5 levels.

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H R J

the internal carotid arteries, with widespread calcifications

visible in the bilateral regions corresponding to the

C3, C4, and C5 vertebral levels [Figure 4A].

Additionally, CBCT examination revealed multiple

discrete calcifications in the vicinity of the hyoid cornu

processes. A total of seven calcified deposits were

identified, with the largest measuring approximately

1.2 mm in maximum dimension. These calcifications

demonstrated bilateral distribution across both right

and left anatomical regions, with predominant localization

occurring at the C4-C5 vertebral levels and one additional

deposit identified in the C3 region [Figure 4B].

The anatomical positioning and morphological characteristics

of these calcifications warrant careful differential

consideration. Based on their precise location and

structural features, these deposits can be definitively

distinguished from carotid stenotic lesions, which would

manifest as intraluminal narrowing with characteristic

atheromatous plaque morphology within the vessel wall.

Similarly, the observed calcifications are anatomically

inconsistent with tonsillar calcifications (tonsilloliths),

which would be expected to occur within the palatine

tonsillar crypts and fossae, positioned significantly more

superior and medial to the documented findings.

The spatial relationship of these calcifications to the

styloid process complex, combined with their distribution

pattern extending from C3 to C5 levels, further

supports the diagnosis of stylocarotid syndrome rather

than isolated vascular or tonsillar pathology. This anatomical

differentiation is crucial for accurate diagnosis

and appropriate clinical management.

The initial provisional diagnosis took into account

several differential possibilities, including ossified thyroid

cartilage, isolated atherosclerotic carotid disease

without styloid involvement, calcified cervical lymph

nodes, carotid artery aneurysm with associated calcification,

and classic Eagle's syndrome with pharyngeal

symptomatology.

However, the diagnosis of stylocarotid syndrome

was unquestionably supported by the radiographic

findings' bilateral symmetry, linear morphology, and

anatomical location, as well as the distinctive measurements

acquired through CBCT imaging. The patient's

past complaints of intermittent orofacial pain, which

were previously attributed solely to dental pathology,

most likely reflected concealed signs of styloid-mediated

neurovascular compromise that had been mistakenly

treated symptomatically rather than being examined

diagnostically.

Eagle's syndrome, initially characterized by Watt Eagle

in 1937, encompasses a spectrum of clinical manifestations

arising from pathological elongation of

the styloid process or ossification of the stylohyoid

ligament complex. This condition presents in two distinct

phenotypic variants: the classical form involving

pharyngeal symptomatology, and the vascular variant

termed stylocarotid syndrome, which poses significant

cerebrovascular risk through mechanical compression

of the internal carotid artery. Contemporary understanding

of stylocarotid syndrome has evolved considerably,

with recent investigations demonstrating that

styloid process lengths exceeding 30 mm can precipitate

carotid artery dissection and subsequent ischemic

stroke, particularly in individuals under 50 years of age.

The pathophysiological mechanism underlying stylocarotid

syndrome involves direct mechanical compression

of the carotid vessels during normal cervical

movements, creating hemodynamic alterations that

predispose patients to thrombotic events and arterial

dissection. Epidemiological studies indicate that while

elongated styloid processes affect approximately 4-28%

of the population radiographically, symptomatic manifestations

occur in fewer than 0.16% of cases, suggesting

that anatomical variation alone is insufficient for

clinical expression.

Based on several cooperating factors, including advanced

age, chronic hypertension, bilateral stylocarotid

syndrome with documented carotid compression

potential, and the presence of extensive atherosclerotic

calcifications indicating concurrent vascular disease,

risk stratification categorized this patient as extremely

high-risk for cerebrovascular events. Immediate interdisciplinary

consultation was arranged with vascular

surgery for comprehensive carotid assessment and hemodynamic

evaluation, neurology for stroke risk stratification

and medical management optimization, and

cardiology for holistic cardiovascular risk assessment.

The patient received extensive counseling regarding

the potentially fatal nature of his condition and was

provided with emergency contact protocols should any

neurological symptoms develop.

This case represents a paradigmatic example of how

routine dental imaging can facilitate the detection of

potentially fatal systemic pathology. The diagnostic

71

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VOLUME 11 | ISSUE 1

challenge inherent in this case centers on the phenomenon

of symptom masking, whereby the patient's

legitimate dental pathology provided a plausible explanation

for his orofacial discomfort, inadvertently

obscuring the underlying vascular etiology. This case

underscores the importance of maintaining diagnostic

vigilance even when obvious pathology provides apparent

explanations for patient symptoms, and highlights

the critical role of interdisciplinary collaboration in

comprehensive healthcare delivery. R

Conflict Of Interest

The authors declared no conflicts of interest.

Funding

This project did not receive any specific funding.

References

1. Ahmad I, Ramadhan A, Hussain M. Carotid artery type

of Eagle syndrome: an uncommon cause of ischemic

stroke. Cureus. 2022;14(8):e27897.

2. Leonard MK, Nason RW,Oby CM. Surgical management

of stylocarotid Eagle syndrome in a patient with bilateral

internal carotid artery dissection: illustrative

case. J Neurosurg Case Lessons. 2024;7(3):CASE23440.

3. Hansen F, Pandey S, Weber J, Jeremic D. Eagle syndrome:

pathophysiology, differential diagnosis and

treatment options. Head Neck Surg. 2025;4(1):15-28.

4. More CB, Asrani MK. Eagle syndrome. J Oral Maxillofac

Pathol. 2010;14(2):654-660.

5. Cvetko E, Bosnjak R, Derganc M. The proximity between

styloid process and internal carotid artery as

a possible risk factor for dissection: a case-control

study. Eur Radiol. 2023;33(7):4860-4868.

6. Khandelwal S, Hada YS, Harsh A, et al. Classic Eagle's

syndrome: styloidectomy via the transcervical

approach. Indian J Otolaryngol Head Neck Surg.

2021;73(3):390-394.

7. Dutra MEP, Santos PPA, Cançado RP, et al. Detection

of carotid artery calcifications using artificial

intelligence in dental radiographs: a systematic

review and meta-analysis. BMC Med Imaging.

2025;25(1):12.

8. Almog DM, Illig KA, Carter LC, et al. Carotid artery

calcification on dental radiographs. Br Dent J.

2021;230(1):17-22.

9. Zhang H, Park CK, Raza H, et al. Can styloid process

and internal carotid artery anatomy be used to

predict carotid artery dissection? Ann Vasc Surg.

2021;76:292-299.

10. Tweedy R, Lo WD, Huisman TA, et al. Styloid process-related

internal carotid artery dissection: extensive

literature review of diagnosis, treatment and outcomes.

Neuroradiology. 2024;66(12):2087-2098.

Ready - Made

Citation

Prasanna Srinivas Deshpand, Karthikeya Patil, Meera Theenathayalan.

72-Year-Old Male with Chronic Untreated Pain and Incidental Radiographic

Findings, Hell J Radiol 2026; 11(1): 68-72.

72

H R J

Acute Shoulder Pain with Inflammatory Imaging Features: A Diagnostic Challenge, p. 74-76

VOLUME 11 | ISSUE 1


Musculoskeletal Imaging

Acute Shoulder Pain with Inflammatory

Imaging Features: A Diagnostic

Challenge

Evangelia Kalaitzidou, Aikaterini Tavernaraki, Dimitrios Exarchos

Department of CT & MRI, Evangelismos General Hospital, Athens, Greece


Part A

Clinical History

A middle-aged patient presented with acute, rapidly

progressive shoulder pain of a few days’ duration. The

pain was severe, associated with marked restriction of

both active and passive shoulder movement and local

tenderness. Low-grade fever was reported. Laboratory

tests demonstrated elevated inflammatory markers

and leukocytosis, raising clinical concern for an infectious

process. There was no history of trauma, previous

shoulder disease, or recent intervention.

Figure 1: Axial PD- FAT SAT. Figure 2: Coronal PD- FAT SAT. Figure 3: Axial T1.

Corresponding

Author,

Guarantor

Evangelia Kalaitzidou,

Department of CT & MRI, Evangelismos General Hospital, Athens, Greece.

Email: evaggeliakalaitzidou12@gmail.com

74


VOLUME 11 | ISSUE 1

H R J

Based on the clinical presentation and imaging findings,

the differential diagnosis includes both infectious

and non-infectious conditions.

The combination of acute pain, raised inflammatory

markers, and extensive bone marrow edema raises

concern for osteomyelitis; however, the presence of

focal low-signal material on all MRI sequences and the

absence of aggressive features suggest an alternative diagnosis.

Careful correlation with radiographic findings

is essential.

Part B

Diagnosis

Intraosseous migration of calcific tendinopathy

of the rotator cuff with associated calcific osteitis

Discussion

Calcific tendinopathy is a common condition characterized

by deposition of calcium hydroxyapatite crystals

within tendons, most frequently involving the rotator

cuff [1]. Although the imaging appearance of typical calcific

tendinopathy is well recognized, extension of calcific

material beyond the tendon, particularly into adjacent

bone, is uncommon and may pose a significant diagnostic

challenge [2].

Intraosseous migration is believed to occur during the

acute resorptive phase, when intense local inflammation

and increased intratendinous pressure cause cortical

erosion and penetration of calcific material into the

adjacent humeral head [1,2]. The resulting intraosseous

lesion often has a cyst-like appearance and is commonly

associated with extensive bone marrow oedema, which

may appear disproportionate to the size of the lesion itself

[2] (Figures 1,2,3).

On plain radiographs, calcific tendinopathy typically

appears as amorphous peri-tendinous calcifications

adjacent to the greater tuberosity [3]. Subtle cortical irregularity

may be present in cases of intraosseous extension,

although radiographs frequently underestimate the

extent of osseous involvement [4].

MRI is particularly valuable in recognizing this entity

and avoiding misdiagnosis. Characteristic findings include

a central focus of very low signal intensity on all

sequences, corresponding to calcific material, surrounded

by pronounced bone marrow oedema [2]. Associated

findings may include reactive changes of the adjacent

tendon and subacromial–subdeltoid bursitis, which

may itself contain calcific deposits [3] (Figure 4). Gradient-echo

sequences are helpful in demonstrating blooming

artefact, further confirming the presence of calcium

[2] (Figure 5).

Clinically, patients often present with severe acute

pain, functional impairment, and occasionally systemic

inflammatory features, including fever and raised inflammatory

markers [1].

This combination of clinical and imaging findings may

closely mimic osteomyelitis, leading to unnecessary biopsy

or antibiotic treatment if the diagnosis is not recognized

[2].

Figure 1. Axial PD- FAT SAT:

Cystic lesion with central calcium

deposition and reactive bone

marrow edema.

Figure 2. Coronal PD- FAT SAT:

Associated tendon abnormalities.

Figure 3. Axial T1: Bone erosion

related to calcium migration.

75

H R J


VOLUME 11 | ISSUE 1

Figure 4. Fluid collection within

the bursa and calcific tendinitis.

Figure 5. T2-blooming artifact.

The main differential diagnoses include osteomyelitis,

occult fracture, primary or metastatic bone tumors, and

rotator cuff tears with reactive marrow changes [2,4].

The absence of aggressive features such as cortical destruction,

periosteal reaction, soft tissue mass, or true

abscess formation favors a benign inflammatory process

[2]. Awareness of intraosseous migration of calcific

tendinopathy and careful correlation with radiographs

are essential for radiologists, allowing accurate diagnosis

and appropriate conservative management [1,2]. R

References

1. Uhthoff HK, Loehr JW. Calcific tendinopathy of the rotator

cuff: pathogenesis, diagnosis, and management.

J Am Acad Orthop Surg. 1997;5:183–191.

2. Flemming DJ, Murphey MD, Shekitka KM, et al. Osseous

involvement in calcific tendinitis. AJR Am J Roentgenol.

2003;181:965–968.

3. Loew M, Sabo D, Wehrle M, et al. Relationship between

calcifying tendinitis and subacromial impingement.

J Shoulder Elbow Surg. 1996;5:314–319.

4. Hayes CW, Rosenthal DI, Plata MJ, Hudson TM. Calcific

tendinitis associated with cortical bone erosion. AJR

Am J Roentgenol. 1987;149:967–970.

Key words

Calcific Tendinopathy, Rotator Cuff, Radiology, MRI

Ready - Made

Citation

Evangelia Kalaitzidou, Aikaterini Tavernaraki, Dimitrios Exarchos.

Acute Shoulder Pain with Inflammatory Imaging Features: A Diagnostic

Challenge, Hell J Radiol 2026; 11(1): 74-76.

76

Guidelines for Authors

1. Scope


(“HjR”) is the official journal of the

Hellenic Radiological Society, first

published in 1968. This revived edition

of HjR, published in English, aspires

to promote scientific knowledge

in Radiology and allied sciences

both at diagnosis and image guided

therapy, worldwide. It is a peer-reviewed

Journal, aiming at raising the

profile of current evidence-based

imaging practice and at improving

the scientific multidisciplinary dialogue.

HjR presents clinically pertinent,

original research and timely

review articles. It is open to International

authors and readers and offers

a compact forum of communication

to medical imaging and related

science specialists.

2. Language

British English is the official language

of the journal. All submitted

manuscripts should be written in

British English.

3. How to submit a paper

All submissions for peer-review

should be performed online through

the journal website www.hjradiology.org.

The Editor-in-Chief and the Associate

Editors will perform the initial

assessment of the manuscript and

if the manuscript is suitable for the

journal and the submission is complete,

it will be sent to the relative

reviewers by the appropriate section

Editor. The reviewing process

that is followed is double blinded.

During on-line submission, authors

can enter the name/s of non-preferred

reviewers. The time allocated

for reviewers to assess the manuscript

and submit their recommendation

is three weeks. The Editor-in-chief

makes the final decision

for publication.

The Editorial office will communicate

the reviewer’s comments and

the decision to the authors.

4. Manuscript originality and copyright

The submitted manuscript should be

original, should not contain previously

published material and should

not be under consideration for publication

in another journal. Previous

publication of an abstract as an

oral presentation or scientific exhibit,

either in print or electronically,

does not preclude submission of an

original article for publication. Any

potential overlap with prior publications

should be clearly stated by

theauthors to avoid redundant publications.

The submission needs to

be approved by all co-authors and,

in case of original research, a ‘guarantor’

of the study is required. As

‘guarantor’ may be considered a

senior author that is deemed to take

overall responsibility for all aspects

of the study (ethics, originality, consent,

data handling, and all aspects

of Good Medical Practice). The ‘guarantor’

of the study does not necessarily

need to be the corresponding

author. The HjR will not hold legal

responsibility should there be any

claim for compensation. All authors

need to sign the copyright transfer

form (http://hjradiology.org/docs/

Copyright Transfer Form.doc).

5. Ethical issues

Authorship should be based on the

criteria defined by the International

Committee of Medical Journal

Editors recommendations (http://

www.icmje.org/icmje-recommendations.pdf).

Complaints and appeals

The Editorial Board (EB) will discuss

in detail all the complaints and appeals

on the decision of rejection of

a submitted manuscript or any concerns

or allegations regarding misconduct,

and will decide accordingly.

An independent panel of international

experts, including renowned

journal editors and directors of academic

departments, may be consulted

if these issues arise.

Conflict of interest - competing

interests

It is the authors’ responsibility to

fully disclose in the cover letter any

financial interests (shareholding or

employment by industry, etc.) relative

to the work under consideration.

Any conflict should be stated

in the manuscript before the Reference

section. Authors should acknowledge

any source of funding

provided for the submitted subject

matter (i.e. grants, financial support

for presentations at meetings, etc).

For clinical trials, the registration

number, if available, should be included.

Advertisements will be kept

out of the main text body of the journal

and it is the Editor’s responsibility

that the editorial decisions will

not be influenced by advertisers and

sponsors. Special issues follow the

routine editorial process and are by

no means influenced by advertisers.

The EB retains the right to refuse

any advertisement for any reason.

Data sharing and communication

The EB may permit the use of figures

or text for scientific reasons. Audits

of rejection rates, review of completion

time and other data, such as the

impact factor of the journal, will be

regularly published. Premature publication

in the mass or social media

is not advised until the article has

appeared electronically in public.

Patient data

It is the authors’ responsibility to

protect patient anonymity. All identifying

data (name, identification

numbers, initials) must be removed

from text, images and tables. If it

is mandatory for a patient’s face to

be included in the manuscript, the

eyes should be sufficiently masked.

If there is a possibility that a patient

may be identified from a photograph

or relevant legend and text, the patient’s

written consent should be

submitted.

Research ethics and compliance

The HjR follows the guidelines of the

International Committee of Medical

Journal Editors (www.icmje.org). It

is the authors’ responsibility to confirm

that any experimental investigation

on human subjects report-

77

H R J

ed in a submitted manuscript has

been performed with the subjects’

informed consent and following the

approval of the appropriate institution

review board. For prospective

clinical studies with human subjects,

the authors are required to

confirm that both an appropriate

institution review board approval

and informed consent have been

obtained. For retrospective clinical

studies, the authors are required

to confirm than an institution review

board waiver of informed consent

has been obtained. For clinical

studies involving human subjects

with no access to ethics review committees,

the authors should confirm

that they followed the principles

outlined in the Helsinki Declaration

(World Medical Association

Declaration of Helsinki: ethical

principles for medical research involving

human subjects. JAMA 2013;

310(20): 2191-2194). Authors may be

asked to document the above at any

time point.

For studies involving animals, the

authors should indicate whether the

procedures followed the local regulatory

principles on animal experimentation.

In this case, the following

statement needs to be added in

the text: “All applicable international,

national, and/ or institutional

guidelines for the care and use of

animals were followed”.

Permissions and plagiarism

Figures and images should have

not been previously published. For

the use of any figures already published

elsewhere by one of the authors

or by means of another publication,

the authors are required to

obtain written permission from the

copyright owner(s) and to submit

the evidence in the submission process.

Disclosure should be made at

the time of submission, accordingly.

Plagiarism will not be accepted

in any case. Dedicated software will

be used on this purpose. All submissions

will be first screened by a similarity

detection software before

being assigned for peer review. If

the overall text similarity index is

>20%, or the duplication rate is >5%,

the manuscript is returned to the

authors without peer review. The

similarity report will be included

in the editor’s message. In cases of

plagiarism, citation manipulation,

data and results fabrication, or any

suspicion of research misconduct,

the EB will follow the guidelines of

the Committee on Publication Ethics

(https://publicationethics.org/

guidance/Guidelineshumansubjects).

The EB reserves the right of

rejecting submissions if there is

any doubt about whether the procedures

described above have been

followed accurately.

Options for publication,

post-publication discussions and

corrections

All manuscripts are subjected to

blind peer review after being initially

assessed for quality by the section

editors. The section editors will first

evaluate the possibility of duplicate

publications. Reviewers are selected

for their known expertise, objectivity

and proven commitment and

professionalism.

Reviewers should handle the material

confidentially and are not allowed

to share or copy. In case of

major disagreement between two

reviewers, the manuscript will either

be assigned to a third reviewer,

or the section editor will make

a decision. The decision on acceptance

or rejection is based solely on

the reviewers’ evaluation, the importance

of the manuscript and its

relevance to the aims of the journal.

The EB will decide upon any letters

to the editor commenting on prior

publications. Corrections on prior

publications related to authors’

names, affiliations, major flaws or

any kind of errors will also be discussed

by the EB and prompt changes

will be published in a subsequent

issue. The changes will be listed in

the table of contents to ensure that

they will be linked to the initial publication

to which they pertain in major

databases such as in PubMed.

6. Types of manuscript

The HjR accepts the following types

of articles:

• Original articles: The paper

needs to offer new knowledge on

diagnostic or interventional radiology.

The conclusions need to be

sound and supported by statistical

analysis.

When the accuracy of a diagnostic

test is assessed, following the

Standards for Reporting of Diagnostic

Accuracy (STARD) flow diagram

(http://www.stard-statement.

org) is suggested. A structured abstract

of 250 words, 3-5 keywords,

text upto 4,500 words, figures (up to

four figures or eight figure parts), a

maximum of six tables, a maximum

of fifty references and a maximum

of seven authors are required for

original articles.

Original articles on relative to Radiology

scientific fields, i.e. Medical

Physics, Nuclear Medicine, Radiotherapy,

Advanced image analysis/

AI and Biomedical Engineering, are

welcome for submission.

• Review Articles: The journal may

accept systematic reviews, meta

analyses and literature reviews of

a subject. An unstructured abstract

of 200 words, 3-5 keywords, text of

no more than 6,000 words, figures

(up to eight figures), a maximum

of six tables, a maximum of a hundred

references and a maximum of

three authors are required for review

articles.

• Pictorial Essays: The purpose

of pictorial essays is to provide a

teaching message through high

quality images. A brief text is required

to accompany figures. An

unstructured abstract of 200 words,

3-5 keywords, text of no more than

6,000 words, a maximum of fifteen

figures, a maximum of six tables, a

maximum of a hundred references

and a maximum of four authors are

required for pictorial essays.

• Letters to the editor: Communication

to the editor is welcome and

will be published if it offers pertinent

and/ or constructive comment

on articles published in the HjR. Let-

78

H R J

ters are published at the discretion

of the Editorial team and should be

received within three months after

on-line publication of an article.

Following acceptance, letters will

be sent to authors for response. Letter

communications should include

text of no more than 500 words, up

to two figures and ten references,

without any abstract or keywords

and a maximum of three authors.

• Clinical Case-Test Yourself:

The purpose of the “Clinical Case-

Test Yourself” manuscript is to offer

readers the chance to test their

skills in diagnosing rare disorders.

The submitted cases should contain

radiologic features that allow

a narrow differential or an accurate

diagnosis. The “Clinical Case-

Test Yourself” manuscripts are not

case reports with previously unreported

imaging findings. The format

for this manuscript consists of

two parts. Part “A” represents the

“Question” and consists of a title, a

brief clinical history (maximum 100

words) and up to five figure parts

with at least two showing pathology.

The figure legends should only

indicate the modality and should

not reveal the abnormal findings.

Part “B” represents the “Answer”

and consists of a line statement of

the diagnosis, and a discussion of up

to 1,000 words, with no more than

ten references. In Part “B” the same

figures as in Part “A” are repeated

with the addition of explanatory

legends and arrows. A maximum

of three authors is allowed.

• Commentary: Commentary articles

are based on a current hot topic

published by experts. They are published

following an invitation of the

Editorial team, should target a research

or review article and should

be received before the on-line publication

of the targeted article. Commentaries

should include a text of

no more than 800 words, up to five

references, without any abstract or

key words and a maximum of two

authors.

• Editorial: The Editorials are published

by a member of the EB upon a

special occasion or by an expert who

will address a topic of general interest

following an EB invitation. Editorials

should include a text of no

more than 1000 words, up to ten references

and up to one figure and/or

table-drawing.

7. Manuscript organisation

A manuscript must contain the following

parts for submission:

• Cover letter: Each manuscript

needs to be accompanied by a cover

letter signed by the corresponding

author on behalf of the rest of

the authors stating that the article

is not under consideration in another

journal. In case of article resubmission

a point-by-point answer to

the reviewers’ comments needs to

be submitted with the cover letter.

• Title page: It includes the title

of the manuscript, the names, affiliations

and e-mail addresses of

all authors and the affiliation, address,

e-mail address, telephone

and fax number of the corresponding

author.

The name and affiliation of the

‘guarantor’ of the study needs to be

included in the title page for original

articles.

• Blinded manuscript: Blinded title

page including only the title of

the manuscript with no affiliation.

• Abstract: An abstract presenting

the most important results and

conclusions is required for all papers

except for Letters to the Editor.

For Original Articles the abstract

needs to be structured as follows:

Purpose, Material and Methods,

Results, Conclusions.

For Reviews and Pictorial Essays, a

1-paragraph unstructured abstract

is required.

• Keywords: Below the abstract,

3 to 5 keywords are required. Keywords

need to be selected from the

Medical Subject Headings (MeSH)

database of the National Library of

Medicine.

• Text structure: the text of the

Original Articles needs to be organised

as follows: Introduction, Material

and Methods, Results and Discussion.

Review Articles and Pictorial

Essays require Introduction and

Discussion sections only.

• Fonts: The suggested font is double

spaced Times New Roman (12

pt). The text should display page

and line numbers throughout its

length.

• Abbreviations: Abbreviations

should be used as minimum as possible.

When used, they should be

defined the first time they are used,

followed by the acronym or abbreviation

in parenthesis.

• Measurement Units: All measurements

should be mentioned in

international units (SI). The full

stop should be used as a decimal

(i.e. 3.5 cm). Spaces should be added

around the plus/minus symbol (i.e.

13.6 ± 1.2). There should not be any

spaces around range indicators (i.e.

15-20) or equality/inequality symbols

(i.e. r=0.37, p<0.005).

• Acknowledgements, sponsorships

and grants: Acknowledgements

need to be placed at the end

of the manuscript before ‘References’

section. Any grant received or

sponsorship from pharmaceutical

companies, biomedical device manufacturers

or other corporations

whose products or services have

been used needs to be included in

the Conflicts of Interest Form and

also mentioned in the acknowledgements

section. If not, the phrase

“This project did not receive any

specific funding.” should appear at

the end of the text.

• Ethical approval: The name of

the Ethics Committee that approved

the study should be mentioned at

the end of the text. Depending on

the type of study (experimental investigation

on human subjects, prospective

or retrospective clinical

study with human subjects, clinical

study involving human subjects

with no access to ethics review committee,

study involving animals) appropriate

institution review board

approval or waiver, informed consent,

accordance of the Helsinki

Declaration principles or local regulatory

principles on animal experi-

79

H R J

mentation, should appear at the end

of the text. Specific details are outlined

in the section on Research ethics

and compliance.

8. Figures and Tables

All figures and tables need to be cited

in text consecutively in the order

in which they appear in text

into brackets and in Arabic numbers:

i.e. (Fig. 1) and (Table 1). Figure

parts need to be identified with

lower case letters, i.e (Fig. 1a).

Figures need to be of high quality.

Vector graphics, scanned line

drawings and line drawings need

to be in bitmap format and should

have a minimum resolution of 1,200

dpi. Halftones (photographs, drawings

or paintings) need to be in TIFF

or JPEG format, up to 174 mm wide,

up to 234 mm high and in minimum

resolution of 300 dpi.

A figure caption and a table caption

need to be added in the figure

and table section respectively for

each figure and table. Explanatory

signs (arrows, asterisks etc) should

be used when imaging findings are

not obvious. These should be white,

black or in shades of grey and proportionate

in size compared to the

size of the image. Please refrain

from using coloured signs.

Tables should appear at the end

of the main document, numbered in

Arabic numerals, each on a different

page. Each table should have a title

describing its content.

Abbreviations appearing in the

table need to be explained in a footnote.

All table columns must have a

subhead that describes the type of

data included in the column.

9. References

The accuracy of references is the responsibility

of the authors. The EB

suggests to the authors to be accurate

regarding citations and check

meticulously the correct primary

source.

References need to be cited in the

text in the order in which they appear.

The numbering needs to be in

Arabic numbers and placed in the

respective areas of text into square

brackets i.e [1].

References that have not been

published at the point of submission

need to cited with the respective

DOI (digital object identifier) number

given for on-line first articles.

All authors (surnames and initials

of first name) should be listed

when they are three or fewer. If authors

are more than three, the first

three authors should be listed, then

‘et al.’ needs to follow the name of

the third author.

When a book chapter is cited,

the authors and title of the chapter,

editors, book title, edition, city

and country, publisher, year and

specific chapter pages should be

mentioned.

For Online Document, the following

should be mentioned: authors

(if any), title of page, name of institution

or owner of Web site; URL;

dates of publication, update, and

access.

Reference examples:

Journal article:

Krokidis M, Hatzidakis A. Percutaneous

minimally invasive treatment

of malignant biliary strictures: current

status. Cardiovasc Intervent

Radiol 2014; 37(2): 316-323.

or

Krokidis M, Hatzidakis A. Percutaneous

minimally invasive treatment

of malignant biliary strictures: current

status. Cardiovasc Intervent

Radiol 2014; doi: 10.1007/s00270-

013-0693-0. Epub 2013 Jul 13.

Book chapters:

Allen G, Wilson D. Current role for

Ultrasonography. In: Karantanas A

(ed). Sports Injuries in children and

adolecents (Medical Radiology, Diagnostic

Imaging). Springer, Berlin

Heidelberg New York 2011, pp 83-97.

Online document:

National Institute for Health and

Care Excellence. SIR-Spheres for

treating inoperable hepatocellular

carcinoma. Available via nice.org.

uk/guidance/mib63. Published May

10, 2013. Updated October 2, 2013.

Accessed January 25, 2014.

10. Review of manuscripts

Revised manuscripts should be resubmitted

according to the Editor’s

letter. For accepted manuscripts,

authors need to make proof corrections

within 72 hours upon pdf

supplied, check the integrity of the

text, accept any grammar or spelling

changes and check if all the Tables

and Figures are included and

properly numbered. Once the publication

is online, no further changes

can be made. Further changes

can only be published in form of

Erratum.

11. Submission Preparation Checklist

As part of the submission process,

authors are required to check off

their submission’s compliance with

all of the following items, and submissions

may be returned to authors

that do not adhere to these

guidelines:

•The submission has not been previously

published, nor is it before

another journal for consideration

(or an explanation has been provided

in Comments to the Editor).

•The submission file is in OpenOffice,

Microsoft Word, RTF, or Word-

Perfect document file format.

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Hjr Radiology T11 Iss1

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