The objective of this study was to describe CT findings and to determine the diagnostic value of CT in diagnosis of acute mediastinitis. CT findings were retrospectively studied in 40 patients with suspected acute mediastinitis, including 28 postoperative patients, five with acute descending necrotizing mediastinitis (ADNM), and seven with suspected post-traumatic perforation of the esophagus. Findings included increased attenuation of mediastinal fat (100%), localized mediastinal fluid collections (55%), free gas bubbles in the mediastinum (57.5%), mediastinal lymph nodes (35%), pericardial effusions (27.5%), pleural effusions (85%), lung infiltrates (35%), sternal dehiscence (40%), and pleuromediastinal fistula (2.5%). The sensitivity and specificity of CT in postoperative patients in the first 17 days was 100% and 33% respectively, and after day 17, 100% and 90%. In patients with ADNM sensitivity was 100% while in patients with suspected esophageal perforation sensitivity and specificity were 100%. CT is a highly sensitive technique for the detection of mediastinitis of various causes. For the postoperative patients there is clear time dependence for CT interpretation and accuracy. In patients with suspected ADNM, and traumatic esophageal perforation CT is highly specific early after clinical presentation.

MRI is of only limited diagnostic performance, while BIPSS is the most accurate way to establish the diagnosis of CD. The routine use of a multimodality diagnostic approach including BIPSS, MRI, and biochemical tests is suggested to avoid the risk of mismanagement for patients with CS.

Contrast-enhanced ultrasound (CEUS) is an imaging technique with various indications, most of which refer to scheduled examinations. However, CEUS can also be performed under urgent conditions for the investigation of many different clinical questions. This article reviews basic physics of ultrasound contrast agents and examines the commonest urgent clinical applications of CEUS. These include, among others, abdominal solid organ trauma and infarcts, scrotal and penile pathology and blood vessel imaging. Patients can be examined with a very short time delay at their bedside, without exposure to ionising radiation or risk of anaphylactic reaction and renal failure, while contraindications are minimal. CEUS technique is described for various urgent indications and imaging examples from our department’s experience are presented. Safety matters and limitations of CEUS are also mentioned.Teaching PointsContrast-enhanced ultrasound (CEUS) can be performed urgently for various clinical applications.Abdominal indications include solid organ trauma and infarcts.CEUS in abdominal organ trauma correlates well with CT and can replace it for patient follow-up.CEUS images testicular torsion, infection and infarction, as well as testicular and penile trauma.Blood vessels can be assessed with CEUS for obstruction, aneurysm, thrombosis and dissection.

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Angiosarcoma is a rare soft tissue highly malignant tumor of vascular origin, accounting for only 1% to 2% of these tumors. We present a rare case of De novo (unrelated to irradiation or pyothorax) angiosarcoma of the thoracic outlet with a 10-year disease free survival. Α 49-year-old male was admitted to our department due to a tumor of the thoracic outlet referred by the neurologists to whom he addressed complaining for vertigo and instability. After a thorough examination including chest X-ray, CT scan and MRI, a well circumscribed vascularized lesion of a diameter of 5cm was detected in the thoracic outlet. A head and neck angiography was performed along with a full staging in order to exclude metastatic disease. The patient was submitted to high axillary thoracotomy. The adjacent structures were dissected, small arterioles arising from the subclavian artery, neo-vessels were ligated or cauterized and the soft largely encapsulated tumor was excised. Gross observation of the resected specimen demonstrated a regular-shaped neoplasm. Histology revealed a well differentiated angiosarcoma comprised of multiple anastomosing blood vessels lined by endothelial cells showing malignant features but with little nuclear pleomorphism. The recovery was uneventful. The patient did not receive postoperative radiation or chemotherapy and 10 years postoperatively is free of disease. In conclusion, de novo primary pleural angiosarcoma are rare entities that should not be misdiagnosed. The immunohistochemical examination is the key for diagnosis and will offer the definite histotype. Although the prognosis is bad, early detection will give the patient the best chance for successful surgical treatment. Our patient being well and asymptomatic after 10 years follow-up represents a rare case and the first mentioned in the literature with a location of the lesion in the thoracic outlet.