Chronic expanding hematoma of the spleen caused by angiomyolipoma in a patient with tuberous sclerosis

We report a case of a chronic expanding hematoma caused by an angiomyolipoma of the spleen in a patient diagnosed with tuberous sclerosis in infancy. Computed tomography showed large bilateral renal angiomyolipomas. A splenic mass that increased in size during the follow-up period of 62 months was also noted. A large subcapsular hematoma of the spleen finally developed, and a splenectomy was performed. The splenic mass consisted of a chronic hematoma with prominent granulation tissue, which was considered to be caused by repeated bleeding from a small angiomyolipoma in the spleen.

Laparoscopic splenectomy for an inflammatory pseudotumor of the spleen: operative technique and case report

The case of a primary inflammatory pseudotumor of the spleen in a 44 year-old female is herein reported. This lesion is extremely rare, with only 33 cases previously reported. The splenic tumor was preoperatively diagnosed as a hemangioma by the combined modalities of ultrasonography, computed tomography and magnetic resonance imaging. A laparoscopic splenectomy was, thus, performed in order to make a final diagnosis. Pathological examination of the mass revealed an inflammatory process. Based on the above findings, a laparoscopic splenectomy is recommended when the tumor is suspected to be benign.

Structures of spider toxins: hydroxyindole-3-acetylpolyamines and a new generalized structure of type-E compounds obtained from the venom of the Joro spider, Nephila clavata

Facile structure determination of acylpolyamines, glutamatergic nerve blocker obtained from the venom of the Joro spider (Nephila clavata) was carried out with the use of micro-column LC/MS and high energy collision induced dissociation (CID) mass spectrometry. 6-hydroxyindole-3-acetyl was proposed previously as a putative partial structure, for the acyl moiety of hydroxyindole-type polyamines (NPTX-1 to -6). The NMR data obtained for NPTX-6, NPTX-687 and hydroxyindole-3-acetic acid which was released by acid hydrolysis of Nephila clavata crude venom extracts proved that the lipophilic head is the 4-hydroxyindole-3-acetic acid. Various hydroxyindole-3-acetyl polyamines were found in N. Clavata venom and characterized by mass spectrometry. As a result, type-E, a new class of generalized acylpolyamine structure was proposed in addition to the previously reported polyamine backbones type-A to -D.

Role of virus-induced apoptosis in a host defense mechanism against virus infection

Many animal viruses are known to induce apoptosis in infected cells. This virus-induced apoptosis has been often described as a mechanism of host defense against virus infection, based on the finding that mutants of an insect virus with the ability to induce extensive apoptosis in some cells cannot grow in the same cells. In animal virus infection, we have shown that (1) viruses can somehow overcome this defense mechanism and that (2) virus multiplication in the apoptotic cells is not as completely suppressed as in the insect virus infection. These results suggest that, in the case of animal viruses, the virus-induced apoptosis does not play the same role in the host defense system as in insect cells. However, by examining the virus infection under the conditions comparable to the infection in vivo, we demonstrated the defensive role of apoptosis in animal virus infection.

MRI of groove pancreatitis

PURPOSE

The purpose of this work is to describe the findings on MRI in patients with groove pancreatitis, a specific form of chronic pancreatitis affecting the groove between the pancreatic head, the duodenum, and the common bile duct.

METHOD

MR images, including MR cholangiopancreatography, of five patients with groove pancreatitis were reviewed. Three patients underwent pancreatoduodenectomy due to serve duodenal stenosis, and the MR findings were compared to the histologic findings.

RESULTS

A sheet-like mass was demonstrated between the pancreatic head and the duodenum in all patients. The masses were hypointense relative to pancreatic parenchyma on T1-weighted images and iso- to slightly hyperintense on T2-weighted images. After administration of Gd-DTPA, the masses showed delayed enhancement. Histologically, fibrous scar tissue was detected in the groove.

CONCLUSION

MR images can clearly demonstrate the fibrous tissue in the groove in groove pancreatitis, and MR cholangiopancreatography can also provide useful information.

Autoimmune pancreatitis: CT and MR characteristics

OBJECTIVE

Our goal was to elucidate the CT and MR imaging characteristics in patients with autoimmune pancreatitis, which is a reversible chronic pancreatitis with an autoimmune cause.

CONCLUSION

On CT and MR imaging, a capsulelike rim, which is thought to correspond to an inflammatory process involving peripancreatic tissues, appears to be a characteristic finding of autoimmune pancreatitis. Also, diffuse pancreatic enlargement along with hypointensity on T1-weighted MR images and delayed enhancement on dynamic CT and MR studies are other features of this disorder.

Herpes simplex virus hepatitis in macrophage-depleted mice: the role of massive, apoptotic cell death in pathogenesis

Infection with herpes simplex virus or hepatitis viruses can lead to fulminant hepatitis, but there is controversy about the underlying conditions needed for such disease. To investigate how the impairment of host defences might be involved, macrophages were depleted by administration of silica to mice before intravenous injection with herpes simplex virus type 1 (HSV-1). Such mice died rapidly and their livers were yellowish and shrunken (acute yellow atrophy), and occasionally grossly haemorrhagic. Small foci of apoptotic cells developed in the liver lobules; these rapidly became confluent and zonal over time. The overall lesion pattern was similar to massive hepatic necrosis, and there was extensive HSV replication in the liver lesions. In the liver, DNA fragmentation characteristic of apoptosis followed the time course of HSV-1 propagation. These findings suggest that one of the underlying conditions for fulminant viral hepatitis may be inadequate macrophage response, and that the massive hepatic damage, often defined as cell necrosis, may actually be apoptosis of liver cells subsequent to virus infection.

Uterine lipoleiomyoma: MRI appearances

A case of uterine lipoleiomyoma demonstrated on computed tomography (CT) and magnetic resonance imaging (MRI) is described and usefulness of MRI is discussed in diagnosing this entity.

Optimal MR cholangiopancreatographic sequence and its clinical application

PURPOSE

To determine the appropriate acquisition parameters for magnetic resonance cholangiopancreatography (MRCP) with a half-Fourier rapid acquisition with relaxation enhancement (RARE) sequence; to determine the optimal MRCP technique by comparing half-Fourier RARE, steady-state free precession (SSFP) two-dimensional (2D) fast spin-echo (SE), and three-dimensional (3D) fast SE sequences; and to clarify the usefulness and limitations of MRCP in diagnosing pancreatic abnormalities.

MATERIALS AND METHODS

Half-Fourier RARE MRCP images with varying parameters were compared by using a phantom. Duct conspicuity and contrast-to-noise ratios (C/Ns) were compared for the four MRCP techniques in a phantom and healthy volunteers. The optimal MRCP technique was used to study healthy volunteers and clinical cases. Receiver operating characteristic (ROC) curves were created for data analysis.

RESULTS

A 5-mm-thick section without intersection gap was appropriate for half-Fourier RARE MRCP. Only half-Fourier RARE MRCP could depict a 1-mm duct. C/N was the highest with half-Fourier RARE, followed by 3D fast SE, 2D fast SE, and SSFP sequences. ROC curve analysis revealed no interobserver differences, and the area under the curve for detection of strictures of the main pancreatic duct was as high as 0.89.

CONCLUSION

Half-Fourier RARE MRCP has the highest contrast and spatial resolution among the four techniques studied and may play an important role in diagnosing pancreatic abnormalities.

[A case report of coronary artery bypass grafting in a patient with ankylosing spondylitis]

We reported a case of ankylosing spondylitis who successfully underwent coronary artery bypass grafting (CABG) for unstable angina pectoris. A 67-year-old man was admitted with symptom of anginal pain. Selective coronary angiography revealed coronary artery stenoses; 90% in seg 6, 90% in seg 11, proximal 75%, distal 90% in seg 3, 99% in 4 PD and 99% with delay in 4 AV. The left internal thoracic artery was anastomosed to seg 7 and saphenous vein (SVG) to PL-2, PL-1 sequentially, and another SVG to 4 PD. His postoperative course was uneventful. Cardiac lesions accompanied by ankylosing spondylitis are rare in Japan. Perioperative problems of these lesions therefore, are discussed.

Hypervascular renal transitional cell carcinoma with extension into the renal vein and inferior vena cava

A rare case of transitional cell carcinoma (TCC) with extension into the renal vein and inferior vena cava (IVC) is presented. Computed tomography, magnetic resonance imaging, and angiography successfully delineated tumor thrombus in the right renal vein and IVC. TCC should be included in the differential diagnosis of renal tumors that can cause IVC thrombosis.

[Early HCC and adenomatous hyperplasia: evaluation of arterial and portal blood flow with CTA, CTAP, and pathologic correlation]

In order to analyze the hemodynamic properties of early hepatocellular carcinoma (HCC) and adenomatous hyperplasia (AH), three lesions (two HCCs, one AH) depicted as hypoattenuating at CTA and iso attenuating at CTAP were correlated with the histopathological findings. The number of normal hepatic arteries in the tumor was lower than in the liver. Degeneration and narrowing of the lumens were also seen microscopically. All tumors showed the replacing growth pattern and had similar numbers of the portal tracts in the tumor to the liver. The decreased number of intratumoral normal arteries is suspected to be a characteristic finding of the early stage of HCC.

Factors affecting hypertrophic scar development in median sternotomy incisions for congenital cardiac surgery

BACKGROUND

Even after successful operations on children, unattractive postoperative scars are often distressing to patients and their parents. There are no reports about the factors affecting keloid or hypertrophic scar (HS) development after congenital cardiac surgery.

STUDY DESIGN

Postoperative scars were studied in 75 patients 3 months after congenital cardiac surgery by median skin incision. The mean age of the 51 males and 24 females was 2.7 +/- 2.3 years (range, 2 days-12 years). The scars were evaluated according to degree of redness, expressed as redness score, and skin blood flow, as measured by laser Doppler imaging. Skin blood flow ratio was calculated as blood flow at the scar divided by blood flow below the navel. After surgery, 40 patients received 5 mg/kg/day of tranilast, which inhibits the collagen synthesis of keloid fibroblasts.

RESULTS

None of the 75 patients had keloid formation and 21 (28%) developed HS after operation. Mean age of patients with HS (HS (+) group) was 4.4 +/- 3.3 years and that of patients with no HS development (HS (-) group) was 1.5 +/- 1.9 years (p < 0.01). There were no significant differences between these two groups in gender or in pre- or postoperative cyanosis. Hypertrophic scar (+) patients exhibited significantly higher skin blood flow ratios than HS (-) patients (2.7 +/- 1.3 versus 1.4 +/- 0.6; p < 0.001). Hypertrophic scar was seen in 11 of 40 tranilast administered patients (28%) and in 10 of 34 patients not receiving tranilast (29%) (NS). Hypertrophic scar was less apparent in the patients who received tranilast versus those who did not; redness scores were 29.5 +/- 16.5 and 51.6 +/- 14.9, respectively (p < 0.01).

CONCLUSIONS

These data suggest that age and skin blood flow ratio were the factors affecting HS development. Postoperative use of tranilast did not affect the frequency of HS development but did reduce its redness.

[A case report of emergency mitral valve replacement for infective endocarditis in pregnancy]

Infective endocarditis is extremely rare in early pregnancy. We report an emergency mitral valve replacement performed successfully on a 16 week pregnant woman for infective endocarditis without preexisting heart disease. On admission, the patient was in acute heart failure, and the fetus had been already dead. Induced abortion was performed uneventfully 6 days after the cardiac operation.

Anatomy and clinical importance of cholecystic venous drainage: helical CT observations during injection of contrast medium into the cholecystic artery

OBJECTIVE

The purpose of this study was to use helical CT to elucidate the anatomy and clinical importance of cholecystic venous drainage.

SUBJECTS AND METHODS

We performed helical CT of the upper abdomen during injection of contrast medium through a superselectively catheterized cholecystic artery (cholecystic artery CT) in 28 patients, all of whom were surgical candidates for suspected hepatobiliary abnormality. In nine of these patients, CT during arterial portography (CTAP) was also performed.

RESULTS

Cholecystic venous blood most frequently entered peripheral portal branches of hepatic segment V (27 of 28 patients, 96%) and segment IV (26 of 28, 93%). In order of decreasing frequency, cholecystic venous blood also drained to segments I, VI, VIII, III, and VII. Cholecystic venous blood subsequently drained into the middle hepatic vein (21 of 28, 75%) or right hepatic vein (20 of 28, 71%). In two patients with adenocarcinoma involving the gallbladder associated with multiple liver metastases, cholecystic venous drainage was seen around each metastatic focus. In the nine patients in whom both cholecystic artery CT and CTAP were performed, nontumorous portal perfusion defects were attributable to cholecystic venous drainage.

CONCLUSION

Recognition of cholecystic venous drainage as a possible pathway for spread of disease from the gallbladder to the liver and also as one of the causes of non-tumorous portal perfusion defects seen on CTAP is important.

[Transverse submammary skin incision for congenital cardiac surgery]

Submammary skin incision has been accepted as cosmetic approach for open heart surgery. During November 1990 to February 1995, 39 ASD patients under 15 years old were operated with either median or submammary skin incision in Okayama University Medical School. For these patients, retrospective study was carried out to determine whether submammary skin incision made surgical procedure complex and whether patients were satisfied with the scar by submammary skin incision. There were 14 submammary skin incision (Group S) and 25 median skin incision (Group M). There was no significant difference in patients profile between the two groups except for sex. Operative time, cardiopulmonary bypass time and aortic cross clamp time had no significant difference between the two groups. Postoperative ICU stay and hospital stay also did not differed between the two groups. Questionnaires for evaluation of the subjective operation scar was sent with 32 answers (82%). There was no significant difference on questionnaire findings. However for the patients without hypertrophic scar, more patients in Group S were significantly satisfied with their scars. Submammary skin incision was safe and easy. It could be alternative of median skin incision. If hypertrophic scar formation could be prevented, more patients would be satisfied with submammary skin incision than median skin incision.

Dynamic MRI of the gallbladder lesions: differentiation of benign from malignant

Forty-nine pathologically proven gallbladder lesions were evaluated in 45 patients using dynamic MRI with a spoiled gradient pulse sequence (SPGR), to access the ability of this technique to differentiate benign from malignant gallbladder lesions. The studies were reviewed retrospectively. Signal intensity of the lesions were measured. Twenty-one malignant and 28 benign lesions were classified into three categories: polypoid, diffuse wall thickening, and exophytic. Early and delayed enhancement patterns were evaluated. For the polypoid masses, malignant lesions (n = 9) demonstrated early and prolonged enhancements, whereas benign lesions (n = 14) had early enhancement with subsequent washout (P < .05). For diffuse gallbladder wall thickening, malignant lesions (n = 6) demonstrated early and prolonged enhancement and benign lesions (n = 14) showed relatively slow, prolonged enhancement (P < .05). The exophytic masses (n = 6) all were malignant and demonstrated early and prolonged enhancement. Dynamic MRI can help differentiate benign from malignant gallbladder lesions.

Comparison of helical CT and MR imaging in detecting and staging small pancreatic adenocarcinoma

BACKGROUND

To compare the value of helical computed tomography (CT) and various pulse sequences of magnetic resonance (MR) imaging in the detection and staging of small pancreatic adenocarcinoma.

METHODS

Small pancreatic adenocarcinomas (< or = 2 cm in diameter) in eight patients were evaluated with both helical CT and MR imaging. Five MR imaging pulse sequences that included fat-suppressed T1-weighted images and dynamic study using fast multiplanar spoiled gradient-recalled technique were compared for the tumor detectability. To evaluate the tumor vascularity, angiographic findings were also investigated.

RESULTS

Helical CT delineated the tumor in five cases, and MR imaging depicted the tumor in seven cases. MR imaging could detect the tumor of 0.8 cm in diameter clearly. Although helical CT and dynamic MR imaging missed the tumor of 2 cm with relative hypervascularity, fat-suppressed T1-weighted MR imaging demonstrated it precisely. As for the tumor staging, MR imaging was equal or slightly superior to helical CT.

CONCLUSION

MR imaging is the first modality of choice to evaluate small pancreatic adenocarcinoma, and fat-suppressed T1-weighted images and dynamic study must be performed.

Treatment of hepatic encephalopathy by retrograde transcaval coil embolization of an ileal vein-to-right gonadal vein portosystemic shunt

A 43-year-old non-cirrhotic woman suffered from encephalopathy caused by an extrahepatic portosystemic shunt between the ileal vein and inferior vena cava via the right gonadal vein. Percutaneous transcatheter embolization with stainless steel coils was performed by the retrograde systemic venous approach. Encephalopathy improved dramatically.

New evaluation method for postoperative scar redness

Even after successful operations, ugly postoperative skin scars are often distressing to patients and their parents. To judge the success of surgical methods and postoperative treatment, postoperative scars should be evaluated using a quantitative system. Height and width are easily measured, but scar redness is not. We have developed a simple and effective method for evaluating scar redness. According to the color definitions employed in computer graphics, each color can be expressed as RGB (red, green or blue) coordinates (r, g, b): 0 < or = r, g, b < or = 10. The degree of scar redness is defined by the following formula: redness score (RS) = (r1 - r0)2 + (g1 - g0)2 + (b1 - b0)2. Here, (r1, g1, b1) = coordinates of the scar color and (r0, g0, b0) = coordinates of the surrounding skin color. RS was evaluated in 59 children (35 males, 24 females; ages 1 month to 12 years old) who had scar redness after congenital cardiac surgery. For each patient, scar color and surrounding skin color was identified on the color sample table. Scar redness was also evaluated by the conventional grading method: 1 = mild, 2 = moderate and 3 = severe. The RS of the colored scars ranged from 4 to 100 (38 +/- 27). By the conventional grading method, 44 scars were grade 1, 15 grade 2 and none grade 3. RS was significantly higher among grade 2 than grade 1 patients, 52 +/- 25 and 33 +/- 27, respectively (P < 0.05). Given its subjectivity, the conventional grading method yields variable data surrounding skin color, moreover, is not considered. Our new evaluation method using RS effectively and accurately defines scar and skin colors, and allows quantitative studies of these factors.

Small hepatocellular carcinoma on magnetic resonance imaging. Relation of signal intensity to angiographic and clinicopathologic findings

RATIONALE AND OBJECTIVES

The authors discuss the clinicopathologic features and angiographic vascularity of various signal intensity patterns on magnetic resonance (MR) imaging of small hepatocellular carcinomas (HCCs).

METHODS

Magnetic resonance images of 88 resected HCCs (< or = 3 cm) were obtained using T1- and T2-weighted spin-echo images and T1-weighted images after gadolinium (Gd)-DTPA administration. Images were compared with angiographic and histopathologic findings.

RESULTS

Forty HCCs (45%) were depicted on T1-weighted images, 51 (58%) on T2-weighted images, and 41 (49%) on T1-weighted images after Gd-DTPA administration. Overall, 64 (76%) were found on at least one image. On T1-weighted images, hyperintense HCCs histologically showed fatty metamorphosis and portal tracts within the tumor. On T2-weighted images, HCC hyperintensity correlated with expansive growth, peliotic change, and hypervascularity. By contrast, HCCs that were undetected or hypointense on T2-weighted images were well differentiated with replacing growth and portal tracts. On T1-weighted images after Gd-DTPA, hyperintense HCCs had peliotic change; undetected HCCs were well differentiated and hypovascular.

CONCLUSIONS

Histologic grade, vascularity, portal tracts and peliotic change correlate with MR signal intensity. For hyperintense HCCs on T1-weighted images and hypo- or isointense HCCs on T2-weighted images, treatment methods must be assigned with the consideration that HCCs may be receiving transsinusoidal and portal blood supplies.

Helical CT evaluation of arterial invasion in pancreatic tumors: comparison with angiography

BACKGROUND

Although helical computed tomography (HCT) has been widely employed for the evaluation of pancreatic tumors, its capability in the diagnosis of peripancreatic arterial invasion has not been established.

METHODS

HCT with a sequential cine-display was carried out in 34 patients with solid pancreatic tumors and 28 control subjects without angiographic abnormality. The HCT scans were compared with angiograms.

RESULTS

All major arteries (celiac, superior mesenteric, splenic, gastroduodenal) and superoanterior pancreaticoduodenal arteries were well demonstrated by HCT in control subjects. However, posterior pancreaticoduodenal arcades and other smaller arteries were poorly identified. Although 19 major arterial invasions were equally diagnosed by HCT and angiography in patients with pancreatic tumors, only 4 of 11 minor arterial invasions were correctly diagnosed by HCT.

CONCLUSIONS

Although HCT has some limitations in the evaluation of minor peripancreatic arteries, it can provide enough information for making a decision about conducting pancreatic surgery.

Efficacy of helical CT in T-staging of gastric cancer

PURPOSE

The purpose of this study was to evaluate the performance of helical CT in preoperative T-staging in patients with gastric cancer.

METHOD

A total of 71 patients with an established diagnosis of gastric cancer [75 lesions, 46 early (T1) and 29 advanced (T2 or more) cancers] were evaluated with helical CT. Helical CT was performed with 5-mm slice thickness at 5-mm/s table incrementation. Using the volumetric data by helical scanning, axial CT images (5-mm slice thickness at 5-mm intervals) and multiplanar reconstruction (MPR) images were obtained. CT findings were compared with histopathologic studies of the resected specimen.

RESULTS

Sensitivity of helical CT for gastric cancer was 26% (12 of 46) for early and 100% (29 of 29) for advanced cancer. Three lesions were misdiagnosed as gastric cancer by helical CT. Histopathologically, all early gastric cancers detected by helical CT were either polypoid or elevated types or showed massive invasion of the submucosal layer. The differentiation between T1 cancer with massive submucosal invasion and advanced cancer was difficult. The differentiation between T2 and T3 cancer was possible in 73% (19 of 26) and between T1/T2 and T3/T4 (extraserosal invasion) in 83% (34 of 41). Overall T-staging was correct in 66% (27 of 41). MPR images improved the detection rate (three lesions) or increased confidence in T-staging (eight lesions) over axial CT images.

CONCLUSION

When helical CT detected gastric cancer that was not a polypoid or elevated type with underlying normal-appearing gastric wall, it was either T1 cancer with massive invasion of the cancer cells into the submucosal layer or advanced cancer. However, differentiation between these two stages was difficult on CT. Diagnosis of serosal invasion was not markedly improved by helical CT. MPR images increased confidence in the staging of certain gastric cancers, such as those in locations where CT images are susceptible to partial volume averaging effects.

MR imaging of focal nodular hyperplasia of the liver: value of contrast-enhanced dynamic study

To clarify the role of MR imaging of hepatic focal nodular hyperplasia (FNH), MR images of 11 patients with 13 FNH were retrospectively reviewed. MR imaging with T1- and T2-weighted spin echo sequences was performed for all lesions. Dynamic studies using the SPGR technique followed by postcontrast delayed T1-weighted images were performed in four patients with five lesions. Gd-DTPA enhanced T1-weighted images were obtained in five patients with six lesions. Two patients with single lesions received no contrast agent. The signal intensity, morphologic appearance, and enhancement patterns were evaluated. Dynamic MR study revealed homogeneous early vigorous enhancement and prolonged enhancement in all five lesions. On T1-weighted images, three lesions were hypointense, six were isointense, and four were hyperintense to the surrounding hepatic parenchyma. On T2-weighted images, four lesions were isointense and nine were hyperintense. A central scar was identified in eight lesions and showed delayed enhancement. It is concluded that dynamic MR studies are mandatory for diagnosing FNH.

Indications and problems of coronary artery bypass grafting without cardiopulmonary bypass

As an alternative method of myocardial protection and to obviate the inherent risks of cardiopulmonary bypass (CPB), we have been performing coronary artery bypass grafting (CABG) without CPB in carefully selected patients. Since the first such operation was successfully performed in January 1995 on a patient with angina pectoris and lung cancer, four other patients have subsequently undergone this technique. This series of 5 patients, being 1 man and 4 women ranging in age from 68 to 80 years, is presented in this report. The reasons for the selection of this procedure were concomitant diseases including lung cancer, a calcified aorta, and myocardial infarction. The mean time of ischemia for each anastomosis was 15.3 +/- 5.3 min, and the maximum cardiac muscle creatine phosphokinase (CPK-MB) was less than 14 unit/l postoperatively. None of the patients required ventilatory support for longer than 24 h postoperatively, and oral intake was started within 24 h after extubation in all patients. Postoperative angiography confirmed graft patency and none of the patients developed any ischemic symptoms. All the patients were discharged between 1 and 2 months postoperatively. Thus, the off-pump technique is useful when concomitant diseases are present and will become an alternative method of treatment for coronary artery disease in selected patients.