Drs. Maurovich-Horvat, Bosserdt, and Kofoed contributed equally to this article. This article was published on March 4, 2022, at NEJM.org.

Pelvic floor failure is a common disorder that can seriously jeopardize a woman's quality of life by causing urinary and fecal incontinence, difficult defecation, and pelvic pain. Multiple congenital and acquired risk factors are associated with pelvic floor failure, including altered collagen metabolism, female sex, vaginal delivery, menopause, and advanced age. A complex variety of fascial and muscular lesions that range from stretching, insertion detachment, denervation atrophy, and combinations of pelvic floor relaxation to pelvic organ prolapse may manifest in a single patient. Thorough preoperative assessment of pelvic floor failure is necessary to reduce the rate of relapse, which is reported to be as high as 30%. Magnetic resonance (MR) imaging of the pelvic floor is a two-step process that includes analysis of anatomic damage on axial fast spin-echo (FSE) T2-weighted images and functional evaluation using sagittal dynamic single-shot T2-weighted sequences during straining and defecation. This article presents high-resolution FSE T2-weighted MR images that permit detailed assessment of anatomic lesions and briefly describes pelvic floor pathophysiology, associated clinical symptoms, and patterns of dysfunction seen with dynamic MR imaging sequences. MR imaging is a powerful tool that enables radiologists to comprehensively evaluate pelvic anatomic and functional abnormalities, thus helping surgeons provide appropriate treatment and avoid repeat operations.

We present the case of a 67-year-old woman affected by hypertension and hypercholesterolemia. She had a history of alcoholism, anxiety disorder with panic attacks, and paroxysmal atrial fibrillation. Despite a previous transient ischemic attack and her thromboembolic risk (CHA 2 DS 2 -VASc score: 5), she had not been taking anticoagulants at home without a reasonable motivation. Moreover, around eighteen years prior, she had breast cancer and underwent surgical intervention, radiotherapy and several years of hormone-therapy. However, in the following years, she had pelvic bone metastasis needing multiple orthopaedic procedures.The patient was admitted to the Emergency Department with complaints of diarrhoea lasting one week and palpitations associated with dyspnoea in the last 24-hours.Laboratory tests showed severe hypokalaemia (2.8 meq/l), hypomagnesemia (0.4 mg/dl) and elevation, although not significant, of troponin I (0.09 ng/ml -NV ≤ 0.07).ECG showed atrial fibrillation with fast ventricular rate (140/min) and diffuse inverted T-wave, while echocardiography revealed a normal left ventricular function (EF ≈ 60%).A few hours after intravenous replacement of K + and Mg 2+ , the patient showed spontaneous restoration of sinus rhythm. However, suddenly, she became confused and developed generalized motor and non-motor seizures, causing aggravation of diarrhoea and electrolyte disorders. An urgent cerebral CT scan was performed, which excluded acute cerebral events.Contextually, the patient had severe hypotension (systolic blood pressure < 90 mmHg). A significant elevation of troponin I (34.9 ng/ ml) and lactates with low bicarbonates were detected. ECG was normal; however, the echocardiography revealed a severe left ventricular dysfunction (EF: ≈ 20%) due to akinesia of all basal segment and hyperkinesia of apex. Considering the clinical scenario and that regional wall motion abnormalities extended beyond a single epicardial vascular distribution, a basal Takotsubo syndrome (TTS) was hypothesized.After adequate refilling with bolus fluids and intravenous replacement of bicarbonates and electrolytes, the hemodynamic status improved.Simultaneously, in the following 48-hours neurologists tried multiplies oral and intravenous antiepileptics drugs (oxcarbazepine, levetiracetam, sodium valproate and phenytoin) without success, suggesting a non-convulsive status epilepticus, which was confirmed by electroencephalogram ( Fig. 1A). Finally, a deep sedation with propofol was induced and the patient was assisted by mechanical ventilation. In the following days, we assisted in the resolution of the cardiological and neurological states, and the patient was then extubated.

Objectives Forty sites were involved in this multicenter and multivendor registry, which sought to evaluate indications, spectrum of protocols, impact on clinical decision making and safety profile of cardiac magnetic resonance (CMR). Materials and methods Data were prospectively collected on a 6-month period and included 3376 patients (47.2 ± 19 years; range 1-92 years). Recruited centers were asked to complete a preliminary general report followed by a single form/patient. Referral physicians were not required to exhibit any specific certificate of competency in CMR imaging. Results Exams were performed with 1.5 T scanners in 96% of cases followed by 3 T (3%) and 1 T (1%) magnets and contrast was administered in 84% of cases. The majority of cases were performed for the workup of inflammatory heart disease/cardiomyopathies representing overall 55.7% of exams followed by the assessment of myocardial viability and acute infarction (respectively 6.9% and 5.9% of patients). In 49% of cases the final diagnosis provided was considered relevant and with impact on patient's clinical/therapeutic management. Safety evaluation revealed 30 (0.88%) clinical events, most of which due to patient's preexisting conditions. Radiological reporting was recorded in 73% of exams. Conclusions CMR is performed in a large number of centers in Italy with relevant impact on clinical decision making and high safety profile. © 2013 Elsevier Ireland Ltd