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Journal de radiologie
Vol 78, N° 11  - novembre 1997
p. 1201
Doi : JR-11-1997-78-11-0221-0363-101019-ART78
 

Revue bibliographiqueJR 432 J Radiol 1997; 78 : 1201-1206.

© Editions françaises de radiologie, Paris, 1997.

DIGESTIF

Differenctiation of achalasia from pseudoachalasia by computed tomography.

Michele Carter, C Deckmann, RC Smith,
MI Burrell, M Traube

Departments of Internal Medicine and Diagnostic Radiology, Yale University School of Medicine, New Haven , Connecticut.

The American Journal of Gastroenterology 1997, 92, n° 4.

Objectives. The purpose of this study was to determine the computed tomography (CT) findings in idiopathic achalasia and in the pseudoachalasia of malignancy.

Methods. We identified 12 patients with the manometric diagnosis of achalasia who also had CT scans available for review: eight had idiopathic achalasia, and four had pseudoachalasia. As controls, we selected nine patients with endoscopically obvious esophageal cancer who also had CT scans. The CT scans were blindly reviewed to determine esophageal wall thickness, symmetry of the esophageal wall, presence of esophageal dilation or mass, and a radiological diagnosis.

Results. Six of the eight patients with achalasia had a dilated esophagus. Five had symmetric wall thickening >5 mm (range 7-10 mm) at the gastroesophageal junction. One patient with a 10-mm wall thickening was incorrectly diagnosed with a mass. All others were correctly diagnosed with achalasia. Three of the four patients with pseudoachalasia had esophageal dilation. Two had an obvious esophageal mass. The other two were given an indefinite diagnosis: one had asymmetric wall thickening (11 mm) at the gastroesophageal junction, and the other had symmetric thickening of 18 mm. Eight of the nine patients with obvious esophageal cancer had a mass on CT; the other patient had asymmetric wall thickening of 6 mm at the gastroesophageal junction and was given an indefinite diagnosis.

Conclusions. Most achalasia patients have CT findings of esophageal dilation and mild, symmetric wall thickening. Therefore, symmetric esophageal wall thickening (<10 mm) should not dissuade one from the diagnosis of achalasia. Most pseudoachalasia patients have CT findings of esophageal dilation, more marked and/or asymmetric wall thickening, or mass. In this group, asymmetric or marked thickening (>10 mm) indicated pseudoachalasia. Therefore, CT can be helpful in differentiating between achalasia and the pseudoachalasia of malignancy.

Computed tomography in acute left colonic diverticulis.

P Ambrosetti, M. Grossholz, C Becker, F Terrier, Ph Morel

Clinique de Chirurgie Digestive, University Hospital, Geneva, Switzerland.

British Journal of Surgery 1997; 84 : 532-534.

Background. The use of computed tomography (CT) in acute left colonic diverticulis remains controversial. The purpose of this study was to define the value of CT both during the acute phase of inflammation and, later, to indicate secondary complications after successful medical treatment.

Methods. Some 43 patients with radiologically or histologically proven diverticulis were studied prospectively from 1986 to 1995. Diverticulis was considered moderte when CT showed localized thickening of the colonic wall (5 mm or more) and inflammation of pericolic fat; it was considered severe when abscess and/or extraluminal air and/or extraluminal contrast were observed.

Results. The sensitivity of CT was 97 per cent. Of 42 patients who failed conservative treatment, 32 had severe diverticulis on CT, compared with 74 (24 per cent) of 303 who had successful conservative treatment (P <0.0001). After a median follow-up of 46 months, 60 (20 per cent) of 300 patients had secondary complications despite initially successful conservative treatment: 28 (47 per cent) of these had initial severe diverticulis on CT compared with 44 (19 per cent) of 236 patients who had non complications (P <0.0001).

Conclusion. Abscess formation and extracolonic contrast or gas are findings that may be used to predict failure of medical treatment during the first admission and a high risk of secondary complications after initially successful medical management of acute diverticulis.

Intravenous cholangiography before 1000 consecutive laparoscopic cholecystectomies.

P Berggren, I Farago, N Gabrielsson, K Thor

Department of Surgery, Ersta Hospital, Box 4622, S-11691 Stockholm, Sweden.

British Journal of Surgery 1997; 84 : 472-476.

Background. The advent of laparoscopic cholecystectomy has resulted in an increase in common bile duct (CBD) injuries. Routine intraoperative cholangiography has been advocated to prevent these injuries. This study describes an alternative management strategy applied to a consecutive series of 1000 patients having laparoscopic cholecystectomy.

Methods. In patients with no history of contrast allergy and no suspicion of CBD stones, preoperative intravenous cholangiography (IVC) was performed routinely. Patients with suspected or detected CBD stones were referred for endoscopic retrograde cholangiography. This strategy was supplemented by selective intraoperative cholangiography.

Results. Overall 782 of the 1000 patients has successful preoperative IVC, allowing detecion of 30 CBD stones and providing useful information about anatomical variation in CBD anatomy. Patients with inconclusive IVC studies, or those with a history of contrast allergy, had intraoperative cholangiography, which demonstrated a further 19 CBD stones. There were no contrast reactions and no damage to the biliary system which might have been obviated by intraoperative cholangiography. In the 724 patients who did not require complimentary intraoperative cholangiography, there has been no clinical evidence of missed CBD stones.

Conclusion. Routine preoperative IVC, with reservation of intraoperative cholangiography for indeterminate IVC examinations or the need for anatomical clarification, is a safe strateg for laparoscopic cholecystectomy.

Dilatation kystique congénitale de la voie biliaire principale.

M Vullierme, V Vilgrain, M Zins et al.

Service de Radiologie, Hôpital Beaujon, 100, boulevard du Général-Leclerc, F-92110 Clichy.

Gastroenterol Clin Biol 1997; 21 : 201-208.

Objectifs. Le but de cette étude était de confronter les résultats de l'évaluation radiologique en cas de dilatation kystique congénitale de la voie biliaire principale aux données chirurgicales et anatomo-pathologiques, afin de déterminer la meilleure stratégie et prise en charge préopératoire des malades.

Méthodes. Nous avons étudié rétrospectivement 14 malades ayant tous été opérés. L'exploration radiologique comprenanit 20 échographies, 13 tomodensitométries, 8 écho-endoscopies, 10 cholangio-pancréatographies rétrogrades endoscopiques, 3 cholangiographies trans-hépatiques, et 11 cholangiographies per-opératoires. Une confrontation radio-chirurgicale du type morphologique, selon la classification de Todani et al., et de l'aspect de la jonction bilio-pancréatique, une confrontation radio-anatomique concernant la paroi du kyste et la vésicule biliaire, et des complications, en particulier la cancérisation, étaient effectuées.

Résutats. Les kystes étaient de type Ia (n = 2), Ib (n = 1), Ic (n = 4), IVa (n = 5) et IVb (n = 2). La corrélation radioanatomique était excellente pour le siège de l'atteinte et assez bonne pour l'extension en hauteur. Une anomalie de la jonction bilio-pancréatique était identifiée dans 4 cas par cholangiographie per-opératoire et dans un cas uniquement par cholangio-pancréatographie rétrograde endoscopique; la jonction bilio-pancréatique n'était pas analysable en pré- ou per-opératoire dans 7 cas. Des calculs étaient présents dans la vésicule biliaire dans deux cas, dans la voie biliaire principale dans deux cas, et dans les voies biliaires intra-hépatiques dans un cas; l'échographie les a toujours diagnostiqué. Deux cas de cancérisation étaient observés : l'un, qui n'avait pas été diagnostiqué radiologiquement ou au cours de l'intervention, dans la partie basse du canal cholédoque lors del'examen anatomopathologique; l'autre, de siège intra-hépatique, avait été diagnostiqué par la tomodensitométrie et confirmé par l'examen histologique de la pièce de résection.

Conclusion. En cas de dilatation kystique congénitale de la voie biliaire principale, l'échographie et la tomodensitométrie permettent le plus souvent de faire le diagnostic et le bilan d'extension intra-hépatique et des complications. L'opacification biliaire, rétrograde ou per-opératoire, est indispensable au bilan d'extension à la convergence et à l'étude de la jonction bilio-pancréatique.

GYNÉCOLOGIE

Magnetic resonance imaging in the treatment planning of radiation therapy in carcinoma of the cervix treated with the four-field pelvic technique.

L Thomas, B Chacon, M Kin et al.

Department of Radiotherapy, Institut Bergonié, Regional Cancer Center, 180, rue de Saint-Genès, 33076 Bordeaux Cedex, France.

Int. J. Radiation Oncology Biol. Phys 1997; 37, 4 : 827-832.

Purpose. To evaluate magnetic resonance imaging (MRI) in the planning of radiation therapy for patients with carcinoma of the cervix treated with a four-field technique.

Methods and materials. Between May 1994 and February 1995, 18 patients with carcinoma or the cervix were entered in the study (1 T1 N­; 2 T2a N­; 1 T2b NO; 10 T2b N­; 2 T2b N+; 2 T3b N+). Node status was assessed by a laparoscopic pelvic lymphadenectomy. During the first step, all the patients were simulated with an isocentric four-field pelvic technique. In one group (11 patients) simulation was done based on clinical examination, computed tomography (CT), and standard guidelines. In the second group (seven patients) simulation was based on clinical examination, CT, and with the help of diagnostic MRI, which was available at that time. During the second step, MRI in tre atment position with skin markings of the isocenter of the radiation fields was then performed in every patient. During the third step, in each patient, the simulated radiation fields were correlated with the MRI defined target volume by superimposing them on midsagittal and midcoronal MR images. The adequacy of the margins was arbitrarly defined as 1 cm around the MRI defined target volume (tumor of the cervix and its extension, and uterus).

Results. In the first group (11 patients), MRI in treatment position led to a change in 7 patients: six inadequate margins in the lateral fields and one in the anterior and lateral field. In almost all the cases, the adjustments were of an increase of 10 mm, equally matched between the anterior and posterior borders of the lateral fields. In the second group (seven patients), MRI in treatment position has led to a change in lateral fields in five patients. The mean adjustment was 10 mm: four increases (two anterior border, one posterior border, one anterior and posterior border), and one decrease of the posterior border. In the two groups, modifications of the anterior border of te lateral fields have allowed adequate margins around the uterine fundus and modifications of the posterior border have allowed adequate coverage of the cervical tumor.

Conclusion. When treating carcinoma of the cervix with a four-field radiation technique, standard portals do not exist. The design of lateral fields has to be based on individual morbid anatomy, which is given accurately by diagnostic MRI. Magnetic resonance imaging in treatment position assesses the design of simulated lateral fields.

OBSTÉTRIQUE

Assessment of fetal thyroid function by colored doppler echography.

D Luton,, D Fried, OSibony et al.

Service de gynécologie-obstétrique, Hôpital Robert-Debré, 48, boulevard Sérurier, F 75019 Paris .

Fetal Diagn Ther 1997; 12 : 24-27.

Background. The association of hyperthyroidism and pregnancy is a rare but serious condition which can jeopardize fetal outcome. Classical follow-up relies on: serial clinical and echographic assessment; serial funipuncture to determine fetal thyroid status, and maternal propylthiouracil (PTU) treatment to treat fetal and/or maternal hyperthyroidism.

Case. We report the case of a euthyroid patient with Graves' disease who had already been delivered of two hyperthyroid fetuses; the present pregnancy revealed a hyperthyroid fetus diagnosed by funipuncture. Echography showed a fetal goiter at 28 weeks of gestation (WG) with important signal on colored Doppler echography. We observed an extinction of this signal as maternal PTU treatment was intensified. The patient was delivered of a mildly hyperthyroid newborn at 37 WG. Both newborn and patient are doing well.

Conclusion. Fetal thyroid assessment by colored Doppler echography could help in the management of fetal thyroid dysfunction.

NEUROLOGIE

A new leukoencephalopathy with vanishing white matter.

MS van der Knaap, PG Barth, FJM Gabreëls et al.

Department of Child Neurology, Free University Hospital, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.

Neurology 1997; 48 : 845-855.

We identified nine children with a leukoencephalopathy of similar type according to clinical and MRI findings. The patients included three affected sibling pairs. The age range was 3 to 19 years. The onset of the disease was infections and minor head traumas, and these could result in unexplained coma. In eight patients with advanced disease, MRI revealed a diffuse cerebral hemispheric leukoencephalopathy, in which increasing areas of the abnormal white matter had a signal intensity close to that of CSF on all pulse sequences. In one patient in the early stages of disease, initial MRI showed diffusely abnormal cerebral white matter, which only reached the signal characteristics of CSF at a matter showed an almost complete disappearance of all normal signals and the presence of glucose and lactate, compatible with the presence of mainly CSF and little brain tissue. Spectra of the cortex were much better preserved. However, in addition to the normal resonances, there were signals representing lactate and glucose. MRS of the white matter in the patient whose disease was at an early stage was much less abnormal. Autopsy in one patient confirmed the presence of extensive cystic degeneration of the cerebral white matter with reactive change and a preserved cortex. Typical involvement of pontine tegmental white matter was suggested by RMI and confirmed by autopsy. The disease probably has an autosomal recessive mode of inheritance, but the basic metabolic defect is not known.

Magnetic resonance imaging : utilization in the management of central nervous system trauma.

JS Nichols, C Elger, L Hemminger et al.

InterMountain Neurosurgery & Neuroscience, 4200 W. Conejos Pl., #410, Denver, CO 80204.

The Journal of Trauma: Injury, Infection and Clinical Care 1997, 42, 3.

Objective. To determine the availability, use, and perceived value of magnetic resonance imaging (MR) in the management of acute central nervous system (CNS) trauma in United States Level I (or equivalent) trauma centers (TCs).

Design, Materials and Methods. One hundred sixty-nine Americain College of Surgeons, state or locally designated Level I (or equivalent) TCs were identified using compiled lists and telephone contacts. Surveys about MR use in CNS trauma were mailed to each institution. Follow-up telephone calls were made to nonresponding institutions. Data were analyzed using frequency distribution.

Measurements. Using returned questionnaires from trauma directors and follow-up telephone contacts, data on the physical location, technologist availability, and patient monitoring capabilities were accrued. The questionnaire addressed the perceived value and cost-effectiveness of MR for acute CNS trauma in general, distinguishing between spinal cord and traumatic brain injury, using a Likert-type rating scale.

Main Results. One hundred nine (65%) of identified TCs responded by mail. Sixty (33%) required contact by telephone. One hundred fifty-two (93%) reported MR scanners "on site". Five of seven TCs without on-site MR had facilities within 5 miles. No TC reported the inability to obtain MR scans. Seventy-four percent of TCs reported MR angiography capabilities. Ninety-seven percent of MR facilities were staffed 24 hours per day, 83% by on-call, out-of-hospital technologists at night and on weekends. TCs reported patient monitoring capabilities including cardiac monitoring (83%) and pulse oximetry (91%). Seventy-one percent reported the ability to scan intubated patients. Forty-five percent of TCs "rarely" use MR, 51% report "occasional" use, and 4% "frequently" use MR for acute trauma. Ninety-four percent of trauma directors agreed or strongly agreed that MR directed management and was cost-effective for spinal cord trauma. Fifty-four percent agreed or strongly agreed that MR directed management and was cost-effective for traumatic brain injury. No correlation existed between perceptions of MR applicability in CNS trauma and the number of trauma admissions or on-site availability.

Conclusions. Most trauma directors consider MR important in the acute evaluation of spinal trauma and, to a lesser extent, for traumatic brain injury. Despite these opinions, the vast majority of these centers reported only "rare" to "occasional" use of MR in the setting of acute CNS trauma. Our results show that most TCs have on-site and continuously available MR facilities capable of cardiac and pulmonary monotoring. Other factors such as the higher relative cost of MR may be responsible for the discrepancy between the perceived value and the actual utilization of MR imaging in the setting of CNS trauma.

High signal intensity on T2-Weighted magnetic resonance imaging and cerebral hemodynamic reserve in carotid occlusive disease.

Y Isaka, K Nagano, M Narita, K Ashida,
M Imaizumi

Department of Nuclear Medicine, Osaka National Hospital, Hoenzaka 2-1-14, Chuo-ku, 540, Osaka, Japan.

Stroke 1997; 28 : 354-357.

Background and Purpose. The importance of MR imaging in carotid artery disease is unclear. We evaluated the sensitivity and specificity of the high signal intensity changes on MR images for diagnosis of hemodynamically compromised unilateral internal carotid artery disease.

Methods. We evaluated the association of high signal intensities on T2-weighted MR images with changes in cerebral perfusion reserve measured using 99mTc-hexamethylpropyleneamine oxime single-photon emission CT an acetazolamide in 23 patients.

Results. Eleven patients had a type I response (normal flow and normal perfusion reserve), 8 patients had a type II response (normal flow and decreased perfusion reserve), and 4 patients had a type III response (decreased flow and decreased perfusion reserve). High signal intensities in the centrum semiovale (11/12) and/or posterior periventricular white matter (6/12) were frequently seen in the hemodynamically compromised groups. Extensive high signal intensities were associated with severely impaired cerebral circulation. MR imaging had high sensitivity (0.92) and specificity (1.0) in predicting hemodynamically compromised patients when we used the presence of T2 high intensity in the centrum semiovale as a criterion.

Conclusions. The centrum semiovale T2 hypertensities lateralized to the side of carotid occlusion are specific and sensitive for the presence and severity of hemodynamic compromise from carotid occlusive disease.

Correlation of clinical, magnetic resonance imaging, and cerebrospinal fluid findings in optic neuritis.

Djacobs, SE Kaba, CM Miller, RL Priore,
M Brownscheidle

Department of Neurology, Buffalo General Hospital, 100 High Street, Buffalo, NY 14203.

Ann Neurol 1997; 41 : 392-398?

We found 42 of 74 patients (57%) with isolated monosymptomatic optic neuritis to have 1 to 20 brain lesions, by magnetic resonance imaging (MRI). All of the brain lesions were clinically silent and had characteristics consistent with multiple sclerosis (MS). None of the patients had ever experienced neurologic symptoms prior to the episode of optic neuritis. During 5.6 years of follow-up, 21 patients (28%) developed definite MS on clinical grounds. Sixteen of the 21 converting patients (76%) had abnormal MRIs; the other 5 (24%) had MRIs that were normal initially (whan they had optic neuritis only) and when repeated after they had developed clinical MS in 4 of the 5. Of the 53 patients who have not developed clinically definite MS, 26 (49%) have abnormal MRIs and 27 (51%) have normal MRIs. The finding of an abnormal MRI at the time of optic neuritis was significantly related to the subsequent development of MS on clinical grounds, but interpretation of the strength of that relationship must be tempered by the fact that some of the converting patients had normal MRIs and approximately half of the patients who did not develop clinical MS had abnormal MRIs. We found that abnormal IgG levels in the cerebrospinal fluid correlated more strongly than abnormal MRIs with the subsequent development of clinically definite MS.

Diagnosis of brain abscess by magnetic resonance spectroscopy. Report of two cases

I MartÍnez-Pérez, Á Moreno, J Alonso et al.

Department of Biochemistry and Molecular Biology, Autonomous University of Barcelona, Spain.

J Neurosurg 1997; 86: 708-13.

Two cases of brain abscess were diagnosed by combining magnetic resonance spectroscopy (MRS) and magnetic resonance (MR) imaging. The resonances observed in vivo were assigned by means of an in vitro MRS study of the exudates extracted during surgical aspiration of the abscesses. The technique of MRS was demonstrated to be very powerful in the differential diagnosis of brain abscesses from other brain pathologies such as neoplasms. Amino acids, probably originating from extracellular proteolysis, and other compounds, such as acetate, arising from bacterial metabolism, were visible in the MRS spectra of the abscess, whereas they are not present in spectra of neoplasms. In this sense, MRS complemented the information provided by MR imaging to achieve a correct diagnosis of brain abscesses and could be added to routine MR examinations with only a small increase in cost and time.

Magnetic resonance imaging of obliterated arteriovenous malformations up to 23 years after radiosurgery

L Kihlström, W-Y Guo, B Karlsson et al.

Departments of Neurosurgery and Neuroradiology, Karolinska Hospital, Stockholm, Sweden.

J Neurosurg 1997; 86: 589-93.

The authors report outcomes in 18 patients with arteriovenous malformations (AVMs) who were treated with gamma knife radiosurgery and in whom magnetic resonance (MR) imaging was obtained a mean of 14 years (range 8-23 years) after treatment and 10 years (range 4-17 years) after confirmed obliteration of the AVM. All patients were asymptomatic after radiosurgery and during the time of the study. In five patients (28%), cyst formation was observed that corresponded to the site of the obliterated AVM. Cyst formation and contrast enhancement on MR imaging could not be statistically correlated to the radiation dose. In 11 (61%) of the 18 patients, contrast enhancement that was not related to a recanalization of the nidus was observed in the target area. In three patients (17%), an increased t2-weighted signal was detected at the site of previous AVM; this was interpreted as gliosis or demyelination, which appeared to be dose dependent. The study illustrates that cyst formation, contrast enhancement, and an increased t2-weighted signal can be observed in asymptomatic patients in the area that was targeted for AVM radiosurgery up to 23 years after the procedure. The report provides new and essential information about long-term effects on normal tissue after radiosurgery and provides a basis for the interpretation of MR studies in the follow up of small AVMs treated by radiosurgery.

PÉDIATRIE

Use of abdominal ultrasonography to assess pediatric splenic trauma.

AS Krupnick, DH Teitelbaum, JD Geiger et al.

Department of Surgery, Section of Pediatric Surgery and the Department of Radiology, the University of Michigan Medical Center and the C.S. Mott Children's Hospital, An Arbor, Michigan.

Annals of Surgery 1997; 225, 4, 408-414.

Objective. The purpose of this study was to evaluate the accuracy of abdominal ultrasonography (US) for screening and grading pediatric splenic injury.

Summary background data. The use of abdomianl US has increased rapidly as a method of evaluating organ damage after blunt abdominal trauma. Despite US's increasing use, little is known about its accuracy in children with splenic injury.

Methods. Children (N = 32) suffering blunt abdominal trauma who were diagnosed with splenic injury by computerized tomography (CT) scan prospectively were enlisted in this study. Degree of splenic injury was evaluatied by both CT and US. The ultrasounds were evaluated by an initial reading as well as by a radiologist who was blinded as to the results of the CT.

Results. Twelve (38%) of the 32 splenic injuries found on CT were missed completely on the initial reading of the US. When the ultrasounds were graded in a blinded fashion, 10 (31%) of the splenic lacerations were missed and 17 (53%) were downgraded. Seven (22%) of the 32 splenic fractures were not associated with any free intraperitoneal fluid on the CT scan.

Conclusions. This study has shown that US has a low level of sensitivity (62% to 78%) in detecting splenic injury and downgrades the degree of injury in the majority of cases. Reliance on free intraperitoneal fluid may be inaccurate because not all patients with splenic injury have free intra-abdominal fluid. Based on these findings, US may be of limited use in the initial assessment, management, and follow-up of pediatric splenic trauma.

PRODUITS DE CONTRASTE

Effects of contrast media and mannitol on renal medullary blood flow and red cell aggregation in the rat kidney.

P Liss, A Nygren, U Olsson, HR Ulfendahl,
U Erikson

Department of Diagnostic Radiology, University Hospital; Department of Physiology and Medical Biophysics, University of Uppsala; and Department of Statistics, Swedish University of Agricultural Sciences, Uppsala, Sweden.

Kidney International 1996; 49 : 1268-1275.

Hemodynamic factors may play a role in the development of acute renal failure following administration of contrast media (CM). In this study the effects of intravenous injection of contrast media and mannitol on red blood cell velocity (VRBC) and red blood cell aggregation in renal medullary vessels was studied in 58 rats. Renal medullary blood flow was investigated by a cross-correlation technique and by a visual aggregation score. The CM, namely diatrizoate, iopromide, iohexol, ioxaglate, iotrolan, were given in iodine equivalent doses (1600 mg/kg body wt). Mannitol (950 mOsm/liter) and Ringer's solution were used as controls. The same vessels were studied 30 minutes before and 30 minutes after injections. VRBC decreased significantly after injection of diatrizoate, iopromide, iohexol, iotrolan and mannitol. Tinger's solution and ioxaglate did not significantly alter medullary blood flow, while iotrolan and mannitol caused the largest decreased in VRBC. All CM and mannitol caused both red cell aggregation and cessation of blood flow. The decrease in blood flow and increase in red blood cell aggregation after injection of CM and mannitol may partly explain the occurrence of contrast medium-induced acute renal failure.

Clinical safety of serial monthly administrations of gadopentetate dimeglumine in patients with multiple sclerosis : implications for natural history and early-phase treatment trials.

RM Tresley, LA Stone, N Fields, H Maloni,
H McFarland, JA Frank

National Institutes of Health, Building 10, Room B1N256, 9000 Rockeville Pike, Bethesda, MA 20892-1074.

Neurology 1997; 48 : 832-835.

Serial contrast magnetic resonance imaging (MRI) has played an increasingly important role in understanding natural-history and early-treatment trials of multiple sclerosis patients. The purpose of this study is to determine whether the serial administration of gadopentetate dimeglumine at the conventional dose has any demonstrable effect on routine hematologic or serum chemistries. This study followed 56 patients with multiple sclerosis in a longitudinal natural-history trial using contrast-enhanced MRI scans over a four-year period between 1988 and 1993. Patients received between 3 and 53 doses of gadopentetate dimeglumine at 0.1 mmol/kg intravenously. A retrospective review of regular blood screening tests over this period identified no significant effect either on routine hematologic studies, as defined by complete blood count (hemoglobin, hematocrit, platelet and white blood cell counts, and mean corpuscular volume); standard serum chemistry studies, including electrolytes (sodium, potassium, chloride) and renal and liver function tests; or serum iron profiles. We conclude, therefore, that serial contrast-enhanced MRIs can be used safely as an outcome measure for Phase I/II evaluations of new therapies for multiple sclerosis.

RACHIS

Three-dimensional computed tomographic imaging in the diagnosis of vertebral column trauma : experience based on 21 patients and review of the literature.

M Domenicucci, R Preite, A Ramieri, MF Osti, P Ciappetta, R Delfini

Clinica Ortopedica e Traumatologica, Università degli Studi di Roma, "La Sapienza", Piazzale Aldo Moro 3-5, C.A.P. 00185, Rome, Italy.

The Journal of Trauma: Injury, Infection, and Critical Care 1997; 42, 2.

Objective. To compare standard x-ray films, two-dimensional computed tomographic reconstructions and three-dimensional (3-D) computed tomographic reconstructions for assessing the grade, extent, and severity of vertebral fracture.

Patients and Methods. 3-D images were created from standard computed tomographic scans obtained using a General Electric PACE scanner. In 21 patients (17 men and four women) these images were obtained during both the acute phase and at longterm follow-up; there were six cervical, four dorsal, five dorso-lumbar, and six lumbar fractures.

Results. The 3-D images supplied useful information in complex traumas with rotation and/or dislocation of the vertebral body and in cases with loss of spinal alignment. The 3-D images also proved to be useful as an adjunctive imaging method for evaluation of bone fusion integrity.

Conclusion. 3-D images produced by recently available, software provide a 3-D understanding much more readily than do multiple two two-dimensional images. Because it would be very difficult to standardize this method of imaging, it seems best that the specialist (orthopedic surgeon, neurosurgeon, neuroradiologist) be present during the investigation to decide the viewing angles. An important limitation to this method is the presence of degenerative disease or osteoporosis, mainly in elderly patients.

Presurgical identification of extradural nerve root anomalies by coronal fat-suppressed magnetic resonance imaging : a report of six cases and a review of the literature.

Y Aota, Y Saito, K Yoshikawa, T Asada,
S Kondo, KI Watanabe

Department of Orthopaedic Surgery, Miura Municipal Hospital, 4-33 Koyo-Cho, Miura-city, Kanagawa, Japan 238-02.

Journal of Spinals Disorders 1997; 10, 2 : 167-175.

In a attempt to depict the anatomy of the nerve roots, we obtained magnetic resonance (MR) images of the lumbar spine in the coronal plane with the frequency-selective fat-suppression technique. With this technique, extradural anomalies were identified in 20 (6.7%) of 300 patients. We report the appearance on coronal MR images of six surgically confirmed extradural anomalous nerve roots together with the myelography findings. These include type Ia, type Ib, and type 3 anomalies. These are readily recognized and allow detailed evaluation of the type of nerve root anomaly.

Vertebral lesions associated with palmoplantar pustulosis.

H Baba, K Uchida, M Wada, S Imura, N Kawahara, K Tomita

Department of Orthopaedic Surgery, Fukui Medical School, Shimoaizuki 23, Matsuoka, Fukui 910-11, Japan.

International Orthopaedics (SICOT) 1997; 21: 19-24.

Revue de 9 patients présentant des lésions vertébrales associées à une pustulose palmo-plantaire. Il s'agissait de 3 hommes et 6 femmes avec une maladie évoluant en moyenne depuis 4,8 ans. Des lésions cervicales ont été trouvées 3 fois, et des lésions lombo-sacrées 7 fois. 7 patients avaient des lésions hyperostosiques de la ceinture scapulaire, ce qui est classique, et tous présentaient un syndrome biologique inflammatoire. Les lésions vertébrales étaient une spondylodiscite 4 fois, une syndesmophytose d'un niveau 1, 1 fois, une hyperostose étendue 4 fois et une vertèbre ivoire 1 fois. 5 patients ont eu un traitement conservateur et 4 qui présentaient une spondylodiscite ont été opérés par curetage et arthrodèse vertébrale antérieure. Au dernier recul, tous les patients ont eu une amélioration tant de la symptomatologie vertébrale que des lésions cutanées et 5 peuvent être considérés comme guéris : les 4 opérés pour spondylodiscite et 1 opéré par amygdalectomie. Les lésions vertébrales associées à la pustulose palmo-plantaire sont variables mais si elles sont d'évolution rapide, le traitement chirurgical est utile pour l'amélioration du syndrome cutanéo-vertébral.

SÉNOLOGIE

Patterns of mammographically detected calcifications after breast-conserving therapy associated with tumor recurrence.

DD Dershaw, CS Giess, B McCormick et al.

Department of Radiology, Memorial Hospital, 1275 York Avenue, New York, NY 10021.

Cancer 1997; 79 : 1355-61.

Background. Some authors have suggested that mammographically evident calcifications that would be considered benign in other situations can be due to carcinoma in women who have undergone breast conservation. This study was undertaken to determine if the pattern of calcifications associated with recurrent tumors detected mammographically differs from that observed in carcinomas developing de novo.

Methods. Mammograms of 22 cases of local tumor recurrence were retrospectively reviewed, and calcifications associated with recurrence were characterized according to the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS) classification.

Results. Tumors were usually associated with >=10 calcifictions (77%; 17 of 22 cases). Recurrences commonly contained very suspicious patterns of calcifications with linear forms present in 15 cases (68%) and pleomorphic calcifications with linear forms present in 15 cases (68%) and pleomorphic calcifications present in 17 cases (77%). The distribution of calcifications was usually clustered (73%; 16 of 22 cases) or segmental (18%; 4 of 22 cases). Recurrences were usually obviously malignant (BI-RADS Category 5), and were characterized as such in 77% of cases. The remainder were indeterminate, requiring biopsy (BI-RADS Category 4). Recurrent tumors containing calcifications always contained some suspicious forms. Less worrisome types of calcifications were sometimes observed, including punctate calcifications in 36% and coarse calcifications in 14% of cases, but were always associated with more malignant patterns.

Conclusions. Local tumor recurrences, when associated with mammographically evident calcifications, usually have a pattern highly suspicious for malignancy, although indeterminate forms can be the only calcifications present. Characteristically benign patterns of calcifications are not observed in recurrent tumors unless they are associated with more suspicious calcifications. Therefore, women without more worrisome patterns need not undergo biopsy because of the presence of these nonworrisome calcifications.

TÉLÉRADIOLOGIE

The impact of teleradiology on the inter-hospital transfer of neurosurgical patient.

KYC Goh, CK Lam, WS Poon

Neurosurgical Unit, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong.

British Journal of Neurosurgery 1997; 11 (1) : 52-56.

The aim of this study was to examine the role of teleradiology in the management of inter-hospital transfer of neurosurgical patients, especially in terms of safety and early therapeutic interventions. Data were collected prospectively, comparing events during the inter-hospital transfer of patients from a district general hospital to a tertiary neurosurgical centre, before and after teleradiology became available. From March to December 1995, 50 referrals made without teleradiology were compared with 66 referrals after teleradiology installation. Our results showed that for patients referred with teleradiologic images, unnecessary transfers were reduced (21%), more therapeutic measures before transfer were implemented (27% vs 20%, p = 0.41), adverse events occurring during transfer were significantly reduced (8% vs 32%, p = 0.002), and transfer time was shortened (72 min vs 80 min, p = 0.38). The potential advantages of this system in facilitating safer transfers and faster management of neurosurgical emergencies therefore merit further attention.

THORAX

Diagnosis of pulmonary embolism with magnetic resonance angiography.

JFM Meaney, JG Weg, L Chenevert et al.

Division of Magnetic Resonance Imaging, Department of Radiology, University of Michigan Hospitals, 1500 E. Medical Center Dr., Ann Arbor, MI 48109.

N Engl J Med 1997; 336 : 1422-7.

Background. Diagnosis pulmonary embolism may be difficult, because there is no reliable noninvasive imaging method. We compared a new noninvasive method, gadolinium-enhanced pulmonary magnetic resonance angiography, with standard pulmonary angiography for diagnosis pulmonary embolism.

Methods. A total of 30 consecutive patient with suspected pulmonary embolism ujnderwent both standard pulmonary angiography and magnetic resonance angiography during the pulmonary arterial phase at the time of an intravenous bolus of gadolinium. All magnetic resonance images were reviewed for the presence or absence of pulmonary emboli by three independent reviewers who were unaware of the findings on standard angiograms.

Results. Pulmonary embolism was detected by standard pulmonary angiography in 8 of the 30 patients in whom pulmonary embolism was suspected. All 5 lobar emboli and 16 of 17 segmental emboli identified on standard angiograms were also identified on magnetic resonance images. Two of the three reviewers reported one false positive magnetic resonance angiogram each. As compared with standard pulmonary angiography, the three sets of readings has sensitivities of 100, 87, and 75 percent and specificities of 95, 100, and 95 percent, respectively. The interobserver correlation was good (k = 0.57 to 0.83 for all vessels, 0.49 to 1.0 for main and lobar vessels, and 0.40 to 0.81 for segmental vessels).

Conclusions. In this preliminary study, gadolinium-enhanced magnetic resonance angiography of the pulmonary arteries, as compared with conventional pulmonary angiography, had high sensitivity and specificity for the diagnosis of pulmonary embolism. This new technique shows promise as a noninvasive method of diagnosing pulmonary embolism without the need for ionizing radiation or iodinated contrast material.

UROLOGIE

Traitement laser de l'hypertrophie bénigne de la prostate : corrélation du résultat histologique à l'imagerie par résonance magnétique nucléaire.

T Sulser, W Jochum, A Huch Böni, J Briner, GP Krestin, D Hauri

Institut für Diagnostische Radiologie, Dept. Med. Radiologie, Universitätsspital Zürich, 8091 Zürich, Frauenklinikstr. 10, CH-8091 Zürich (Schweiz).

Ann Urol 1997, 31, 1 : 19-26.

Les traitements peu invasifs de l'hypertrophie bénigne de la prostate sont actuellement très controversés. La thermocoagulation transurétrale de l'adénome de la prostate au laser Nd:YAG est la technique la plus fréquemment utilisée. L'objectif de ce travail est d'étudier la corrélation entre les effets morphologiques constatés et les changements visibles à l'imagerie par résonance magnétique lors d'un tel traitement sur la prostate humaine, afin d'évaluer les effets tissulaires obtenus en fonction de la puissance appliquée et du temps d'interaction. Chez 10 patients qui devaient se soumettre à une prostatectomie radicale pour un cancer urologique, une thermo-ablation visuelle au laser de l'adénome a été réalisée au cours des 10 jours qui précédaient l'intervention radicale (intervalle de 1 à 9 jours). L'ensemble de la glande a été soumis à un examen anatomopathologique, afin de corréler le résultat obtenu à l'imagerie par résonance magnétique contrastée réalisée chez 6 patients, au moyen d'une antenne endorectale standard parfois combinée à une antenne multiple, 12 à 24 heures avant l'exérèse complète de la glande prostatique. L'examen morphologique a montré des zones de nécrose périurétrale de volume variable, accompagnées d'hémorragie étendue en périphérie, avec des vaisseaux dont la lumière était partiellement oblitérée. Les images par résonance magnétique contrastée (T1) ont montré que les lésions induites par le laser prenaient un aspect hypodense et paraissaient parfaitement bien délimitées avec, en périphérie, des zones hyperdenses et hétérogènes. A l'inverse des investissements expérimentales réalisées à ce jour, nous avons pu mettre en évidence un effet tissulaire nettement retardé. Notre expérience démontre qu'un délai de quelques heures entre le traitement laser et le prélèvement de la pièce opératoire n'est pas suffisant pour évaluer l'extension des lésions dues au laser. L'imagerie par résonance magnétique de haute résolution avec antenne endorectale standard, parfois combinée à une antenne multiple, est de grande valeur pour juger des effets du laser.

Three-dimensional CT scan reconstruction of renal calculi.

J Hubert, A Blum, L Cormier, M Claudon, D Regent, P Mangin

Service d'Urologie, CHU de Brabois, F 54511 Nancy.

Eur Urol 1997; 31 : 297-301.

Objectives. The development of CT scanners (CT scan) with continuous rapid spiral acquisition now allows three-dimensional reconstructions of mobile organs such as kidneys. The aim of this study was to appreciate the merits of this new technique in the field of renal lithiasis.

Method. This non-invasive technique was applied in 27 renal calculi (23 staghorn and 4 radiolucent stones). The acquisition does not require any injection of contrast material. Reconstruction was carried out by three-dimensional (3D) shaded surface display.

Results. 3 D reconstruction of calculi permits a precise study of the shape of the stone, and of the number size and direction of its branches. Therefore, it allows for better planning of the PCNL (number of ports, peroperative pelvi-caliceal exploration...). Large radiolucent calculi are clearly defined with 3DS, facilitating the follow-up under medical treatment.

Conclusion. 3D CT scan reconstruction is a noninvasive, cost-effective method which offers high quality 3D images of renal calculi. These results should spur the more widespread use of this technique.

Percutaneous drainage in the treatment of emphysematous pyelonephritis : 10-year experience.

MT Chen, CN Huang, YH Chou, CH Huang, CP Chiang, GC Liu

Departments of Urology and Radiology, Chung-Ho Memorial Hospital, Kaohsiung Medical College, Kaohsiung, Taiwan, Republic of China.

The Journal of Urology 1997; 157 : 1569-1573.

Purpose. We investigated the effect of percutaneous drainage for the treatment of emphysematous p yelonephritis.

Materials and methods. A retrospective analysis was done of 25 patients with emphysematous pyelonephritis who were treated initially with computerized tomography (CT) guided percutaneous drainage during a 10-year period. The patients were concomitantly treated with antibiotics, fluids, and correcting blood glucose and/or ureteral obstruction. We also compared our results of percutaneous drainage to CT findings.

Results. CT identified 12 patients with emphysematous pyelonephritis who had gas with little fluid and 13 who had gas with renal or perirenal fluid collections. In 20 of 25 patients (80%) antibiotic therapy combined with percutaneous drainage constituted the only treatment required. Three patients (12%) whose clinical status improved after percutaneous drainage required. Three patients (12%) whose clinical status improved after percutaneous drainage subsequently underwent elective nephrectomy without further complications. Two patients (8%) died of multiple organ failure. There was no correlation between the gas patterns of emphysematous pyelonephritis and initial success with the antibiotics and percutaneous drainage. There were non recurrences and no complications during a followup of 1 to 10 years (mean 5). Mean duration of treatment was 5.54 weeks (range 1 to 12.6).

Conclusions. CT is an efficient imaging method for diagnosis, guiding the drainage procedures and monitoring response to percutaneous drainage of emphysematous pyelonephritis. Antibiotic therapy combined with CT guided percutaneous drainage of emphysematous pyelonephritis is an acceptable alternative to antibiotic therapy with surgical intervention.

VASCULAIRE

Natural history of proximal deep vein thrombosis assessed by duplex ultrasound.

AM O'Shaughnessy, DE Fitzgerald

Department of Physiology, Trinity College, Dublin 2, Dublin, Ireland.

Int Angiol 1997; 16 : 45-9.

Background. The late sequelae of an acute deep vein thrombosis (DVT) are difficult to predict. There are many retrospective studies which suggest that the post-phlebitic syndrome is associated with the development of valvular incompetence but these have lead to little understanding of the changes involved in the venous system following an acute thrombotic event. Duplex ultrasound imaging is an useful method to study changes in the venous system because it can locate a thrombus, assess the changes which occur over time and monitor the development of recanalization and reflux of blood flow.

Methods. In this study, 50 patients were followed by serial duplex ultrasound examination to determine if a more accurate prediction of patients at risk could be found. Rapid thrombolysis and extent of the thrombosis are both factors which influence the return of the vein to normal function.

Results. Complete thrombolysis within a short period of time occured in 24% of patients resulting in preserved valvular function. After one year there were 34% with early post-phlebitic symptoms. All of these patients had veins which recanalized slowly and developed valvular incompetence with reflux. Veins remained occluded in 14% of patients and of these 8% had competent collateral channels. This appeared to be a better outcome because none of these patients had developed symptoms after one year. Recurrent DVT's occurred in 8% within the year. Of these, 4% presented with symptoms and 4% were without symptoms but thrombus was found by ultrasound examination.

Conclusions. Serial duplex examination leads to better understanding of the natural history of an acute DVT. This may have clinical implications and lead to better management of acute DVT thereby reducing the long term risks of the post phlebitic limb.

Cost-effectiveness of screening for carotid stenosis in asymptomatic persons.

TT Lee, NA Solomon, PA Heidenreich, J Oehlert, AM Garber

Ann Intern Med 1997; 126 : 337-346.

Background. The Asymptomatic Carotid Atherosclerosis Study (ACAS) showed that carotid endarterectomy was beneficial for symptom-free patients with carotid stenosis of 60% or more. This finding raises the question of whether widespread screening to identify cases of asymptomatic carotid stenosis should be implemented.

Objective. To determine whether a screening program to identify cases of asymptomatic carotid stenosis would be a cost-effective strategy for stroke prevention.

Design. Cost-effectiveness analysis using published data from clinical trials.

Setting. General population of asymptomatic 65-year-old men.

Intervention. Patients who were screened for carotid disease with duplex Doppler ultrasonography were compared with patients who were not screened. If ultrasonography found significant carotid stenosis (>=60%), disease was confirmed by angiography before carotid endarterectomy was done.

Measurements. Quality- adjusted life-years, costs, and marginal cost-effectiveness ratios.

Results. When the conditions and results of ACAS were modeled and it was assumed that the survival advantage produced by endarterectomy would last for 30 years, the lifetime marginal cost-effectiveness of screening relative to no screening was $ 120000 per quality-adjusted life-year. Sensitivity analysis showed that marginal cost-effectiveness decreased to $ 50000 or less per quality-adjusted life-year only under implausible conditions (for example, if a free screening instrument with perfect test charateristics was used or an asymptomatic population with a 40% prevalence of carotid stenosis was found.

Conclusions. Surgery offers a real but modest absolute reduction in the rate of stroke at a substantial cost. A program to identify candidates for endarterectomy by screening asymptomatic populations for carotid stenosis costs more per quality-adjusted life-year than is usually considered acceptable.

REFERENCE(S)


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