Cardiovascular radiography

The differential diagnosis of acute chest pain and shortness of breath is extensive. A plain chest radiograph often is ordered to aid in establishing the precise diagnosis. Frequently, this useful imaging tool is viewed quickly, and thus, many important diagnostic clues can be missed. This article provides an organized approach to interpreting the chest radiograph and reviews some of the important radiographic findings of various diseases.

TRISS methodology in penetrating trauma: 198 patients at Baragwanath Hospital

TRISS methodology is a statistical technique by which the probability of survival in injury can be estimated. It combines an anatomical index of injury severity (the injury severity score, ISS), a physiological index (the revised trauma score, RTS), age and the mechanism of injury. In this study TRISS was used to assess 198 patients with penetrating injury at Baragwanath Hospital. One hundred and sixty-two patients had stab wounds, 26 gunshot wounds, and 10 received other injuries. Fifty patients were seriously injured (ISS > 15). Four patients (2%) died. The respective probabilities of survival for these four patients, as derived by TRISS, were 0%, 0%, 6% and 46%. TRISS demonstrated that the outcome of the patients as a group was comparable to other centres. TRISS is a useful method for monitoring the effectiveness of a trauma unit and objectively identifying cases for peer review.

Treatment options in high-grade brain tumors: brain brachytherapy

The extremely poor prognosis of high-grade brain tumors (glioblastoma multiforme and anaplastic astrocytomas) has been well documented in the literature. Almost 90% of patients die within 18 months after therapy, most commonly because of local persistence of the tumor, which may be controlled if a sufficient amount of irradiation can be delivered. Currently, postoperative radiation therapy offers the best median survival rate. However, the response to external-beam radiation therapy has reached a plateau because of the intolerance of healthy brain tissue to excessive irradiation. To treat these tumors, brachytherapy (interstitial implantation of radioactive sources) can be used with debulking surgery. This therapy is becoming an effective alternative to conventional external-beam radiation therapy, since it allows a higher dose to be delivered to the tumor bed without damaging the surrounding healthy brain tissue. With continual refinements of the technique, brachytherapy, performed by a skilled brachytherapy team, offers an opportunity to improve patient survival.

Central pontine myelinolysis as a manifestation of the paraneoplastic syndrome

We have described a patient who had lung carcinoma, syndrome of inappropriate antidiuretic hormone, and central pontine myelinolysis (CPM). Although this association is well-known, it appears to be the first report having radiographic documentation of both the intracranial and intrathoracic abnormalities. When searching for the cause of CPM, the possibility of an underlying malignancy should also be considered. This may be more common than the radiology literature would suggest.

Positron emission tomography and its role in the evaluation of brain tumors

Positron emission tomography (PET) is a newly evolving, biological method for quantitative imaging of regional function and metabolism within various organs of the living human body. Whereas existing conventional tomographic imaging modalities--CT and MRI--provide only anatomical information, positron emission tomography provides quantifiable information about organ metabolism and function. Brain tumors are the disease entities for which positron emission tomography is most widely applied. PET has the great potential for providing clinically important information about disease processes. PET has not only had a major impact on the diagnostic role of radiology in brain tumors, but also has potential role for therapeutic application to brain brachytherapy.

Gastrointestinal radiology from the time of Walter B. Cannon to the 21st century

From its very inception, gastrointestinal radiology was at the forefront of radiology, combining physiologic and anatomic information. From evaluation of esophageal motility to the first depiction of gastric ulcers and carcinomas of the alimentary tube, gastrointestinal radiology became indispensable to physicians and surgeons. Improvements in fluoroscopic and radiographic equipment, the tilting table, the image intensifier with the television train, the introduction of selective visceral angiography with safer contrast media and, more recently, digital subtraction angiography, digital ultrasound (US), color Doppler US, computed tomography, and magnetic resonance (MR) imaging--all of these advances have made imaging diagnosis more precise and specific. A new modality--localized tissue MR spectroscopy--should offer an insight into metabolism and suggest optimal modes of treatment and follow-up. The gastrointestinal radiologist of the future will have to be multimodality trained. A new generation of alimentary tract interventional radiologists will further the trend toward less invasive surgical therapy. No end of advances is in sight.

Complementary use of Doppler sonography and delayed right lateral scintigraphy for the diagnosis of choledochal cysts

Both sonography and hepatobiliary scintigraphy can help to demonstrate a choledochal cyst. Our case further demonstrates that Doppler sonography and right lateral or oblique scintigraphic views can be used to differentiate more completely this entity from other infantile cholestatic syndromes. These additional maneuvers may be particularly advantageous in the affected infant under a year old in whom a confusing clinical picture may obscure the correct diagnosis.

Duplex sonography of the portal venous system: pitfalls and limitations

Duplex pulsed-Doppler sonographic examinations of the portal venous systems of 14 patients were reviewed, and the results were compared with the findings of other examinations including endoscopy and angiography. The sonograms of virtually every patient in the sample showed at least one of four pitfalls. The "mirror-image" artifact, in which the Doppler signal contained simultaneous and symmetric elements on both sides of the zero baseline, was identified in 11 patients (79%). The "flip" artifact, in which the Doppler signal would either flip from one side of the zero baseline to the other or would indicate a direction of blood flow opposite to that normally expected, was seen in six patients (43%). In four patients (29%), a Doppler flow signal could not be obtained from small vessels that were identified on standard real-time images. In 10 patients (71%), important vascular channels including bleeding gastroesophageal varices were obscured by bowel gas, ascites, or the patient's body habitus. Duplex sonography may still provide useful information about portal venous hemodynamics. However, it remains a prodigious technical undertaking whose accuracy can be severely hampered by artifacts and inherent technical difficulties.

Routine CT screening of psychiatry inpatients

During a 3-year period, all inpatients in the psychiatry unit underwent routine screening computed tomography (CT) in an effort to detect clinically unsuspected intracranial abnormalities. Of 261 patients examined who had no focal neurologic deficits, 103 had schizophrenia, 71 had depression, 48 had bipolar disorders, and 39 had paranoid delusions. Findings on 230 (88.1%) of the CT scans were within normal limits, and 27 (10.4%) showed only cortical atrophy. The remaining four cases (1.5%) demonstrated basal ganglia calcification (n = 2), old lacunar infarction (n = 1), or osteoma arising from the inner table of the skull (n = 1), all of which were considered to be clinically unrelated to the patients' psychiatric conditions. In the absence of focal neurologic deficits or other findings suggesting an intracranial abnormality (eg, papilledema, seizures, persistent or increasing headaches), there is no justification for routine CT scanning in patients admitted to the hospital for psychiatric disorders.

Evaluation of plain abdominal radiographs in the diagnosis of abdominal pain

In an effort to develop referral criteria for the ordering of abdominal radiographs for patients presenting with abdominal symptoms, we prospectively studied the relation between clinical data and radiographic abnormalities. Of 1780 examinations, 179 (10.0%) showed some radiographic abnormality. If abdominal radiographs would have been limited to those patients who had moderate or severe abdominal tenderness, or to patients with a high clinical suspicion of bowel obstruction, renal or ureteral calculi, trauma, ischemia, or gallbladder disease, regardless of the degree of tenderness, 956 (53.7%) examinations would not have been done. All radiographic abnormalities reflecting a serious pathologic process would have been identified. Only 33 (3.5%) abnormalities of limited significance, almost all localized or generalized ileus, would have been undetected. The adoption of these referral criteria would result in minimal loss of clinically useful information, large financial savings, and a reduction in radiation exposure.