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Journal de radiologie
Vol 79, N° 2  - mars 1998
p. 170
Doi : JR-03-1998-79-2-0221-0363-101019-ART90
REVUE BIBLIOGRAPHIQUE
 

J Frija

J Radiol 1998; 79 : 170-179

© Editions françaises de radiologie, Paris, 1998.

REVUE BIBLIOGRAPHIQUE

JR 489JR 471

CARDIOVASCULAIRE

The value of duplex ultrasound in the follow-up of acute calf veinthrombosis.

AM O'Shaughnessy, DE Firtzgerald

Vascular Medicine Unit, James Connolly Memorial Hospital, Blanchardstown,Dublin 15, Ireland.

Int Angiol

1997;

16

: 142-6.

Calf veins are one of the most common sites for deep vein thrombosis(DVT) but the management of patients with calf vein thrombosis differs.Many centres consider pharmacologicl treatment unnecessary and elect notto examine the calf veins with duplex ultrasond. Others advocate monitoringthe thrombus with serial venous duplex sanning and commence treatment ifthere is evidence of propagation. In this laboratory duplex scanning ofthe calf veins is routinely carried out as part of the diagnostic procedurefor DVT. A study was carried out where 50 patients with isolated calf veinthrombosis were followed over a one year period to determine the long termoutcome in the calf veins. Note was made of the choice of treatment. A highpercentage (85%) were treated with heparin/warfarin and only 15% receivedno pharmacological treatment. There was a propagation rate of 15%, one ofwhich resulted in a fatal pulmonary embolus (PE). The DVT recurrence ratewas 14% within the year. No long term effects such as valvular damage werenoted during the follow-up period. The results suggest the need for betterguidelines for the diagnosis and treatment of isolated calf vein thrombosis.Futures studies with larger groups of patients need to be carried out todetermine the significance of the recurrence rate and the long term effects.Duplex scanning enhances the diagnosis of calf vein thrombosis and shouldbe used for closer observation of potential thrombus propagation.

Étude de la viabilité myocardique après infarctusdu myocarde. Intérêt et limites de l'imagerie par résonancemagnétique comparée à la scintigraphie myocardique.

M Cohen, Y Cottin, F-X Soto et al.

Service de médecine nucléaire, centre Georges-François-Leclerc,1, rue du Professeur-Marion, 21034 Dijon Cedex.

Arch Mal Coeur 1997;

90

: 817-25.

Le but de cette étude est de comparer l'épaisseur myocardiquemesurée en imagerie par résonance magnétique et lafixation quantifiée du thallium. Nous avons étudié21 patients de 61,2 ± 11 ans après un infarctus du myocarde.La fraction d'éjection est de 46,5 ± 19 %. La tomoscintigraphiea comporté une épreuve d'effort ou un stress pharmacologique,suivi d'une étude de redistribution et de réinjection. Lafixation maximale de ces deux dernières études est considérée.Les données ont été analysées par une méthodequantitative. L'imagerie par résonance magnétique a étéréalisée avec des coupes grand axe vertical et horizontalen systole et en diastole en suivant la même segmentation du ventriculeen 12 régions. Trois groupes sont définis en fonction de lafixation en redistribution. Groupe I : fixation supérieure à80 % (n = 155), groupe II : 60 à 80 % (n = 78) ; groupe III : inférieureà 60 % (n = 19). Résultats : toutes les épaisseursmyocardiques sont corrélées avec le pourcentage de fixationdu thallium en redistribution (p < 0,01). L'épaississement systoliqueest significativement plus élevé dans le groupe I (3,80 ±3,1 mm) que dans les groupes II (2,20 ± 3,8 mm) et III (1,56 ±2,4 mm) où il est comparable. Les régions du groupe III ontune épaisseur systolique (8,61 ± 3,53 mm) et diastolique (6,89± 3,3 mm) significativement plus basse que dans les groupes I (13,79± 4,4 mm ; 9,95 ± 2,8 mm) et II (11,59 ± 5,5 mm ; 9,38± 2,9 mm). Quatre-vingt-dix pour cent des régions dont l'épaisseursystolique est supérieure à 10 mm ont une fixation en redistributionsupérieure à 60 %. Cette étude démontre queles épaisseurs myocardiques sont corrélées aux donnéesscintigraphiques. L'épaisseur systolique supérieure à10 mm permettrait d'affirmer la viabilité de la région considérée.

DIGESTIF

Tumeurs intracanalaires papillaires mucineuses pancréatiques.Aspects cliniques et morphologiques chez 30 malades.

L Barbe, P Ponsot, V Vilgrain et al.

Service de Gastroentérologie, Hôpital Beaujon, 92118Clichy Cedex.

Gastroenterol Clin Biol

1997;

21

: 278-286.

Objectifs.

Les tumeurs intracanalaires papillaires mucineusespancréatiques sont rares et caractérisées par un risquede transformation maligne. Le but de ce travail a été de préciserleur présentation clinique ainsi que les performances des différentsexamens d'imagerie pour déterminer leur nature bénigne oumaligne et réaliser le bilan d'extension.

Malades et méthodes.

Les caractéristiques épidémiologiques,cliniques, biologiques et radiologiques de 30 malades présentantune tumeur intracanalaire papillaire mucineuse pancréatique ont étéétudiées rétrospectivement. Les données desexamens d'imagerie ont été comparées aux donnéeshistologiques recueillies sur les pièces opératoires afind'évaluer leurs performances respectives.

Résultats.

Les tumeurs intracanalaires papilllaires mucineusespancréatiques ont été révéléespar une pancréatite aiguë dans 37% des cas. L'anciennetédes symptômes au moment du diagnostic était de 2,5 ans. Unediarrhée et un diabète étaient présents dans33 et 23 % des cas, respectivement. L'association de la tomodensitométrie,de la cholangio-pancréatographie rétrograde endoscopique etde l'échoendoscopie a permis de faire le diagnostic de tumeur intra-canalairepapillaire mucineuse pancréatique dans 100 % des cas. La mise enévidence d'une dilatation canalaire pseudokystique ainsi que la présencede matériel intracanalaire et d'irrégularités pariétalesa permis de préciser la topographie des lésions. Les maladesporteurs de formes malignes (40 %) présentaient une survie actuariellede 43 % à 2 ans. Plusieurs facteurs étaient associésà la malignité : envahissement vasculaire, dilatation de lavoie biliaire principale, sténose du canal pancréatique principalet composition solide des lésions.

Conclusion.

L'association de la tomodensitométrie, de lacholangio-pancréatographie rétrograde endoscopique et de l'échoendoscopiepermet de faire le diagnostic et d'évaluer la topogaphie et la malignitédes tumeurs intracanalaires papillaires mucineuses pancréatiques.

"Surgical" ultrasound in suspected acute appendicitis.

A Zielke, C Hasse, H Sitter, O Kisker, M Rothmund

Department of General Surgery, Philipps-University of Marburg, BaldingerStrasse, PO-Box 100, 35043 Marburg, Germany.

Surg Endosc 1997;

11

: 362-365.

Background.

Ultrasonography (US) by acknowledged experts enhancesthe diagnostic performance and reduces the rate of negative laparotomiesin patients with suspectd acute appendicits (AA).

Methods.

The diagnostic accuracy and clinical impact of routineUS performed by surgical residents was prospectively studied in 504 unselectedpatients admitted for AA. Clinical and US findings were correlated withlaparotomy findings and pathological outcome in 135 patients (113 caseswith proven AA, prevalence 22.4%) and clinical as well as follow-up datawere compared in the memainder.

Results. The overall accuracy, sensitivity, and specificity of the clinicaldiagnosis of AA were 84.9%, 51.3%, and 94.6% and those of US were 93.6%,83.1%, and 96.6%. Joint evaluation of the results from clinical evaluationand US further improved diagnostic performance (accuracy 93.4%, sensitivity84.1%, specificity 96.2) and significantly reduced the rate of diagnosticerrors to 3.4% (

p

<0.001) and unnecessary laparotomies to 9.6%(

p

<0.01) in patients with suspected AA.

Conclusions.

Ultrasonographic evaluation of the patient with suspectedAA is considered to be of value in surgical practice.

Diagnostic strategies for extrahepatic cholestasis indefinite origin:endoscopic ultrasonography or retrograde cholangiography? Results of a prospectivestudy.

P Burtin, L Palazzo, JM Canard, B Person, F Oberti, J Boyer

Hepatogastroenterology Unit, University Hospital, Angers, France.

Endoscopy

1997;

29

: 349-355.

Background and Study Aims.

Due to its lower morbidity, it hasbeen suggested that endoscopic ultrasonography (EUS) might replace endoscopicretrograde cholangiography (ERC) in the management of extrahepatic cholestasisof unknown origin. The present study aimed to compare the disagnostic accuracyof EUS and ERC in the management of cholestasis of unknown origin, takinginto account the patient's general status and the necessity of endoscopictherapy.

Patient and Methods.

Sixty-eight patients with cholestasis ofunknown origin were studied prospectively. EUS followed by ERC was carriedout on a blinded basis by two endoscopists; diagnostic and therapeutic suggestionswere made after either examination. During the ERC procedure and beforewithdrawing the tube, the endoscopist provided the final conclusions andcarried out appropriate endoscopic treatment.

Results.

A correct diagnosis was obtained with EUS and ERC in94% and in 92% of cases, respectively (not significant). After EUS, diagnosticERC was necessary for diagnosis and therapy in 24% and 58% of cases, respectively.After ERC, EUS was requested in 41% of cases. The higher the American Societyof Anesthesiologists (ASA) grade, the less it was necessary to perform acomplementary investigation. In ASA grade 1 patients, endoscopic therapywas suggested in 38% of cases after EUS and in 33% after ERC (not significant);in ASA grade 33 patients, it was suggested in 93% of cases.

Conclusions.

The diagnostic sensitivities of EUS and ERC are similarfor extrahepatic cholestasis. ERC is first indicated in poor candidatesfor surgery, since endoscopic therapy is frequently required. In good candidatesfor surgery, EUS should ne carried out first in order to stage a tumor oridentify choledocholithiasis.

Rôle de l'imagerie dans la surveillance abdomino-pelvienne aprèsrésection des cancers colo-rectaux.

N Lassau, J Leclère, D Elias, P Lasser

Département d'Imagerie, Institut Gustave-Roussy, 39 rue Camille-Desmoulins,94805 Villejuif.

J Chir (Paris),

1997;

134

: 51-58.

L'objectif de ce travail a été de faire une revue de lalittérature concernant les différentes méthodes d'imagerie,leurs indications, avantages et limites pour la surveillance hépatique,abdominale et pelvienne des patients opérés d'un cancer colo-rectal.

Pour la surveillance hépatique, la sensibilité de l'échographieest très variable selon que l'on cherche à déterminerle nombre de malades porteurs de métastases (sensibilité moyenne= 83 %) ou le nombre de nodules avant chirurgie (sensibilité = 53à 82 %). L'échographie est le plus souvent recommandéecomme examen de première intention par les auteurs françaisalors que dans la littérature anglo-saxonne, les discussions portentplutôt sur le choix entre les différentes modalitésde scanner ou d'IRM. Une échographie hépatique normale estgénéralement considérée comme suffisante s'iln'y a aucun point d'appel clinique ou biologique. Certains auteurs préconisentl'utilisation du Doppler pour déceler la présence de métastasesoccultes qui modifieraient l'hémodynamique hépatique.

Le scanner spiralé, qui a remplacé le scanner classique,est l'examen de 2

e

intention le plus utilisé aprèsl'échographie, sa sensibilité serait supérieure à90 % pour les lésions de plus de 1 cm. L'IRM et le portoscanner n'interviennentpas dans la surveillance, mais parfois dans les cas difficiles et avanthépatectomie; leur fiabilité a été largementétudiée dans la littérature.

L'examen échographique n'est pas limité au foie mais portesur l'ensemble de l'abdomen et le pelvis. Si les ACE sont normaux, une échographietechniquement satisfaisante est généralement suffisante pourl'abdomen, mais en cas de doute clinique ou biologique, le scanner spiraléest l'examen le mieux adapté. Un scanner de référence2 à 4 mois après l'intervention, tous les 6 mois pendant 2ans puis annuel, est recommandé par la plupart des auteurs. Le mêmeprotocole est préconisé pour la surveillance du pelvis aprèsAAP. La sensibilité du scanner pour la détection des récidiveslocales varie, selon les études, de 69 à 88 %; il ne permetpas de distinguer fibrose et récidive. Pour ce diagnostic, certainsauteurs rapportent une sensibilité supérieure à 90% avec les dernières techniques d'IRM (imagerie rapide et produitde contraste). Après résection antérieure, l'échographieendorectale est un examen performant, adapté à une surveillancepelvienne répétée tous les 4 à 6 mois, complétantla rectoscopie. La tomographie par émission de positron a montrédes résultats très prometteurs pour la détection delocalisations métastatiques et le diagnostic entre fibrose et récidive.Si elle devenait accessible, cette technique pourrait représenterl'examen de référence le plus performant pour la surveillance.

Effect of oral contrast administration for abdominal computed tomogaphyin the evaluation of acute blunt trauma.

BD Tsang, EA Panacek, WE Brant, DH Wisner

University of California, Davis, and University of California, Davis,Medical Center, Sacramento, CA.

Ann Emerg Med

July 1997;

30

: 7-13.

Study objective.

To determine how frequently oral contrast medium(OC) is essential for computed tomography (CT) diagnosis of blunt intraabdominalinjury and to quantify delay associated with OC administration and the incidenceof adverse effects.

Methods.

This retrospective chart review, with prospective reevaluationof CT scans for diagnostic value of OC, took place in a university teachinghospital and Levl I trauma center. Participants were blunt-trauma victimsadmitted between June 1, 1988, and November 1, 1993, who had abdominal CTas part of their initial evaluation. Trauma registry records were used toidentify study patient. Available charts and CTs were reviewed for all patientswith intestinal/mesenteric and pancreatic injuries. Randomly selected casesof liver injury, spleen injury, and to intraabdominal injury were also reviewed.Blinded CT scans were reevaluated for quality of bowel opacification andvalue of OC to diagnostic impression.

Results.

During the study period, 2, 162 blunt-trauma patientshad an abdominal CT; 297 intraabdominal injuries were diagnosed in 248 patients.Full reviews was done on 124 charts, and 70 CT scans were reevaluated. Thirty-one(100%) of 31 liver and spleen injuries were diagnosed on CT, and OC wasconsidered essential in none of these studies. One (4.5%) of 22 intestinaland mesenteric injuries was seen on CT, but this was the only such injurytreated nonoperatively. None of 21 surgically confirmed intestinal/mesentericinjuries was seen on CT. Free air or free OC was seen in none of 7 casesof intestinal perforation. OC was judged essential in none of 20 scans inpatients without intraabdominal injury. On 2 scans, OC was considered essentialfor the radiographic diagnosis. One of these was a normal pancreas at exploration(radiographic false-positive result). The only pancreatic injury requiringspecific surgical treatment was missed on CT. Twenty-one percent of patientsrequired placement of a nasogastric tube for contrast administration afterfailing oral administration, and 23% vomited OC. One of 124 had documentedaspiration of AC. Averag additional time incurred in the ED for administrationof OC was 144 minutes.

Conclusion.

OC is rarely essential for CT diagnostic of intraabdominalinjury. It may improve sensitivity for pancreatic injury, but it does nothelp identify injuries requiring surgical treatment. Even with OC, CT isinsentitive for intestinal injury. Vomiting and aspiration are significantrisks. Use of OC adds a significant amount of time to ED evaluation. Adverseeffects of OC administration, in this setting, mays outweigh its benefits.

GYNÉCOLOGIE

Magnetic resonance imaging of the uterus after endometrial resection.

LW Turnbull, A Jumaa, S Dhawan, A Horsman, SR Killick

Centre for MR Investigations, Hull Royal Infirmary, Anlaby Road, HullHU3 2JZ, UK.

British Journal of Obstetrics and Gynaecology,

vol. 104, pp. 934-938.

Objective.

Despite the increasing popularity of endometrial resectionfor the treatment of menstrual problems, the long term sequelae of thisprocedure are poorly recognised. As diagnostic hysteroscopy following endometiralresection is frequently unrewarding and transvaginal ultrasound is incapableof detecting subtle changes in endometrial morphology, magnetic resonanceimaging was employed to evaluate the uterus.

Design.

Retrospective study of unselected post-operative women.

Methods.

Fifty-nine women, of whom 22 were amenorrhoeic, werestudied a mean number of 34 months after endometrial resection, using a1.5 Tesla magnetic resonance imaging system with a pelvic phased aray coilfor signal reception. T2-weighted FSE images were acquired through the longand short uterine axis and volumetric assessement of each uterine layerperformed using an ISG Allegro workstation.

Main outcome measures.

The location and volume of residual endometrium,the volume of junctional zone and myometrial tissue, and the presence ofadditional intrauterine and pelvic pathology were recorded.

Results.

Residual edometrium was demonstrated in alll except threeamenorrhoeic women, with a similar mean volume present in menstruating andamenorrhoeic groups. Additional findings included adenomyosis, haematometra,fallopian tube dilatation and free intraperitoneal fluid.

Conclusions.

The majority of amenorrhoeic and all mestruatingwomen have residual endometrium after endometrial resection. The lack ofcommunication of islands of residual endometrium with the uterine cavityresults in haematometra formation, fallopian tube dilatation and possiblyfree intraperitoneal fluid.

ORL

The use of spiral computed tomography in the localization of impactedmaxillary canines.

L Preda, A La Fianza, EM Di Maggio et al.

Istituto di Radiologia, Università di Pavia, IRCCS PoliclinicoSMatteo, P Ic C Golgi 2, 27100 Pavia, Italy.

Dentomaxillofacial Radiology

1997;

26

: 236-241.

Purpose.

To compare spiral CT with conventional radiography inplanning the orthodontic treatment of impacted permanent maxillary canines.

Methods.

Nineteen patients with 29 malpositioned permanent maxillarycanines (15 palatal and 12 buccal impactions,one ectopic and one transposition)were examined with conventional panoramic and lateral cephalometric radiographyand with spiral CT (at 1 mm slice thickness, and 1 : 1 or 2 : 1 pitch) usingmultiplanar (MPR) and 3D reconstruction.

Results.

Conventional radiography failed to depict root resorptionespecially on the buccal surfaces of the incisor teeth. CT located impactedteeth better. Contact between impacted maxillary canines and incisor rootswas demonstrated in 26 cases and root resorption in eight. MRP proved tobe superior for the orientation of impacted teeth, and, in two cases, confirmedthe presence of minimal root lesions for which axial images had proved inconclusive.The 3D reconstructions were useful in targeting the MPR.

Conclusions.

CT facilitates the treatment of impacted canine especiallywhen the teeth are very oblique to the arch. Root resorption is better demonstratedespecially on the palatal and buccal surfaces of the adjacent incisors.Spiral CT reduces examination time and riks of accidental movement, thusoptimizing MPR quality. Examination at 2 : 1 pitch enables a significantreduction in radiation exposure without loss of image quality.

Retropharyngeal lymphadenopathy in patients with nasopharyngeal carcinoma.A computed tomography-based study.

DTT Chua, JST Sham, DLW Kwong, GKH Au, DTK Choy

Department of Radiation Oncology, The University of Hong Kong, QueenMary Hospital, Pokfulam, Hong Kong.

Cancer

1997;

79

: 869-77.

Background.

The purpose of this study was to investigate the incidenceand prognostic value of retropharyngeal lymphadenopathy in nasopharyngealcarcinoma patients using contrast enhanced computed tomography (CT).

Methods.

From January 1989 to December 1991, 364 patients withnewly diagnosed nasopharyngeal carcinoma without distant metastasis hada baseline CT performed. All patients had radiotherapy as their primarytreatment. Eighty-seven patients also received neoadjuvant chemotherapyfor locally advanced disease. All patients with clinical N0 disease hadprophylactic lymph node irradiation. The contrast enhanced CT given priorto all treatment was evaluated for the presence of retropharyngeal lymphadenopathy.Criteria for involved lymph nodes included a lymph node size of 10 mm ormore, the presence of central necrosis within the lymph node, or the presenceof a contrast enhancing rim.

Results.

The incidence of retropharyngeal lymphadenopathy was29.1%. A higher incidence of retropharyngeal lymph node involvement wasobserved in Ho's T2/T3 disease compared with T1 disease, and a higher incidencewas also found in patients with cervical lymph node disease compared withthose with clinical N0 disease. No significant differences in relapse freesurvival rates, local control rates, lymph node control rates, or distantfailure rates were observed between patients with or without retropharyngeallymphadenopathy after adjusting for T and N classifications. In 134 patientswith clinical N0 disease, retropharyngeal lymphadenopathy was found in 21patients, whereas 113 had no evidence of retropharyngeal lymphadenopathy.However, no significant difference in treatment outcome was observed betweenthe two groups.

Conclusions.

Using CT imaging, the presence of retropharyngeallymphadenopathy in patients with nasopharyngeal carcinoma does not appearto affect the prognosis. In patients with clinical N0 disease, the identificationof retropharyngeal lymphadenopathy based only on CT imaging is not sufficientevidence for an N1 classification.

Magnetic resonance imaging of the development of otitis media witheffusion caused by functional obstruction of the eustachian tube.

Cuneyt M Alper, Reza Tabari, James T Seroky, William J Doyle

Dept of Pediatric Otolaryngology, One Children's Place, 3705 FifthAve at DeSoto St, Pittsburgh, PA 15213-2583.

Annals of Otology, Rhinology & Laryngology

1997;

106,

5.

In this study, magnetic resonance imaging (MRI) was used to define invivo the effect of experimental functional obstruction of the eustachiantube (ET) on vascular permeability and the development of middle ear (ME)effusion. After collection of baseline data for ME pressure and MRI, theright tensor veli palatini muscle of 10 cynomolgus monkeys was injectedwith botulinum toxin A to induce ET obstruction. The left tensor veli palatinimuscle was injected with saline in 4 monkeys. Right and left ME pressuresand compliances were measured twice daily over a follow-up period of 36days, and MRI scanning sessions including administration of a contrast agent,gadopentetate dimeglumine, were repeated on days 3, 6, 11, 15, 21, 29, and36 in animals and on days 15, 21, 29, and 36 in 4 animals. Two right earsdid not develop underpressures, 5 developed persistent underpressures, buta progressive brightening of the ME on T2-weighted images, indicative ofthe development of inflammation and effusion, was noted for the others.Also, an increasing rate of transfer of the contrast a gent between thevascular and ME compartments, indicative of increasing vascular permeability,was observed to track the temporal changes in ME pressure. These resultssupport a causal relationship between ET dysfunction, ME underpressures,increased vascular permeability, and otitis media with effusion.

OSTÉO-ARTICULAIRE

Diagnosis of lateral ankle ligament injuries. Comparison between talartilt, MRI and operative findings in 112 athletes.

C Gaebler, C Kukla, MJ Breitenseher et al.

University of Vienne, Clinic for Trauma Surgery, AKH-WähringerGürtel 18-20, 1090 Vienna, Austria.

Acta Orthop Scand

1997;

68

(3) : 286-290.

We evaluated the reliability of the radiographic talar tilt best by MRIexaminations in 112 athletes with injuries to the lateral ligaments of theankle. 25 athletes with a talar tilt >15° were treaed operatively.Intraoperative findings and the talar tilt test were compared with MR imagingresults. Our results suggest that MRI is a reliable method for diagnosinginjuries of the lateral ankle ligaments. The talar tilt test cannot evaluatethe specific pathology of lateral ankle ligaments, but it was reliable inindicating complete double-ligament ruptures (anterior talofibular and calcaneo-fibularligaments), when talar tilt was 15° or more than on the uninjured side.

Evaluation of bone marrow iron by magnetic resonance imaging.

M Isokawa, F Kimura, T Matsuki et al.

Second Department of Internal Medicine, Okayama University MedicalSchool, 2-5-1 Shikata cho, Okayama 700, Japan.

Ann Hematol

1997;

74

: 269-274.

Bone marrow iron was estimated by magnetic resonance imaging (MRI) usingspin-echo sequences with multiple echoes in 22 patients with varying degreesof tissue storage iron. Levels of bone marrow iron concentration (BMIC)were determined chemically in biopsied specimens concurrently. Concentrationsof serum iron, serum ferritin,and transferrin saturation were also measuredto evaluate body iron status. Significant correlation was observed betweenBMIC and T

2

relaxation rate (1/T

2

) (

r

=0.77;

p

<0.001) in all patients with BMIC levels below 400 µg/ml,while BMIC was not correlated with T

2

in patients with extremelyhigh BMIC levels. MRI was considered to be inappropriate for quantificationof 1/T

2

in patients with extremely high BMIC due to an extremeshortening of T

2

relaxation time. These observations suggestthat MRI may be a useful and noninvasive method for systemic quantificativedetermination of bone marrow iron.

MRI can prevent unnecessary arthroscopy.

IW Carmichael, AM MacLeod, J Travlos

Staffordshire General Hospital, Weston Road, Stafford ST16 3SA, UK.

J Bone Joint Surg [Br]

1997;

79-B

: 624-5.

We compared the practice of four orthopaedic consultants as regards theuse of MRI and arthroscopy to diagnose problems of the knee. In one year324 arthroscopies and 66 MR scans were performed for this purpose.

We found that MRI is a reliable and cheaper alternative to "diagnosticarthroscopy". We consider that patients with definite clinical signsmerit an early "therapeutic arthroscopy", but that all other kneesshould be investigated by MRI. This policy spares patients from unnecessaryand expensive surgery.

Arthroscopy for diagnostic purposes should be used only with a specificpurpose. Modern MRI can and should replace "having a look".

Detection of joint pathology by magnetic resonance imaging in patientswith early rheumatoid arthritis.

K Forslind, EM Larsson, A Johansson, B Svensson

Rheumatology Section, Department of Medicine, Helsingborgs lasarett,S-251 87 Helsingborg, Sweden.

British Journal of Rheumatology

1997;

36

: 683-688.

Magnetic resonance imaging (MRI) permits the visualization of anatomicalstructures not appreciated by conventional radiography imaging, and mayassess inflammatory disease and its progression with greater sensitivitythan conventional radiography. In this study of 30 patients with early rhumatoidarthritis (RA), which could be considered as a pilot study because of therelatively small number of patients, we compare MRI of the knee and thefifth metatarsophalangeal joint with clinical and radiographic findings.A parallel study of 10 healthy individuals served as a reference group.In all but one of the 30 patients, MRI revealed some kind of joing abnormality,whereas conventional radiography was normal in 14 patients. The presentstudy thus suggests that MRI may detect inflammatory and/or destructivejoing changes in patients with early RA, and that these changes may occurin the absence of clinical symptoms or signs and/or radiographic signs inthe examined joint. If these data prove to be confirmed in further controlledstudies, MRI may be of importance both for the assessment of prognosis andfor the decision to treat in the early critical stages of RA.

Magnetic resonance imaging of the wrist in defining remission of rheumatoidarthritis.

J Lee, S Lee, JS Suh, M Yoon, J Song, CH Lee

CPO Box 8044, Yonsei University College of Medicine, Seoul, Korea.

J Rheumatol

1997;

24

: 1303-8.

Objective.

To assess the fficacy of magnetic resonance imaging(MRI) in objectively defining a state of remission in rheumatoid arthritis(RA) after treatment.

Methods.

Ten patients with RA involving the wrist were evaluatedbefore treatment with methotrexate and hydroxychloroquine, and then mean14 mo later with a followup evaluation. Clinical variables, laboratory measurements,and MRI using various techniques (T1 weighted image, T2 weighted image,fat suppression T2 weighted image, postcontrast T1 weighted image, postcontrastdynamic image, postcontrast 3 dimensional image) were observed. Remissionwas defined by ACR criteria. MRI changes were observed using 3 variables:extent of synovial proliferation; extent of bone marrow edema; and developmentof new erosion. In 6 of 10 patients, synovial signal intensity time curvechanges at 30 s (E

30

ratio) were determined for quantitativeassessment of synovitis.

Results.

Four patients achieved remission and 6 did not. All patientsin remission showed decrease in extent of synovial proliferation and bonemarrow edema with no newly developed erosion after treatment, compared tobaseline. Five of 6 patients in nonremission showed newly developed erosionswith variable changes in extent of synovial proliferation and bone marrowedema. E

30

ratio was determined in 3 patients in the remissiongroup and 3 in the nonremission group, with 48% reduction in the formercompared to 9% reduction in the latter.

Conclusion.

MRI is feasible for objectively defining remissionand assessing the therapeutic effect of antirheumatic drugs; utility ofMRI measures in clinical remission criteria remains to be verified.

PÉDIATRIE

Osteonecrosis in children treated for acute lymphoblastic leukemia:a magnetic resonance imaging study after treatment.

AE Ojala, FP Lanning, E Pääkkö, BM Lanning

Department of Diagnostic Radiology, Oulu University Central Hospital,Kajaanintie 50, SF-90220, Oulu, Finland.

Oncology

1997;

29

: 260-265.

The purpose of the study was to find out the prevalence of osteonecrosisin children with acute lymphoblastic leukemia (ALL) in complete bone marrowremission at the end of the treatment. Twenty-eight children with ALL underwentMRI of the upper and/or lower extremities. Bone marrow signal intensitywas analyzed on T1-weighted images, where circumscribed lesions with a rimof low sinal intensity were considered typical of osteonecrosis. Osteonecrosiswas found in 9 of the 28 children (32%, 95% Cl 16% to 52%). Five of themwere asymptomatic. They had been treated with high risk and intermediaterisk protocols, both of which include a delayed intensification phase withdexamethasone. None of the patients with standard risk ALL were found tohave developed osteonecrosis. Osteonecroses occurred unexpectedly in symptomlesspatients and in patients with mild transient symptoms treated with highrisk and intermediate risk protocols. Our study suggests that the intensificationphase of the treatment protocols with intensive dexamethasone medicationmight be responsible for the development of osteonecrosis.

The reliability of measurements of pelvic radiographs in infants.

FG Boniforti, G Fujii, RD Angliss, MKD Benson

Nuffield Orthopaedic Centre NHS Trust, Windmill Road, Headington,Oxford OX3 7LD, UK.

J Bone Joint Surg [Br]

1997;

79-b

: 570-5.

We have evaluated the reliability of the measurement of radiologicalindicators in developmental dysplasia of the hip. Three observers each independentlyassessed 60 pelvic radiographs from infants aged from 3 to 36 months. Errorsfrom the true value of a single measurement made by a single observer (E1),of the average of two measurements by a single observer (E2), and of theaverage of two single measurements by two different observers (E3) wereestablished for the acetabular index of Hilgenreiner, for the assessmentof superior and lateral femoral displacement and for indicators of pelvicalignment.

The errors for the assessment of the acetabular index were E1 ±5°, E2 ± 5°, and E3 ± 3.5°. There was a significantcorrelation between the presence of an acetabular notch on the radiographand an increased error in measurement (p = 0.01). Yamamuro's measurementof lateral femoral displacement was more reliable than the Hilgenreinerdistance. The errors of indicators of pelvic alignment showed a correlationwith the age of the infants; the quotient of pelvic rotation was more reliableafter seven months of age (p <0.0001). The errors of the measurementof the symphysis os-ischium angle tended to increase with age and thoseof the measurement of the index of pelvic tilt decreased with skeletal maturation(p = 0.002).

RACHIS

Variation in emergency department use of cervical spine radiogaphyfor alert, stable trauma patients.

IG Stiell, A Wells, K Vandemheen et al.

Division of Emergency Medicine, Loeb Research Institute, Universityof Ottawa, Ottawa, Ontario.

Can Med Assoc J

1997;

156

: 1537-44.

Objective.

To assess the emergency department use of cervicalspine radiography for alert, stable adult trauma patients in terms of utilization,yield for injury and variation in practices among hospitals and physicians.

Design.

Retrospective survey of health records.

Setting.

Emergency departments of 6 teaching and 2 community hospitalsin Ontario and British Columbia.

Patients.

Consecutive alert, stable adult trauma patients seenwith potential cervical spine injury between July 1, 1994, and June 30,1995.

Main outcome measures.

Total number of eligible patients, referralfor cervical spine radiography (overall, by hospital and by physician),presence of cervical spine injury, patient characteristics and hospitalsassociated with use of radiography.

Results.

Of 6855 eligible patients, cervical spine radiographywas ordered for 3979 (58.0%). Only 60 (0.9%) patients were found to havean acute cervical spine injury (fracture, dislocation or ligamentous instability);98.5% of the radiographic films were negative for any significant abnormality.The demographic and clinical characteristics of the patients were similaracross the 8 hospitals, and no cervical spine injuries were missed. Significantvariation was found among the 8 hospitals in the rate of ordering radiography(

p

<0.0001), from a low of 37.0% to a high of 72.5%. After possibledifferences in case severity and patient characteristics at each hospitalwere controlled for, logistic regression analysis revealed that 6 of thehospitals, were significantly associated with the use of ordering radiographyamong the attending emergency physicians (

p

<0.05), from a lowof 15.6% to a high of 91.5%.

Conclusions.

Despite considerable variation among institutionsand individual physicians in the ordering of cervical spine radiographyfor alert, stable trauma patients with similar characteristics, no cervicalspine injuries were missed. The number of radiographic films showing signsof abnormality was extremely low at all hospitals. The findings suggestthat cervical spine radiography could be used more efficiently, possiblywith the help of a clinical decision rule.

Pyogenic infectious spondylitis: clinical, laboratory and MRI features.

P Kapeller, F Fazekas, D Krametter et al.

Department of Neurology and Magnetic Resonance Center, Karl-FranzensUniversity, Graz, Austria.

Eur Neurol

1997;

38

: 94-98.

Pyogenic infectious spondylitis (PIS) is an uncommon but serious inflammatorydisorder of the discovertebral junction with frequent involvement of neuralstructures including the spinal cord. We report a series of 41 patients(age 21-75 years, mean age 59 years) with primary PIS confirmed by signalabnormality of the intervertebral disk an adjacent vertebral bodies on magneticresonance imaging. The prevailing clinical symptom was focal back pain aggravatedby percussion in 90% of patients. Radicular signs or symptoms were presentin 59% and spinal cord symptoms in 29% of patients, respectively. Evidenceof inflammation consisted of an elevated sedimentation rate in 76%, leukocytosisin 61% and fever in 61% of individuals. Predisposing factors such as diabetsmellitus, previous nonspinal surgery and other sites of infection or inflammationwere identified in 17 (41%) patients and 30 (73%) were older than 50 years.The lumbar spine was most often affected and PIS was associated with anepidural abscess in 15 (37%) patients. Increased alertness for PIS in thecontext of focal back pain with clinical or laboratory signs of inflammationis needed to speed up its detection.

The intravertebral vacuum phenomenon ("vertebral osteonecrosis").Migration of intradiscal gas in a factured vertebral body?

P Lafforgue, C Chagnaud, V Daumen-Legré, L Daver, M Kasbarian,P-C Acquaviva

Departments of Rheumatology and Radiology, Timone Hospital, Marseille,France.

Spine

1997;

22

: 1885-1891.

Study Design.

Retrospective cohort.

Objectives.

To compare the prevalance of the association betweencontiguous intervertebral disc and vertebral collapses with or without anintravertebral vacuum phenomenon.

Summary or Background data.

The mechanism of occasional gas accumulationwithin some vertebral collapses is poorly known. The current hypothesisis that phenomenon is indicative of bone ischemia.In fact, avascular necrosisas the main pathologic event remains speculative, and should not explain

per se t

he presence of gas within a vertebral body.

Methods.

Comparison of the prevalence of intervertebral disc vacuumphenomenon adjacent to the affected vertebral body in 23 cases of intravertebralvacuum phenomenon in 19 patients (intravertebral vacuum phenomenon group)and in 708 osteoporotic collapses without intravertebral vacuum phenomenonin 199 patients (control group).

Results.

There were no differences in sex ans age between thetwo groups, and all the patients in the intravertebral vacuum phenomenongroup had signs of underlying osteoporosis. A vacuum phenomenon in at leastone intervertebral disc adjacent to the collapses on radiographs, conventionaltomography, computed tomography, or magnetic resonance imaging was foundin 19 cases (83%) in the intravertebral vacuum phenomenon group, comparedwith 13% in the control group (

P

<0.0001). Considering plain radiographsonly, this association was found in 50% of the intravertebral vacuum phenomenongroup and in 9.7% of the control group (

P

<0.0001). The intervertebraland intravertebral gaseous collections were connected through a fracturedendplate in six cases.

Conclusions.

The high prevalence of the association of contiguousintervertebral and intravertebral vacuum phenomenon could have implicationsin the pathogenesis of the intravertebral vacuum phenomenon. We hypothesizethat the intravertebral vacuum phenomenon could simply be the results ofmigration of an intradiscalgaseous collection through the fractured endplateof some osteoporotic collapses. [Key words: intervertebral disc, osteonecrosis,spine, vacuum phenomenon].

Diagnosis of root avulsions in traumatic brachial plexus injuries:value of computerized tomography myelography and magnetic resonance imaging.

GA Carvaho, G Nikkah, C Matthies, G Penkert, M Samii

Neurosurgical Department, Nordstadt Hospital, Hannover, Germany.

J Neurosurg

1997;

86

: 69-76.

Surgical management and prognosis of traction injuries of the brachialplexus depend on the accurate diagnosis of root avulsion from the spinalcord. Myelography, computerized tomography (CT) myelography, and recentlymagnetic resonance (MR) imaging have become the main radiological methodsfor preopertive diagnosis of cervical root avulsions. Most of the previousstudies on the accuracy of CT myelography and MR imaging studies have correlatedthe radioloigical findings with the extraspinal surgical findings at brachialplexus surgery. Surgical experience shows that in many cases extraspinalfindings divrge from intradural determinations. Consequently, only correlationwith the intradural surgical findings will allow assessment of the factualaccuracy of CT myelography and MR imaging studies.

In a prospective study, 135 crvical roots (C5-8) were evaluated by CTmyelography and/or MR imaging and further explored intradurally via a hemilaminectomy.The accuracy of the preoperative CT myelography-based diagnosis in relationto the intraoperative findings was 85%. One the other hand, MR imaging demonstratedan accuracy of only 52%. The most common reasons for false-positive or false-negativefinding were: 1) partial rootlet avulsion; 2) intradural fibrosis; and 3)dural cystic lesions. Computerized tomography myelography scans using 1-to 3-mm axial slices prove to be the most reliable method to evaluate preoperativelythe presence of complete or partial root avulsion in traumatic brachialplexus injuries.

Because extradural judgment of cervical root avulsion can be unreliable,accurate assessment of intraspinal root avulsion enormously simplifies thedecision concerning the choice of donor nerves for transplantation and/orneurodization during brachial plexus surgery.

RADIOLOGIE INTERVENTIONNELLE

Treatment for intracranial dural arteriovenous malformations: a meta-analysisfrom the English language literature.

CP Lucas, JM Zabramski, RF Spetzler, R Jacobowitz

Division of Neurological Surgery Barrow Neurological Institute, St.Joseph's Hospital and Medical Center Arizona State University,Phoenix, Arizona.

Neurosurgery

1997;

40

: 1119-11132.

Objective.

The treatment of intracranial dural arteriovenous malformations(DAVMs) remains problematic. Options include ligature of feeding vessels,endovascular procedures, surgical obliteration, or a combination of thelatter two. We conducted a meta-analysis of the English language literatureon DAVMs to determine the most effective treatment option related to locationand angiographic characteristics.

Methods.

The criteria for inclusion were pre- and post-treatmentangiography, a description of the type of treatment, and clinical outcome.The analysis included a total of 258 patients, 248 from a review of 223published articles and 10 from the authors' series. DAVMs were divided intosix categories by location, and the results of treatment were compared basedon obliteration rates using *

2

analysis.

Results. In transverse-sigmoid sinus DAVMs (n = 64), combined therapy(endovascular plus surgical treatment) proved significantly more effectivethan either therapy alone (

P

<0.01). For lesions of the tentorialincisura (n = 66), combined therapy and surgical obliteration alone provedsuperior to embolization (

P

<0.001). For lesions of the cavernoussinus (n = 67), treatment was primarily endovascular, with success ratesof 62 to 78% for transarterial and transvenous approaches, respectively.In the anterior fossa (n = 23), surgical obliteration was highly effective,with a sucess rate of 95%. The small number of cases in both the superiorsagittal sinus (n = 28) and middle fossa (n = 10) regions, precluded anystatistical analysis. Finally, simple ligature of feeding vessels producedsuccess rates of only 0 to 8% and can no longer be recommended.

Conclusion.

There is no single ideal treatment for the obliterationof DAVMs. The management of each case is best considered individually. Theresults of this review serve as a rational starting point for the selectionof treatment options.

Traitements des névralgies périnéales par atteintedu nerf pudental. A propos de 170 cas.

G Amarenco, J Kerdraon, P Bouju et al.

Service de Rééducation Neurologique, Centre HospitalierRobert-Ballanger, F-93602 Aulnay-sous-Bois.

Rev Neurol (Paris)

1997;

5

: 331-4.

La compression chronique du nerf pudental dans la fossette ischio-rectale(syndrome du canal d'Alcock) ou à hauteur du ligament sacro-épineuxest responsable d'une névralgie périnéale. Nous présentonsles résultats des différents traitements effectuéssur 70 patients (17 femmes et 53 hommes d'âge moyen 60,3 ans) et suivisavec un recul d'au moins un an. Les infiltrations scano-guidées decorticoïdes dans la fossette ischio-rectale ne furent efficaces quedans un tiers des cas avec une récidive dans 66 % des cas. Les infiltrationssous repérage radioscopique du nerf à l'épine ischiatiquefurent plus efficaces d'emblée (57 % de bons résultats) maisne le restèrent à un an que dans 15 % des cas. La neurolysechirurgicale proposée 27 fois, supprima totalement les douleurs 9fois et partiellement 8 fois (soit deux tiers de bons résultats).Toutes techniques thérapeutiques confondues, les patients furentaméliorés dans 65 % des cas, 23 % totalement, 42 % partiellement.Ces résultats justifient un diagnostic précoce aidépar les explorations électrophysiologiques périnéaleset une prise en charge pluridisciplinaire, médico-chirurgicale, desnévralgies périnéales.

Significance of tumor vascularity as a predictor of long-term prognosisin patients with small hepatocellular carcinoma treated by percutaneousethanol injection therapy.

H Toyoda, T Kumuda, S Nakano et al.

Department of Gastroenterology,Ogaki Municipal Hospital, 4-86 Minaminokawa,Ogaki, Gifu, 503 Japan.

Journal of Hepatology

1997;

26

: 1055-1062.

Bakground/Aims.

We estimated the significative of the vascularityof small hepatocellular carcinoma (HCC) as a predictor of long-term prognosisin patients treated with percutaneous ethanol injection therapy (PEIT/PEI).

Methods.

Fifty-four patients who have been followed in our hospitaland who had HCC less than 20 mm in diameter were observed for 199 to 2074days. Hepatic angiography (digital subtraction angiography; DSA and ultrasoundangiography with intraarterial CO

2

microbubbles; USAG) was performedbefore treatment in all cases, and the vascularity f the tumor was clinicallyevaluated. The survival rate was analyzed according to this vascularity.

Results.

Of the 54 tumors, 24 had tumor stain on DSA, while 30did not, and 38 showed enhancement on USAG, while 16 did not. The 3- and5-year survival rates were 48.7 and 34.1% of patients with positive stainingHCC on DSA, and 89.7 and 69.7% of patients with negative staining HCC (

p

=0.0723).The rates were 48.6 and 36.7%, respectively, of patients with positive enhancementHCC on USAG, and both rates were 85.7% of patients with negative enhancementHCC (

p

=0.0231).

Conclusions.

Tumor vascularity will play a role in the long-termprognosis of these patients with small HCC when they are treated with PEIT/PEI.

SÉNOLOGIE

Sensitivity, specificity and predictive values of breast imaging inthe detection of cancer.

LEM Duijm, GL Guit, JOM Zaat, AR Koomen, D Willebrand

Department of Radiology, University Hospital Utrecht, Heidelberglaan100, 3584 CX, Utrecht, The Netherlands.

British Journal of Cancer

1997;

76

(3) : 377-381.

In an observational follow-up study we determined whether the combineduse of mammography and breast ultrasonography is an appropriate diagnostictool to select patients with symptomatic breast disease who need additionalpathological evaluation. Mammography and ultrasound were used as complementarydiagnostic modalities in 3014 consecutively referred and mainly symptomaticpatients. Sensitivity, specificity, predictive values and likelihood ratioswere calculated according to standard procedures. Virtually complete follow-upwas obtained by correlating the radiological diagnosis with clinical recores,final pathological findings, records from the Cancer Register and data fromquestionnaires sent ot the general practitioners of all the referred patients.After an average follow-up period of 30 months, the sensitivity for breastcancer detection was 92.0% and the specificity 97.7%. A positive predictivevalue of 68.0%, a negative predictive value of 99.6%, a positive likelihoodratio of 40 and a negative likelihood ratio of 0.08 were found. The meandiagnostic delay as a result of false negative examinations was 9 months(range 0-20 months). We conclude that breast imaging in routine daily practice,consisting of the integral use of mammography and ultrasonography, is anappropriate tool in the detection of cancer and should be included in thework-up of sympomatic breast disease.

SYSTÈME NERVEUX

Imagerie des tumeurs malignes non osseuses de l'étage antérieurde la base du crâne. Bilan préopératoire.

A Elkeslassy, J-F Meder, F Lafitte, K Rezeai, D Fredy

Service de Neuroradiologie, Centre Hospitalier Sainte-Anne, 1, rueCabanis, 75674 Paris Cedex 14.

Neurochirurgie

1997;

43

: 68-75.

La place de l'imagerie est fondamentale dans le bilan préopératoiredes tumeurs malignes non osseuses de l'étage antérieur, enparticulier en raison des limites de l'examen clinique. Le bilan reposesur deux explorations, complémentaires l'une de l'autre, la scanographieet l'imagerie par résonance magnétique. Le premier objectifdu bilan radiologique est la reconnaissance de la tumeur dont la distinctiondes lésions inflammatoires chroniques est souvent difficile. Le second,essentiel pour guider la stratégie thérapeutique, est l'appréciationde l'extension tumorale, en particulier orbitaire et crânienne. Letroisième est l'évaluation de la réponse tumorale àune éventuelle chimiothérapie d'induction avant exérèse.

Gadolinium enhanced MRI predicts clinical and MRI disease activityin relapsing-remitting multiple sclerosis.

T Koudriavtseva, AJ Thompson, M Fiorelli et al.

Dipartimento di Scienze, Neurologiche, I Clinica Neurologica, Universitàt"La Sapienza" di Roma, Viale dell'Universitàt 30, 00185Roma, Italy.

J Neurol Neurosurg Psychiatry

1997;

62

: 285-287.

The aim of the study was to evaluate the predictive power of baselinegadolinium (Gd) enhanced MRI in relation to subsequent clinical and MRIactivity.

Sixty eight patients with clinically definite relapsing-remitting multiplesclerosis had a baseline Gd enhanced MRI and were followed up clinicallyand by monthly Gd enhanced MRI for six months.

The occurence of relapses during the follow up period was predicted bythe presence of at least one enhancing lesion on the baseline MRI (P <0.05).The number and volume of enhancing lesions at baseline were significantlyassociated with both enhancing lesions observed during the follow up period(P <0.0001). Moreover, the presence of three or more enhancing lesionsat baseline scan was consistently associated with the development of permanentabnormalities on T2 weighted images six months later.

The study suggests that the number and volume of Gd enhancing lesionsat a single examination are strong short term predictors of subsequent clinicaland MRI activity.

Magnetic resonance signal abnormalities along the pyramidal tractsin amyotrophic lateral sclerosis.

F Carella, M Grisoli, M Savoiardo, DTesta

Divisione di Neurologia, Servizio di Neuroradiologia, Istituto NazionaleNeurologico C. Besta, Milano, Italy.

Ital. J. Neurol. Sci

1995;

16

: 511-515.

Magnetic resonance imaging (MRI) studies of the brain were reviewed in16 patients with amyotrophic lateral sclerosis (ALS), representative ofa large and homogeneously studied series, 11 of whom showed signal abnormalitiesalong the pyramidal tracts. These were more frequent in patients with moresevere upper motor neuron signs but did not correlate with disease severity.Our study suggests that MRI signal abnormalities along the pyramidal tractsare common in ALS and may reflect the severity of pyramidal tract degeneration.

Schizencephaly: correlations of clinical and radiological features.

AM Packard, VS Miller, MR Delgado

Department of Neurology, Cornell University Medical Center, 525 East68th Street, New York, New York 10021.

Neurology

1997;

48

: 1427-1434.

Schizencephaly is an uncommon congenital disorder of cerebral corticaldevelopment. Although a well-recognized cause of seizures and developmentaldeficits in children, previous reports describe the range of neurodevelopmentaloutcome in only 47 patients. We report the clinical and cranial imagingfeatures of 47 children with unilateral open-lip (17), unilateral closed-lip(12); bilateral open-lip (12), and bilateral closed-lip (6) schizencephaly,as defined radiologically. The schizencephalic cleft occurred more oftenin the anterior than in the posterior neocortex. Children with closed-lipschizencephaly presented with hemiparisis or motor delay whereas patientswith open-lip schizencephaly presented with hydrocephalus or seizures. Forty-threepatients (91%) has associated cerebral developmental anomalies, most commonlyabsence of the septum pellucidum (45%) and focal cortisal dysplasia (40%).There was a history of seizures in 57% of cases, a third of which were classifiedas difficult to control. Neurodevelopmental outcome was generally poor,with 51% of patients (24/47) having severe deficits, 32% of patients (15/47)having moderate impairment, and 17% of patients (8/47) having mild or noproblems. Patients with closed-lip schizencephaly were more likely to havea mild to moderate outcome than those with open-lip type (78% versus 31%;

p

<0.05). Children with unilateral schizencephaly had a mild oremoderate outcome more frequently than those with bilateral lesions (62%versus 28%;

p

<0.05). Children who had involvement of a singlelobe accounted for 88% of those with mild outcomes and 53% of those withmoderate outcomes. Unilateral closed-lip schizencephaly was associated withthe best neurodevelopmental outcome; in contrast, 11 of 12 children withbilateral open-lip clefts had severe disabilities. Language developmentwas significantly more likely to be normal in those children with unilateralschizencephaly than in those with bilateral clefts (48% versus 6%;

p

<0.002). Thus, the presentation and outcome of children with schizencephalyare quite variable but are related to the extent of cortex involved in theschizencephalic defect.

Occipital condyle fractures.

S Tuli, CH Tator, MG Fehlings, M Mackay

Division of Neurosurgery and Spinal Program, University of Torontoand the Toronto Hospital, Western Division, Toronto, Ontario, Canada.

Neurosurgery

1997;

41

: 368-377.

Objective.

Occipital condyle fracture (OCFs) are infrequentlyrecognized. Three recent cases of OCF in our center prompted a review ofthe incidence, clinical presentation, diagnosis, and treatment of this entity.

Methods.

A retrospective review of medical records and radiographicresults was performed for 93 of 316 consecutive patients who were victimsof trauma, who presented at the Toronto Hospital during a 13-month period,and who had undergone computed tomography of the occiput.

Results.

A review of the literature regarding OCF revealed thatcranial nerve deficits occurred in 31% of the patients with OFs; of those,the deficits were delayed in 38%. Three new cases of OCF, with neck painbut without cranial nerve deficits, have been reported. The cervical spinex-rays revealed nothing abnormal in 96% of the reported cases. In our retrospectivereview, asymptomatic OCF was revealed by computed tomography for 1 of the93 patients.

Conclusion.

OCF is a diagnostic challenge. We suggest that computedtomographic scans of O-C2 be obtained in the following circumstances: presenceof lower cranial nerve deficits, associated head injury or basal cranialfracture, or persistent severe neck pain despite normal radiographic results.We propose a new classification system for the management and treatmentof OCF based on the stability of the O-C1-C2 joint complex reflected bythe presence of displacement of the condyle, computed tomographic or radiographicevidence of O-C1-C2 instabilityj, and magnetic resonance evidence of ligamentousinjury. OCFs are divided into the following types: Type 1 (stable), undisplacedfracture; Type 2A (stable), displaced fracture with no ligamentous instability;and Type 2B (unstable), displaced fracture with ligamentous instability.

THORAX

Computed tomography of the chest in blunt thoracic trauma: resultsof a prospective study.

PA Blostein, C Hodgman

Trauma Surgery Service, Bronson Methodist Hospital, 252 East LovellStreet, Kalamazoo, MI 49007.

Journal of Trauma: Injury, Infection and Critical Care 1997;

43,

n°1.

Background.

Computed tomography of the chest (CTC) is more sensitivethan conventional roentgenography at detecting blunt thoracic injuries.Its effect on subsequent therapy remains incompletely characterized.

Methods.

Nine criteria believed to represent the presence of,or the potential for, significant thoracic injuries were defined, and patientswere followed prospectively. Forty consecutive patients had CTC after initialevaluation. Physiologic and anatomic findings were compared, and the effectof CTC on therapy was analyzed.

Results.

CTC detected 76 injuries not found on plain roentgenograms,and plain roentgenograms detected 25 injuries not visible on CTC scans.Six patients had therapy changes based on CTC findings, five of which involvedchest tube modification. The percentage of pulmonary contusion did not predictthe need for mechanical ventilation but did correlate with physiologic contusion.

Conclusions.

Blunt thoracic injuries detected by CTC infrequentlyrequire immediate therapy. If immediate therapy is needed, findings willbe visible on plain roentgenograms or on clinical exam. Routine CTC in blunttrauma is not recommended but may be helpful in selected cases.

CT-guided fine-needle aspiration cytology of solitary pulmonary nodules.A prospective, randomized study of immediate cytologic evaluation.

L Santambrogio, M Nosotti, N Bellaviti, G Pavoni, F Radice, V Caputo

Via Salomone No, 21, 20138 Milano, Italy.

Chest

1997;

112

: 423-25.

Study objective.

To evaluate the immediate cytologic assessmentduring CT-guided fine-needle aspiration cytology (FNAC) in the diagnosisof operable indeterminable solitary pulmonary nodules (SPNs).

Design.

Prospective randomized study.

Patients and methods.

Two hundred twenty patients with SPN undergoingCT-guided FNAC were divided into two groups. In the first one (group A,110 patients), a cytologist assessed the adequacy of the samole obtainedimmediately, and when the samole was considered inadequate, fine-needleaspiration (FNA) was repeated. In the second group (B, 110 patients), animmediate cytologic examination was not performed, but only a gross assessmentby the surgeon. Histologic study of the SPN was possible in 217 cases, whereasthree patients were followed up radiologically.

Results.

Adequate sample were obtained in 100% of group A and88% of group B (p <0.001). The diagnostic accuracy was 99% in group Aand 81% in group B (p <0.001). Group A required a mean of 1.22 FNAs comparedwith 1.10 in group B (p = 0.015). The rate of pneumothorax in the wholeseries was 24%, and statistically significant differences between the twogroups were not detected.

Conclusions.

Immediate cytologic study significantly increasedthe adequacy and diagnostic accuracy of CT-guided FNAC of indeterminateSPNs without causing a significant increase of complications.

Revisions in the international system for staging lung cancer.

F Mountain

1150 Silverado St, Suite 110, LaJolla, CA 92037.

Chest

1997;

111

: 1710-17.

Revisions in stage grouping of the TNM subsets (T = primary tumor, N= regional lymph nodes, M = distant metastasis) in the International Systemfor Staging Lung Cancer have been adopted by the American Joint Committeeon Cancer and the Union Internationale Contre le Cancer. These revisionswere made to provide greater specificity for identifying patient groupswith similar prognoses and treatment options with the least disruption ofthe present classification: T1N0M0, stage IA; T2N0M0, stage IB; T1N1M0,stage IIA; T2N1M0 and T3N0M0, stage IIB; and T3N1M0, T1N2M0, T2N2M0, T3N2M0,stage IIIA. The TNM subsets in stage IIIB--T4 any N M0, any T N3M0, andin stage IV--any T any N M1, remain the same. Analysis of a collected databaserepresenting all clinical, surgical-pathologic,and follow-up informationfor 5,319 patients treated for primary lung cancer confirmed the validityof the TNM and stage grouping classification schema.

The utility of routine postoperative chest radiography in the postanesthesiacare unit.

M Barak, R Markovits, L Guralnik, B Rozenberg, A Ziser

Department of Anesthesiology, Rambam Medical Center, P.O. Box 9602,Haifa 31096, Israel.

Journal of Clinical Anesthesia 1997; 9

: 351-354.

Study objective.

To evaluate the clinical significance and costeffectiveness of routine chest radiographs in the postanesthesia care unit(PACU).

Design.

Prospective study.

Setting.

University hospital.

Patients.

100 patients who were admitted to the PACU folloingvarious surgical procedures, and in whom a postoperative chest radiographwas routinely performed.

Interventions.

Chest radiograph was taken in each study patientsoon after admission to the PACU. The indications for postoperative chestradiograph were: thoracotomy (30 patients), thoracoscopy (7), central veincatheterization (CVC) (75), pulmonary artery catheterization (3), and mechanicalventiation (36). A staff anesthesiologist examined each patient, evaluatedeach chest radiograph, and decided if a treatment action was to be taken.A chest radiologist later evaluated each chest radiograph, and her interpretationwas compared with the anesthesiologist's interpretation to assess if thismay affect patient management.

Measurements and Main Results.

The anesthesiologist found eightabnormal chest radiographs (8%): three with pulmonary congestion, four inwhom the CVC was in the right atrium, and one with malpositioned CVC. Infour patients (4%), the chest radiographic findings directly affected patientmanagement. The radiologist confirmed the anesthesiologist's interpretationand found four additional abnormalities: one pulmonary congestion, one malpositionedCVC, and two chest radiographs, each with a small pneumothorax.

Conclusions.

Abnormal chest radiographic findings resulted ina change in the management of only 4% of the patients. Therefore, the yieldof a routine postoperative chest radiography in the PACU is low. Performinga chest radiograph for a specific indication rather than on a routine basis,may decrease work load and save expenses. Postoperative chest radiographycan be safely evaluated by a staff anesthesiologist.

UROLOGIE

Computed radiography excretory urography: can the system sensitivityvalue be used as an image quality indicator?

K Andoh, K Odagiri, T Matsumoto, K Yamashita, I Ogino, T Otsuka

Radiology, Kanagawa Cancer Center, 1-2 Nakao-cho, Asahi-ku, Yokohama241, Japan.

Journal of Digital Imaging

1997;

10

: 132-136.

The purpose of this study is to determine whether the computed radiographysystem sensitivity value can be used as an image quality indicator for computedradiography excretory urography with radiation dose reduction. One hundredand twenty-four patients with gynecological malignancies were studied prospectively.Five-minute and 10-minute computed radiographic images of excretory urographywere obtained in each patient with different radiation doses (ie, a standarddose image required with screen-film method and a reduced dose one). Theimages were subjectively scored by three radiologists without knowledgeof the exposure factors or the system sensitivities values. The qualityscores of the reduced-dose images used in the five steps were compared withthose of the standard dose images with reduced exposures were arbitrarilydivided into five steps according to the system sensitivity value (ie, 150to 250, 260-400, 410-600, 610-1000, and 1010-1500). There was a gradualdegradation of the image quality as the system sensitivity values was increased.In terms of visualization of the bones, the images taken with the systemsensitivity values of 150-250 (40%-67% of the standard dose system) showedno statistically significant difference from the standard dose images. Asfor visualization of the renal pelvic margins, the images taken with thesystem sensitivity values of 260 to 400 (25%-38% of the standard dose system)sowed no statistically significant difference. We conclude that system sensitivityvalue can be used as a practical though approximate indicator of the imagequality.

How accurate is computed tomography in predicting the real size ofadrenal tumors? A retrospective study.

DA Linos, N Stylopoulos

From the Department of Surgery, Athens Medical School, Athens, Greece.

Arch Surg

1997;

132

: 740-743.

Background.

The ability to accurately assess tumor size is animportant consideration during the preoperative evaluation of adrenal tumors,particularly solid nonfunctioning mass (incidentalomas or adrenalomas).Does the histological size of the adrenal tumor correspond to the preoperativecomputed tomography (CT)-estimated size?

Objective.

To evaluate the accuracy of CT in predicting the realsize of adrenal tumors.

Design.

Retrospective review of all clinical records of patientswho underwent adrenalectomy from 1984 through 1995. The mean tumor sizereported from CT examinations was compared with the corresponding size obtainedfrom the pathology reports and the statistical difference was evaluated.

Setting.

University and private hospitals in Athens, Greece.

Patients.

Seventy-six patients who underwent adrenalectomy forvarious adrenal diseases and who met strict entry criteria.

Results.

For the entire population, the mean diameter of the tumorswas estimated (CT reports) at 4.64 cm, but the real value (pathology reports)was 5.96 cm (

P

<0.001). The underestimation held true for allof the studied subgroups that were defined by the differant proposed cutoffsfor malignancy. Three patients were incidentally found to have adrenal cancer,with the tumors measuring from 2.6 to 2.9 cm on CT. In addition, 4 pheochromocytomaswere clinically and laboratory "silent" at the time of their discovery.The regression line (

y

= 0.85 + 1.09

x

) elating CT-estimatedand histological tumor size was linear (

r

= 0.90,

P

<.001).

Conclusions.

Computed tomography underestimates the real sizeof adrenal tumors. The CT-estimated value should be corrected accordinglyto obtain the real size. The size of an adrenal tumor, even when corrected,cannot predict the tumor's clinical behavior in many cases. Surgeons shouldalways cautiously interpret the proposed diagnostic cutoffs, especiallywhen considering surgical or conservative management of small nonfunctioningadrenal tumors.

Effects of endocrine therapy on the primary lesion in patients withprostate carcinoma as evaluated by endorectal magnetic resonance imaging.

J Nakashima, Y Imai, M Tachibana, S Baba, K Hiramatsu, M Murai

Department of Urology, Keio University School of Medicine, 35 Shinanomachi,Shinjuku-ku, Tokyo 160, Japan.

Cancer

1997;

80

: 237-41.

Background.

Little effor has been made at the quantitative andqualitative evaluation of patients with prostate carcinoma, including downsizingand downstaging of the primary lesion, after conservative therapy. The currentstudy was undertaken to investigate the qualitative and quantitatives effectsof endocrine therapy on the primary prostate carcinoma using magnetic resonanceimaging (MRI).

Methods.

The primary prostate carcinoma was evaluated by endorectalMRI approximately 4 months after the initiation of endocrine therapy in48 patients with histologically confirmed prostate carcinoma detected byendorectal MRI before therapy.

Results.

The volumes of the prostate gland, the carcinoma, andthe noncarcinomatous components were reduced to 60.2 ± 2.7%, 25.5± 2.9%, and 83.2 ± 6.3% of their pretreatment volumes respectivelyafter endocrine therapy, indicating that the tumors are more susceptibleto endocrine therapy than the nontumorous components. The number of prostatecarcinomas that demonstrated low signal intensity compared with the normalperipheral zone on T2-weighted images decreased after endocrine therapyand the number of carcinomas with enhancement of T1-weighted contrast-enhancedimages increased after therapy. Seven of the 48 patients underwent downstagingafter endocrine therapy, based on the endorectal MRI evaluation.

Conclusions.

The results of the current study suggest that downsizingand occasionally downstaging of the carcinoma may occur after endocrinetherapy in patients with prostate carcinoma. In addition, the androgen sensitivityof the prostate carcinoma tissue is relatively high compared with the residualnoncancerous prostate gland.

Decreased use of post-renal translant imaging.

R. Hefty, RL Wilbrun

Virginia Mason Medical Center, P.PO. Box 900, Seattle, WA 98111.

Urology

1997;

49

: 837-838.

Objectives.

The current need to evaluate necessity and cost ofdiagnostic and therapeutic procedures extends to tranplants services. Wereviewed our experience over the pas 3 years as we have moved away fromroutine post-transplant nuclear medicine scans, ultrasounds, and cystograms.

Methods.

From January 1, 1992 to December 31, 1994, 252 kidneytransplants were performed at Virginia Mason Medical Center. There were74 live donor and 178 cadaver donor kidneys transplanted. The records ofthese patients were reviewed for the type and number of post-transplantimaging done during their initial hospitalization.

Results.

During the study period, the number of post-transplantimaging studies per patient decreased from 2.7 to 1.4 (

P

= 0.000),the percentage of patients discharged without any studies rose from 2.8%to 24.4% (

P

= 0.001), and the trend in 1-year actual graft survivalincreased from 84.7% to 93.0% (

P

= 0.187).

Conclusions.

Post-transplant imaging studies can be safely reduced.Many patients with good initial graft function can avoid having any studies.

DIVERS

Utilization of outpatient diagnostic imaging. Does the Physician'sgender play a role?

MP Rosen, RB Davis, LG Lesky

Department of Radiology, Ansin 250, Beth Israel Deaconess MedicalCenter, East, 330 Brookline Ave., Boston, MA 02215.

J Ger Intern Med

1997;

12

: 407-411.

Objective.

To examine physician and patient characteristics relatedto the ordering of imaging studies in a general medicine practice and todetermine whether physician gender influence ordering patterns.

Design.

Retrospective cohort study.

Setting.

Hospital-based academic general medicine practice of29 attending physicians.

Patients.

All 8,203 visits by 5,011 patients during a 6-monthperiod.

Methods.

For each visit the following variables were abstractedfrom the electronic patient record: patient age, patient gender, visit urgency,visit type, and physician seen. All diagnostic imaging studies performedwithin 30 days of each outpatient visit were identified from the hospital'sRadiology Information System. Screening mammography was not included inthe analysis. Physicians variables included gender and years since medicalschool graduation. Logistic regression analysis was used to evaluate theeffect of various patient, physician, and visit characteristics on the probabilityof a diagnostic imaging study being ordered.

Results.

Patient age, urgen visits, visit frequency, and the genderof the physician were all significantly related to the ordering of an imagingstudy. Correcting for all other factors, the ordering of an imaging studyduring an outpatient medical visit was 40% more likely if the physicianswas female (odds ratio = 1.40; 95% confidence interval [CI] 1.01, 1.95).Female physicians were 62% more likely (95% I 0.99, 2.64) than male physiciansto order an imaging study for a male patient and 21% more likely (95% CI0.87, 1.69) to order an imaging study for a female patient.

Conclusions.

Physician gender is a predictor of whether an outpatientmedical visit generales an imaging study. Reasons for this observation areunclear, but may be the results of different practice styles of male andfemale physicians or unmeasured patient characteristics.

Ionising radiation: are orthopaedic surgeons' offspring at risk?

HG Zadeh, TWR Briggs

The Royal National Orthopaedic Hospital Trust, Stanmore, MiddlesexHA7 4LP.

Ann R Coll Surg Engl

1997;

79

: 214-220.

The hazards of exposure to ionising radiation are well documented. Fearshave been raised that occupational exposure to ionising radiation by orthopaedicsurgeons may have detrimental effects on the future health of their unbornoffspring.

The current members of the British Orthopaedic Trainees' Assocation andorthopaedic consultants appointed during the last 5 years in the UnitedKingdom were contacted using a postal questionnaire. Obstetricians and gynaecologistsof a similar are group were also contacte to act as the control group. Thecollected data were compared with the latest national data as publishedby the Office of Population Censuses and Surveys for England and Wales (OPCS,1991).

In all, 504 questionnaires were posted to orthopaedic surgeons and 1597to obstetricians and gynaecologists. Reply rate were 334 (66%) and 986 (62%),respectively.

Our date reveal a higher rate of congenital abnormalities as comparedwith the normal population in both groups (

P

<0.001). However,there were no statistically significant differences in the rate of congenitalabnormalities between the offspring of orthopaedic surgeons and obstetriciansand gynaecologist (

P

= 0.78). These findings suggest that the increasedrate of congenital abnormalities observed in both groups is more likelyto be associated with factors other than exposure to X-rays.

In this study, male surgeons had a higher incidence of female childrencompared with the normal population (

P

= 0.01).

The incidence of childhood malignancies does not appear to be raised ineither group.

These findings suggest that the current levels of occupational exposureto X-rays by orthopaedic surgeons is unlikely to be associated with an increasedrisk of congenital abnormalities or childhood malignancies in their children.

COMMENTAIRES D'ARTICLE

Pulmonary radiation injuy

B Movsas, TA Raffin, AH Epstein, CJ Link (Chest, 1997;111:1061-76).

Cet article très intéressant analyse les donnéesactuelles du poumon radique.

L'incidence de la symptomatologie varie entre 1 et 34 % avec des signesradiologiques entre 13 et 7 % soit respectivement des signes radiologiquesdans environ en moyenne 43 %. La symptomatologie est très variableavec un délai variant de 1 à 3 mois concernant la pneumonieradique et de 6 à 24 mois concernant la fibrose post-radique.

L'analyse des lésions anatomopathologiques montre une évolutionen trois périodes. Une période précoce de 0 à2 mois est dominée par des lésions vasculaires et par desdépôts de membranes hyalines. La deuxième période,intermédiaire, dure 2 à 9 mois et se traduit par des lésionsd'obstruction vasculaire ainsi qu'une hyperplasie des septa alvéolairesaccompagnées de dépôts de fibroblastes et de l'apparitionde la fibrose. Enfin, la troisième période après 9mois, tardive, est l'installation d'épaississements septaux et dessepta alvéolaires et d'une sclérose traduisant une fibrose.Cette évolution est liée à une cascade de cytokinesdont la sécrétion évolue dans le temps, dominéepar la sécrétion de ß-TGF (beta-transforming growthfactor) qui favorise la prolifération fibroblastique et induit lasynthèse et la sécrétion d'une composante extracellulairede collagène et de fibronectine.

Les lésions radiologiques sont bien décrites avec en particulier,le rappel que l'essentiel des lésions se trouve dans le champ deradiothérapie qui est habituellement limité par des frontièresgéométriques correspondant aux champs d'irradiation et nonpas par des frontières anatomiques. Il est bien souligné quedes lésions peuvent survenir de façon très rare endehors des champs de radiothérapie ce qui est d'ailleurs corrélépar une sécrétion par les deux poumons de lymphocytes obtenusde façon expérimentale par un lavage alvéolaire àpoumons séparés et par une fixation du Gallium. Les lésionsétudiées en tomodensitométrie ne reprennent pas toutela littérature mais montrent qu'il est possible de trouver une relationentre la fréquence des signes tomodensitométriques et l'intensitéde l'équivalent dose. De nombreux marqueurs radioactifs permettentégalement d'analyser les anomalies pulmonaires. Les épreuvesfonctionnelles respiratoires sont très peu modifiées avec,semble-t-il, un indice pronostique de la diffusion de monoxyde de carbonedont l'altération indiquerait l'importance du risque de pneumopathieradique.

Les facteurs prédisposant aux lésions radiques sont égalementtrès bien développés avec notamment, l'importance dela dose totale et de la dose seuil au-delà de laquelle se produisentdes lésions, le fractionnement de la dose, le volume irradiéen rappelant qu'une irradiation des deux poumons >= 30 grays est toujoursfatale. De nombreuses molécules utilisées en chimiothérapiefavorisent également les lésions radiques ainsi que l'arrêtbrutal des corticoïdes. Le problème diagnostique différentielde la pneupopathie radique se fait essentiellement avec le diagnostic d'unerécidive tumorale ou d'une infection, en particulier, la fréquencede pneumocystoses chez les malades immuno-déprimés. Le traitementrepose essentiellement sur la corticothérapie avec environ 80 % deréponses. La corticothérapie prophylactique ne semble pasutile. La prévention de la pneumopathie radique pourrait êtreamenée par un meilleur repérage du volume cible notammentà l'aide de la tomodensitométrie et des simulateurs fondéssur ce principe. Ceci permettrait, d'ailleurs d'augmenter la dose dans lechamp utile avec l'utilisation plus fréquente de collimateurs multilames.

Les voies de recherche sont également bien développéesdans cet article avec, de façon tout à fait surprenante, l'utilisationd'une herbe chinoise administrée quelques jours après uneirradiation chez un rat qui diminuerait le seuil de la pneumopathie radique.De même, la mesure de la TGF-ß pourrait être un indicateurutile, ce qui indique que les recherches se font actuellement dans le domainedes cytokines mais aussi dans la thérapie génique permettantune protection du parenchyme pulmonaire.

J Frija



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