Evaluation of Parkinson disease and Alzheimer disease with the use of neuromelanin MR imaging and (123)I-metaiodobenzylguanidine scintigraphy

BACKGROUND AND PURPOSE

Progressive changes in the substantia nigra pars compacta and locus ceruleus of patients with Parkinson disease and Alzheimer disease visualized by neuromelanin MRI and cardiac postganglionic sympathetic nerve function on (123)I-metaiodobenzylguanidine scintigraphy have not been fully evaluated. We compared the diagnostic value of these modalities among patients with early Parkinson disease, late Parkinson disease, and Alzheimer disease.

MATERIALS AND METHODS

We compared contrast ratios of signal intensity in medial and lateral regions of the substantia nigra pars compacta and locus ceruleus with those of the tegmentum of the midbrain and the pons, respectively, by use of neuromelanin MRI in patients with early Parkinson disease (n = 13), late Parkinson disease (n = 31), Alzheimer disease (n = 6), and age-matched healthy control subjects (n = 20). We calculated heart-to-mediastinum ratios on (123)I-metaiodobenzylguanidine scintigrams after setting regions of interest on the left cardiac ventricle and upper mediastinum.

RESULTS

The signal intensity of the lateral substantia nigra pars compacta on neuromelanin MRI was significantly reduced in early and late Parkinson disease, and that of the medial substantia nigra pars compacta was gradually and stage-dependently reduced in Parkinson disease. The signal intensity of the locus ceruleus was obviously reduced in late Parkinson disease. Signal reduction was not significant in the substantia nigra pars compacta and locus ceruleus of patients with Alzheimer disease. The heart-to-mediastinum ratio on (123)I-metaiodobenzylguanidine scintigrams was stage-dependently reduced in Parkinson disease and normal in Alzheimer disease. The signal intensity ratios in substantia nigra pars compacta and locus ceruleus on neuromelanin MRI positively correlated with the heart-to-mediastinum ratio on (123)I-metaiodobenzylguanidine scintigrams.

CONCLUSIONS

Both neuromelanin MRI and (123)I-metaiodobenzylguanidine scintigraphy can help to evaluate disease progression in Parkinson disease and are useful for differentiating Parkinson disease from Alzheimer disease.

Parenchymal hypointense foci associated with developmental venous anomalies: evaluation by phase-sensitive MR Imaging at 3T

BACKGROUND AND PURPOSE

The risk of hemorrhage in the context of developmental venous anomaly is considered to be very low, but it has never been evaluated by susceptibility-weighted MR imaging at 3T. The goal of the present study was to evaluate the prevalence of hypointense foci (ie, microhemorrhage or cavernous malformation) associated with DVA on phase-sensitive MR imaging, on the basis of principles similar to those of susceptibility-weighted MR imaging, and to evaluate the relationship between the hypointense foci and several factors, such as white matter hyperintense lesions adjacent to DVA on T2-weighted imaging, DVA morphology, and clinical symptoms.

MATERIALS AND METHODS

This study retrospectively evaluated 61 lesions in 59 consecutive patients with DVA who underwent MR imaging including phase-sensitive MR imaging. Two neuroradiologists independently assessed for the presence of hypointense foci and other factors such as DVA location, depth, size, direction of draining vein on phase-sensitive MR imaging, and white matter hyperintense lesion on T2-weighted imaging. Clinical symptoms were also assessed.

RESULTS

Hypointense foci were observed in 62.3% (38/61) of lesions. White matter hyperintense lesion was more frequently observed in patients with hypointense foci (26/38) than in patients without hypointense foci (7/23) (P < .01). There was no significant association between hypointense foci and other factors.

CONCLUSIONS

Our results support the hypothesis that microhemorrhage or cavernous malformation can be related to venous congestion caused by abnormal venous drainage. We conclude that phase-sensitive MR imagingis useful for the detection of microhemorrhage or cavernous malformation in patients with DVA, especially when associated with white matter hyperintense lesion.

Subarachnoid hyperattenuation on flat panel detector-based conebeam CT immediately after uneventful coil embolization of unruptured intracranial aneurysms

BACKGROUND AND PURPOSE

Flat panel detector-based CBCT can provide CT-like images of the brain without transferring patients from the angiography suite to a conventional CT facility. Conventional brain CT after uneventful endovascular treatment sometimes shows focal subarachnoid hyperattenuation with contrast leakage, mimicking SAH. Differentiating this finding from SAH is important for immediate postprocedural medical management. We investigated CBCT for detecting subarachnoid hyperattenuation immediately after coil embolization of unruptured cerebral aneurysms.

MATERIALS AND METHODS

Thirty-six patients with unruptured cerebral aneurysms undergoing CBCT immediately after uncomplicated coil embolization were included. The relationship between the presence of subarachnoid hyperattenuation and total volume of contrast medium injected, aneurysm size and location, and balloon and stent assistance during embolization was investigated. Statistical analyses were performed with the χ(2) test (P < .05).

RESULTS

Nine of the 36 patients (25.0%) showed focal subarachnoid hyperattenuation within the relevant parent artery territory harboring the aneurysm. Subarachnoid hyperattenuation locations included the ipsilateral superior frontal sulcus (n = 5), the bilateral superior frontal sulcus (n = 1), and the ipsilateral superior frontal and precentral sulci (n = 3). Statistically significant differences were observed between the presence of a subarachnoid hyperattenuation and the total volume of contrast medium injected (P < .001) and aneurysm size (P < .05).

CONCLUSIONS

Subarachnoid hyperattenuation can be detected by CBCT immediately after coil embolization for unruptured aneurysms. The increased amounts of contrast medium to be given before CBCT and the specific location of the hyperattenuation may help differentiate benign subarachnoid contrast leakage from SAH.

Successful closure of intractable tracheoesophageal fistula using a combination of a modified silicon stent and metallic stents

Although surgery is the usual management strategy for acquired benign tracheoesophageal fistula, sometimes this approach is contraindicated or the patient declines surgical management. In this report, we describe a case of a patient with tracheoesophageal fistula at the level of the carina due to bronchial arterial infusion chemotherapy. Closure could not be achieved in response to multiple treatment strategies, including airway stenting, esophageal stenting, occlusion with microcoils, or cyanoacrylate glue. We subsequently achieved closure of this fistula through the combination of a modified silicon stent and metallic stents.

Percutaneous radiofrequency lung ablation combined with transbronchial saline injection: an experimental study in swine

To evaluate the efficacy of radiofrequency lung ablation with transbronchial saline injection. The bilateral lungs of eight living swine were used. A 13-gauge bone biopsy needle was inserted percutaneously into the lung, and 1 ml of muscle paste was injected to create a tumor mimic. In total, 21 nodules were ablated. In the saline injection group (group A), radiofrequency ablation (RFA) was performed for 11 nodules after transbronchial saline injection under balloon occlusion with a 2-cm active single internally cooled electrode. In the control group (group B), conventional RFA was performed for 10 nodules as a control. The infused saline liquid showed a wedge-shaped and homogeneous distribution surrounding a tumor mimic. All 21 RFAs were successfully completed. The total ablation time was significantly longer (13.4 +/- 2.8 min vs. 8.9 +/- 3.5 min; P = 0.0061) and the tissue impedance was significantly lower in group A compared with group B (73.1 +/- 8.8 Omega vs. 100.6 +/- 16.6 Omega; P = 0.0002). The temperature of the ablated area was not significantly different (69.4 +/- 9.1 degrees C vs. 66.0 +/- 7.9 degrees C; P = 0.4038). There was no significant difference of tumor mimic volume (769 +/- 343 mm(3) vs. 625 +/- 191 mm(3); P = 0.2783). The volume of the coagulated area was significantly larger in group A than in group B (3886 +/- 1247 mm(3) vs. 2375 +/- 1395 mm(3); P = 0.0221). Percutaneous radiofrequency lung ablation combined with transbronchial saline injection can create an extended area of ablation.

Magnetic resonance imaging findings of ovarian stromal hyperthecosis

Ovarian stromal hyperthecosis is characterized by diffuse distribution of luteinized stromal cells accompanied by varying degrees of stromal hyperplasia. We report a case of ovarian stromal hyperthecosis with particular regard to magnetic resonance (MR)-pathologic correlation. At initial MR imaging, the central areas of the bilateral ovarian masses showed hypointensity on T1-weighted images and hyperintensity on T2-weighted images, while the peripheries of the bilateral masses showed isointensity to myometrium on T1-weighted images and heterogeneous signal intensities on T2-weighted images. At 15 days after the initial MR imaging examination, a second MR imaging demonstrated shrinkage of the bilateral ovarian masses. Change in the peripheries to predominantly isointensity to myometrium on the T2-weighted images was also observed. The patient underwent bilateral oophorectomy. Microscopic examination revealed scattered nests of lutein cells on a background of densely proliferated ovarian stroma with minimal collagen production in both ovaries. Edema was occasionally seen in the outer portion but was marked in the central zone of the ovaries, particularly on the left. The final pathologic diagnosis was stromal hyperthecosis. With regard to MR-pathologic correlation, the MR findings in the peripheries of the bilateral masses (isointensity relative to myometrium on both T1- and T2-weighted imaging) showed the characteristics of stromal hyperthecosis.

Cerebellar lesions in multiple system atrophy: postmortem MR imaging-pathologic correlations

BACKGROUND AND PURPOSE

Cerebellar atrophy and white matter T2-hyperintensities have been characterized as cerebellar lesions of multiple system atrophy (MSA). The aim of the study was to correlate MR images with histologic findings in cerebellar lesions of MSA.

MATERIALS AND METHODS

Postmortem T2-weighted images using 1.5T were compared with histologic findings in 7 postmortem-proved cases with MSA. The MR imaging findings in the cerebellar cortices and deep white matter dentate nucleus regions were compared with their histologic findings in each case.

RESULTS

We detected 3 types of cerebellar changes: type 1, no apparent atrophy or signal-intensity changes; type 2, cerebellar atrophy and inhomogeneous (patchy and/or confluent) cerebellar white matter hyperintensities; and type 3, cerebellar atrophy and diffuse white matter hyperintensities. Hypointensities were seen in the dentate nucleus regions. Atrophy of the cerebellar white matter was more severe than that of cerebellar cortices, and this anatomy was well depicted on coronal images. Histologically, degeneration was more severe in the cerebellar white matter than in the cerebellar cortices. Hyperintensities in the cerebellar white matter showed loss of myelinated fibers and gliosis. Hypointensities in the dentate nucleus regions revealed diffuse ferritin deposition in preserved dentate nuclei and white matter both around and within the nuclei.

CONCLUSIONS

Hyperintensities in the cerebellar white matter reflect degenerated white matter associated with loss of myelinated fibers and gliosis, whereas hypointensities in the dentate nucleus regions reflect diffuse ferritin deposition in preserved dentate nuclei and white matter around and within the nuclei. Degeneration is more severe in the cerebellar white matter than in the cerebellar cortices.

Clinical studies on the visualization of gastric lesions using virtual CT endoscopy

OBJECTIVE

We evaluated the clinical usefulness of virtual CT gastroendoscopy (VCTGE).

METHODS

The subjects were 124 patients with endoscopically identified gastric lesions. VCTGE images were obtained using a GE-Navigator. We evaluated VCTGE in the visualization of gastric lesions for their presence and morphology.

RESULTS

The detection rate of all gastric lesions by VCTGE was 76% (94 of 124 patients). The smallest detectable early gastric cancer was II c measuring 10 x 8 mm. The detection rates of each gastric lesion by VCTGE were 73% in early gastric cancer, and 90% in advanced gastric cancer. VCTGE imaging in the advanced gastric cancer was good in 12 (30%), fair in 25 (60%) and poor in 4 (10%). VCTGE imaging in early gastric cancer was good in 20 (46%), fair in 12 (27%) and poor in 12 (27%). The significance P level was 0.005 between the evaluation of the imaging of advanced and early gastric cancer.

CONCLUSIONS

VCTGE visualized the characteristics of diverse gastric lesions and was considered useful for the detection and the diagnosis of these lesions.

Heterogeneity of hepatic parenchymal enhancement on computed tomography during arterial portography: quantitative analysis of correlation with severity of hepatic fibrosis

Background/Aims: In patients with chronic liver disease, heterogeneous enhancement of liver parenchyma is often noted on computed tomography during arterial portography (CTAP). We investigated the factors contributing to the heterogeneous enhancement and its relationship with postoperative histopathological findings. Methodology: Eighty-seven patients who had undergone a right lobectomy for liver tumor after CTAP were evaluated. The heterogeneity of hepatic parenchymal enhancement on CTAP was assessed quantitatively using standard deviation of mean CT numbers for five ROIs (S.D.) set in the right hepatic lobe, and comparatively evaluated among three histological groups (liver cirrhosis (LC, n=41), chronic hepatitis (CH, n=33), and normal liver (Normal, n=13)). Severity of fibrosis and degree of splenomegaly (Sp) were taken up as factors contributory to the heterogeneity, and were assessed for correlation with the S.D. Results: The range (mean) of S.D. was LC, 3.07-17.64 (9.10); CH, 1.83-11.12 (6.77); and Normal, 2.06-8.89 (5.64) (Scheffe's F-test: LC vs CH, P<0.0005; LC vs Normal, P<0.0002). The higher fibrosis group exhibited significantly greater S.D. values as compared with the lower fibrosis group (Scheffe's F-test: P<0.00003). Coefficient of correlation between the S.D. and the Sp was 0.295 (P<0.005). Conclusion: There was a fair possibility of LC in patients with heterogeneous enhancement of liver parenchyma on CTAP. The severity of liver fibrosis and the degree of splenomegaly were considered to be factors contributing to the heterogeneous enhancement.

Angiographic and histologic changes in artery, vein and portal vein after placement of bare or covered Z-stent; an experimental study in dogs

The aim of this study was to examine stenosis in the aorta, portal vein (PV), and inferior vena cava (IVC) after bare and covered Z-stent placement. Eight beagles underwent bare (n=4) or polytetrafluoroethylene (PTFE) covered (n=4) Z-stent placement in the aorta, PV, and IVC. Angiography was performed 1 and 3 weeks later to evaluate stenosis. The animals were sacrificed after 3 weeks for histopathologic examination. Angiographic findings revealed that stenosis in the bare stent group tended to be smaller than in the covered stent group in 3 vessels and stenosis tended to be smaller in the order of the aorta, PV and IVC in either group. In both groups, stenosis in the PV and IVC was mainly caused by organized thrombus. In addition, in the covered stent group, the space between the cover and native vessel wall (subgraft space) was formed and filled with neointima in every vessel. Preventing thrombus formation in the PV and IVC after bare and covered stent placement and reducing the subgraft space in the aorta after covered stent placement are important for minimizing stenosis.

An experimental study on hepatotoxicity of sclerosant ethanolamine oleate flowed into portal vein

Although endoscopic injection sclerotherapy has been a main treatment option for gastroesophageal varices, intraportal inflow of the sclerosant, ethanolamine oleate, induce liver damage. The aim of this study was to clarify the liver damage due to intraportal inflow of ethanolamine oleate. Ethanolamine oleate suspension was injected into livers of male Wistar rats via the portal (ileocolic) vein. Degrees of liver damage were evaluated by serum levels of transaminases and by histological examination. Intraportal injection of ethanolamine oleate led to extensive liver necrosis, which was marked 1 day after the injection and recovered by 7 days after injection. Liver necrosis became severe as the dose of the injected sclerosant increased. Histologically, neither portal thrombosis nor embolism was evident. Carbon powder particles of India ink, which were injected together with ethanolamine oleate, reached and deposited in sinusoids of the necrotic portions of the liver. These findings suggested that the liver damage had not developed simply as a result of impairment of portal blood flow. Ethanolamine oleate may itself have direct hepatotoxic effects.

Gadolinium enhanced three-dimensional magnetic resonance portography with subtraction

The aim was to evaluate a subtraction technique for breath-hold gadolinium enhanced three-dimensional magnetic resonance portography (3D-MRP). 26 patients with gastric and/or duodenal varices related to portal hypertension were investigated by 3D-MRP with two phase acquisitions. A partial volume maximum intensity projection (MIP) image after subtracting selective arterial phase images from subsequent portal venous phase images (subtraction 3D-MRP) was compared with the partial volume MIP without subtraction (non-subtraction 3D-MRP) to assess visualization of the portal vein and its collaterals. Subtraction 3D-MRP depicted excellent visualization of the portal vein, although this was not significantly better than non-subtraction 3D-MRP. However, subtraction 3D-MRP gave superior visualization of portal collaterals, with effective suppression of arterial and renal signal intensities, compared with non-subtraction 3D-MRP (p<0.001).

Proton MR spectroscopy of the brain in patients treated with TIPS

PURPOSE

To evaluate the utility of proton MR spectroscopy (MRS) for the early detection of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunting (TIPS).

MATERIAL AND METHODS

Six patients, who underwent TIPS for treatment of portal hypertension, were examined by MRS I week before and 1 week after TIPS. They were simultaneously clinically examined for number connection test, blood NH3 level, liver function test and the Fischer ratio.

RESULT

Three of 6 patients showed overt HE 1 to 5 weeks after TIPS and the other 3 patients did not show overt HE. The overt HE group showed the larger ratio of the amounts of glutamine and glutamate/myo-inositol (Glx/MI) than that of non-overt HE group (p<0.05).

CONCLUSION

The Glx/MI ratio estimated by MRS was useful for early detection of HE after TIPS.

Proton MR spectroscopy of the brain in patients treated with TIPS

PURPOSE

To evaluate the utility of proton MR spectroscopy (MRS) for the early detection of hepatic encephalopathy (HE) after transjugular intrahepatic portosystemic shunting (TIPS).

MATERIAL AND METHODS

Six patients, who underwent TIPS for treatment of portal hypertension, were examined by MRS I week before and 1 week after TIPS. They were simultaneously clinically examined for number connection test, blood NH3 level, liver function test and the Fischer ratio.

RESULT

Three of 6 patients showed overt HE 1 to 5 weeks after TIPS and the other 3 patients did not show overt HE. The overt HE group showed the larger ratio of the amounts of glutamine and glutamate/myo-inositol (Glx/MI) than that of non-overt HE group (p<0.05).

CONCLUSION

The Glx/MI ratio estimated by MRS was useful for early detection of HE after TIPS.

Castleman's disease of the spleen: CT, MR imaging and angiographic findings

Since Castleman and Towne [Castleman and Towne, Hyperplasia of mediastinal lymph nodes, New Engl. J. Med. 250 (1954), 26-30] first described hyperplasia of the mediastinal lymph nodes in 1954, many cases of Castleman's disease have been reported. Lesions originating in the spleen arc extremely rare, and we here describe the imaging appearances for such a case, and discuss with a brief review of the literature.

Embolotherapy for venous impotence: use of ethanol

PURPOSE

To evaluate the usefulness of embolotherapy with ethanol for the treatment of venous impotence.

MATERIALS AND METHODS

Twenty-three patients with venous impotence underwent embolotherapy. The diagnosis of venous impotence was made by means of pharmacocavernosometry and cavernosography. After exposure of the deep dorsal penile vein, a intravenous catheter was inserted directly into the deep dorsal penile vein and advanced into just front of the preprostatic plexus. Fifty percent ethanol was injected through the catheter and the endpoint of the procedure was determined based on results of venography immediately after injection. The procedure was finished when lack of venous leakage was confirmed.

RESULTS

In all patients, the deep dorsal penile vein was successfully exposed surgically, the sclerosing agent successfully injected, and the endpoint successfully achieved. Immediate clinical therapeutic effect (restoration of erection) was obtained in 20 cases (87%). No severe complications were observed during or after the procedure. The follow-up period was 6-50 months. Long-term therapeutic effect was confirmed for 18 of 23 patients (78%).

CONCLUSION

The authors' findings suggest that this treatment had satisfactory short-term and long-term clinical results and that longer follow-up is necessary to confirm its safety.

The hemodynamics of dysplastic nodules in the liver evaluated by CT angiography and immunohistochemistry

BACKGROUND/AIMS

Dysplastic nodules diagnosed pathologically exhibit various hemodynamic patterns. To evaluate these differences in their hemodynamics, we observed basement membrane formation of sinusoids.

METHODOLOGY

For 12 low-grade dysplastic nodules, 24 high-grade dysplastic nodules and 16 hepatocellular carcinomas, both computed tomography during arterial portography and CT arteriography were performed preoperatively. Resected specimens were examined immunohistochemically for COL IV (type IV collagen) and laminin to observe basement membrane formation. We compared their hemodynamics on computed tomography during arterial portography and CT arteriography with the expressions of COL IV and laminin.

RESULTS

All of the low-grade dysplastic nodules were not hypervascular on CT arteriography, and negative for COL IV and laminin. All of the hepatocellular carcinomas were hypervascular on CT arteriography, and positive for COL IV and laminin. High-grade dysplastic nodules exhibit four hemodynamic patterns on CT during Arterial Portography/CT arteriography. All of 7 iso/iso and 5 iso/hypo nodules were negative for COL IV and laminin. Of the 9 hypo/hyper nodules, which exhibited hemodynamics similar to hepatocellular carcinoma, COL IV was identified in 7 and laminin identified in 8 nodules. Of the 3 hypo/hypo nodules, COL IV and laminin were identified in one.

CONCLUSIONS

In high-grade dysplastic nodules, most cases exhibited a correlation between the hemodynamic patterns and the degree of the sinusoidal basement formation.

Tumor marker and MR imaging criteria for evaluating the efficacy of cyclic balloon-occluded arterial infusion for advanced cancer of the uterine cervix

We have already reported satisfactory therapeutic results of cisplatin-based cyclic balloon-occluded arterial infusion chemotherapy (BOAI) enabling treatment by simple total hysterectomy (STH) in patients with advanced cervical cancer of the uterus (cervical cancer), with 2- and 5-year survival rates of 88.9% and 66. 7%, respectively. Considering the fact that 3 to 4 months are needed to complete BOAI, the present study was a retrospective assessment of 18 cervical cancer patients to prepare criteria for the early determination of the efficacy of BOAI in patients who can be treated by STH. The results showed that STH could be performed after the first BOAI in patients with SCC value decreased to 34.3+/-8.2% of the pretreatment value (p=0.0001) and whose tumor size had decreased by 45.1+/-7.5% (p=0.0002).

Hepatocellular carcinoma extending into the portal vein: restoration of extended-term patency by placement of uncovered Wallstents

A 74-year-old man presented with hepatocellular carcinoma extending into the main portal vein. Two bare Wallstents were placed to maintain portal vein patency. The main portal vein remained patent for 6 months after treatment. No serious complications were observed during or after treatment.

[Means of effective and practical intra-arterial chemotherapy for locally invasive bladder cancer--with special reference to clinical analysis of bladder cancer patients treated by intermittent intra-arterial infusion using an implantable port system]

Fifty-six patients with locally invasive bladder cancer were treated by chemotherapy with intermittent arterial infusion from an implanted reservoir and alteration of intrapelvic blood flow. The tip of an infusion catheter was inserted selectively into an internal iliac artery by an angiographic technique. Superior gluteal artery and the other internal iliac artery were then embolized with steel coils so that the drugs would perfuse throughout the tumor through a single catheter. Treatment consisted of intermittent injection of cisplatin (10 mg/body) and doxorubicin (10 mg/body) or epirubicin (10 mg/body) or pirarubicin (10 mg/body) in a ten-minute period every week (for the first 8 weeks) or every two weeks (after the 8th week). Fifty patients were objectively evaluated and the response rate was 80%. The overall survival rate in 54 patients at 1, 3, 5 and 8 years was 83.7%, 61.2%, 52.6%, and 52.6%. The 1-, 2-, 3-, 5- and 7-year disease free survival rate in evaluable 22 patients who showed a complete response (CR) was 91.8%, 85.2%, 65.6%, 58.3% and 58.3%. No serious side effects, such as severe myelosuppression or renal and/or liver dysfunction, were noted during treatment. These findings suggest that intermittent arterial chemotherapy with an implanted reservoir is clinically useful. This procedure appears safe and is easily performed in the outpatient clinic for the treatment of locally advanced bladder cancer.

Hepatic microcirculatory changes induced by hepatic artery embolization in rats: original investigation

RATIONALE AND OBJECTIVES

To evaluate the effects of hepatic artery embolization (HAE), hepatic microcirculatory changes induced by HAE were assessed quantitatively in rats.

METHODS

Using in vivo microscopy, the blood-flow velocity (BFV) through terminal portal venules (TPVs) and terminal hepatic venules (THVs) was measured during HAE with gelatin sponge powder (GSP), iodized oil (Lipiodol, 0.1, 0.2, and 0.4 mL/kg), or 0.1 mL/kg Lipiodol followed by GSP.

RESULTS

After HAE with GSP, BFV through TPVs decreased significantly, but BFV through THVs did not decrease. After HAE with Lipiodol (0.2 and 0.4 mL/kg), BFV through TPVs decreased significantly, but BFV through THVs did not. After HAE with Lipiodol followed by GSP, BFV through both TPVs and THVs decreased significantly.

CONCLUSIONS

Neither GSP nor Lipiodol adversely affects hepatic microcirculation when administered alone; however, HAE with a combination of Lipiodol and GSP does adversely affect hepatic microcirculation.

A case of Budd-Chiari syndrome successfully treated by transcatheter recanalization of the right hepatic vein and transjugular intrahepatic portosystemic shunt

A 40-year-old man with Budd-Chiari syndrome due to chronic obstruction of the major hepatic veins was successfully treated by interventional radiologic procedures. Initially, partial splenic embolization was performed to improve thrombocytopenia and coagulopathy of blood. Second, recanalization was done by thrombolic therapy. Finally, the TIPS procedure was carried out through the recanalized right hepatic vein. This resulted in great improvement of Budd-Chiari syndrome, a marked decrease in pressure, and disappearance of gastroesophageal varices on endoscopy.

[Development of non-iodized oily agent in targeting chemoembolization for hepatocellular carcinoma]

The purpose of this study was to evaluate a new oily agent in targeting chemoembilization for hepatocellular carcinoma. The oily preparation was made by mixing non-iodinated poppy seed oil and a thickener to obtain the same viscosity as Lipiodol. The oily preparation and Lipiodol were compared by injecting them into the hepatic artery of rabbits inoculated with VX 2 carcinoma in their liver. On the CT scan following intra-arterial injection, tumors were visibly stained in the non-iodinated preparation group, whereas the Lipiodol group was not evaluable because of excessively high attenuation. The non-iodinated oily preparation was concluded to be of clinical significance.

A triple coaxial catheter system for subselective visceral artery catheterization and embolization: preliminary clinical experience

We developed a triple coaxial catheter system (TCCS) which consists of a 6.1 Fr outer, a 4.1 Fr intermediate, and a 3.0 Fr inner catheter, all coated with a lubricant. The TCCS was used in seven patients with hepatic tumors, after several attempts to access a targeted vessel with conventional catheters and guidewires failed to reach the targeted vessel. No complications were encountered with the use of this system. TCCS may be a useful device for selective abdominal arteriography.

Percutaneous retroperitoneal splenorenal shunt: an experimental study in swine

PURPOSE

To evaluate the technical possibility of creating a percutaneous retroperitoneal splenorenal shunt (PRESS) in swine as a minimally invasive treatment of portal hypertension.

MATERIALS AND METHODS

Five normal domestic swine underwent creation of a PRESS. A modified transjugular intrahepatic portosystemic shunt puncture set was introduced from the right femoral vein into the left renal vein. The proximal splenic vein was punctured transvenously through the retroperitoneal cavity. Noncovered metallic stents were then placed to connect both veins. The animals were sacrificed 1 hour after the procedure, after follow-up splenic venography and necropsy were performed.

RESULTS

Puncture of the splenic vein and stent placement were successfully completed in all cases. In four of five cases, the splenic venogram revealed good flow from the splenic vein to the left renal vein through the shunt track 1 hour after creation of the PRESS, and there was no evidence of leakage. No changes in vital signs were noticed. At necropsy, a small retroperitoneal hematoma along the stent and minimal intraperitoneal bleeding were observed. The stents were found in the retroperitoneal cavity connecting both veins in all animals.

CONCLUSION

Creation of a PRESS is technically possible, and further experimental studies of its efficacy are warranted.

Assessment of aortic invasion by esophageal carcinoma using intraaortic endovascular sonography

OBJECTIVE

Accurate preoperative assessment of aortic invasion by esophageal carcinoma is of great importance for planning surgery. We compared the accuracy of intraaortic endovascular sonography with that of CT in the diagnosis of aortic invasion by esophageal carcinoma.

CONCLUSION

In this study, intraaortic endovascular sonography was sensitive in detecting aortic invasion; both sensitivity and specificity were 100%. Intraaortic endovascular sonography proved useful in detecting aortic invasion by esophageal carcinoma.

Experimental selective segmental ablation of rat liver by transportal ethanol injection

For use in the treatment of malignant hepatic tumors, we undertook selective segmental ablation of the liver by transportal ethanol injection, first studying its efficacy and safety in rats. We forced a 4:1 mixture of ethanol and contrast medium from a syringe into hepatic tissues via a branch of the portal vein in 80 Wistar rats. The amount of ethanol injected was from 0.05 to 0.60 ml. Soon after the injection, the hepatic segment treated with ethanol was yellowish-white with a distinct outline. Two to three weeks after the injection, the segment was completely necrotic. The findings when a mixture of ethanol and India ink was injected suggested that the necrosis was a direct result of the ethanol. The portal branch into which the injection was made was completely obstructed immediately after the injection. The maximum ethanol concentration in the peripheral blood was 0.4 mg/ml. No histological changes were found in any other organ. Liver and kidney function was almost unaffected. This technique might be useful clinically for the treatment of malignant hepatic tumors.

[Transrectal portal scintigraphy for evaluation of portal hemodynamics before and after TIPS]

In order to evaluate portal venous hemodynamics before and after TIPS, transrectal portal scintigraphy was performed in 8 patients. In all 8 patients, scintigram before TIPS demonstrated hepatofugal flow in the portal vein and less accumulation of radioisotope in the liver. In the scintigrams for follow-up of TIPS, the flow direction in the portal vein changed to be hepatopedal. In 3 of the patients in whom stent shunt was occluded after TIPS, the portal blood flow was turned to be hepatofugal again. It is concluded that transrectal portal scintigraphic studies of the TIPS patients provide noninvasive evaluation of portal hemodynamics.

[Transjugular intrahepatic portosystemic shunt for patients with hepatoma]

Nine patients with hepatoma, 5 with massive ascites, 3 with rupture of esophageal varices and 1 with hematoemesis, successfully underwent TIPS without technical complications. Two of the patients died 3 and 5 months, respectively, after TIPS due to hepatic failure and/or tumor extension. Another patient in whom hepatoma ruptured 1 month after TIPS was experienced. It is concluded that TIPS is a useful and safety treatment for portal hypertension even in patients with hepatoma which was not existed through the puncture route. However TIPS should be performed in patients in whom hepatoma has been controlled by hepatic embolization and/or ethanol injection therapy.

[MR pyelography using fast spin echo technique in hydronephrosis]

MR pyelography using the fast spin echo technique and and a body coil were performed in ten patients with hydronephrosis. In all cases, pyelograms of the dilated urinary tract were obtained by this method, although they were obtained in only two cases by drip infusion pyelography. MR pyelography is an effective method with which to obtain images of dilated urinary tract non-invasively, and in a relatively short time. This method was also useful to evaluate intraureteral structure.

[Usefulness of MR cholangiography with flex coil]

Fast SE MR cholangiography was performed in 10 healthy volunteers and 10 patients with biliary disease, using body, shoulder and flex coils. Surface coils provided better images than the body coil. Although high SNR images were obtained near surface coils, signal intensity decreased in areas distant from the shoulder coil. The flex coil greatly improved image quality, especially in intrahepatic bile ducts, compared with the shoulder coil. The application of a flex coil to MR cholangiography is a highly useful method to evaluate the biliary system.

[Intermittent intraarterial infusion chemotherapy using a subcutaneously implanted reservoir in patients with hepatoma]

Hepatocellular carcinomas that should not be treated with transarterial embolization (TAE) were treated with intermittent intraarterial infusion chemotherapy using a subcutaneously implanted reservoir. Among 37 patients, in whom objective evaluation of the initial response was possible, 3 cases of CR, 12 of PR, 10 of NC and 12 of PD were obtained. The response rate was 40.5%. Culminate 1 year survival rates were 80.0% for responders (CR + PR), 4.5% for non-responders (NC + PD) and 35.1% as an average for all patients. The survival in responder patients was better than in non-responders (p < 0.001). To determine the role of this therapy we divided the cases into two groups by anamnesis of TAE and investigated the initial response and prognosis based on the grade of portal vein invasion in each group. In one group of 18 patients, who had not been treated with TAE, there were no relationships between the grade of portal vein invasion and the initial response and between the grade of portal vein invasion and the prognosis. In this group the initial response was better in patients whose one shot infusion chemotherapy immediately before intermittent intraarterial infusion chemotherapy had been effective than in the others. In the other group of 19 patients, who had been treated with TAE, the initial response and prognosis were better in patients with lower grades of portal vein invasion (Vp0-2) than in those with the highest grade (Vp3).

[Percutaneous arterial prostheses of femoro-femoral bypass: using a new method of Modified Seldinger technique]

An experimental study of percutaneous arterial prostheses of femoro-femoral bypass was performed in 3 dogs using Modified Seldinger technique. Modified Seldinger technique with an arc needle was a newly designed method to penetrate the arterial wall due to introduce a bypass graft into the artery percutaneously. In all dogs, the bypass graft was successfully placed and proved to be effective in excellent blood flow. No significant complication was encountered. It is concluded that this method is feasible in the dog model.

Clinical evaluation of intermittent arterial infusion chemotherapy with an implanted reservoir for hepatocellular carcinoma

A total of 45 patients with advanced hepatocellular carcinoma were treated at Osaka City University Hospital by intermittent arterial infusion chemotherapy with an implanted reservoir. The treatment consisted of intermittent infusion of doxorubicin (5-20 mg/body), mitomycin C (4-10 mg/body) or degradable starch microspheres (600-1200 mg/body) plus doxorubicin (30 mg/body). In all, 26% of the patients received this treatment for disease recurrence following transcatheter arterial embolization (TAE). Among 43 evaluable patients, 4 showed a complete remission (CR) and 16 showed a partial response (PR) on computed tomograms and angiograms. For all 45 patients, the 1-year survival value was 41% and the 2-year value was 14%. Of the 20 patients who showed a CR or PR, 77% survived for 1 year and 29% survived for 2 years. Tumor regression showed a close relationship with the duration of survival. Intermittent arterial infusion with an implanted reservoir caused the least adverse reactions and seems to be appropriate for use in patients with advanced tumor extension or stenosis of the hepatic artery caused by repeated TAE.

[Ethanol injection for embolization of varicocele]

Five patients were treated for varicocele by embolization with the use of ethanol, which has not been used before. The ethanol was injected into the spermatic vein involved in the varicocele by the technique of spermatic venography. Embolization was successful in all five patients. During the follow-up period, the varicocele became smaller or disappeared in four of the five patients. In one patient, catheterization was difficult, and the effect of ethanol was unsatisfactory because of the location of its release. The varicocele appeared again 13 months after embolization. Serious side effects were not found in all patients. Embolization therapy with ethanol is easily performed and is considered to be a safe and effective method.

[Selective segmental sclerotherapy of the liver by transportal ethanol injection--a complete remission case of hepatocellular carcinoma]

Selective segmental sclerotherapy of the liver by transportal ethanol injection (SSS) was devised and evaluated in a case of hepatocellular carcinoma. The patient was a 72-year-old man suffering from unresectable hepatoma. Injected ethanol with an amount of 20 ml into the portal branch under occluding the portal flow by balloon catheter produced complete necrosis of the liver proportional to the injected liver segment including the tumor on CT. Because of ethanol perfusion into sinusoid level by wedge injection, its cytotoxicity maybe affected liver cells directly. In this case, there has been no evidence of inadvertent liver damage and a significant rise in the blood ethanol level. The present technique of SSS in this clinical case and our past animal experience seemed to yield the same condition as resection without surgical disadvantages and be apparently a safe method, which is suggested for clinical use for several hepatic tumors.

[Experimental and clinical studies on degradable starch microspheres (DSM) in the treatment of hepatic neoplasms]

To evaluate the effect of hepatic arterial chemotherapy combined with DSM, experimental and clinical studies were performed. Experimental study: Hemodynamic and histological changes induced by intra-arterial administration of DSM were investigated in the kidneys of rabbits. The degree of blockade of arterial blood flow was correlated with the dosage of DSM, and estimated by the angiographic change. Histological changes also depended on the dosage of DSM. Although administration of less than 6 mg DSM induced little or no histological changes, more than 15 mg of DSM induced extensive necrosis of renal tubules. Clinical study: The hepatic arterial chemotherapy combined with DSM was performed in 63 patients (hepatomas in 45 and metastatic tumors in 18). Fourteen patients (30%) showed partial or complete response. Patients with a higher degree of blockade of arterial blood flow tended to have a better response. Analysis of CT images suggested that DSM not only enhance the chemotherapeutic agents but also the ischemic effect. In conclusion, degree of blockade of arterial blood flow is controlled by the change in DSM dosage, and DSM administration combined with chemotherapeutic agents may have the potential to improve the therapeutic effect.

Changes in serum enzyme activity after transcatheter arterial embolization for hepatic neoplasm

We assayed serum levels of certain enzymes and tumor markers in patients after transcatheter arterial embolization (TAE) to evaluate the effectiveness of this treatment. Twenty patients had hepatocellular carcinoma and two patients had metastases to the liver from colon cancer. Assays were first done immediately after TAE and were continued for the next 12 days. Glutamic oxaloacetic transaminase (GOT; EC 2.6.1.1, L-aspartate:2-oxoglutarate aminotransferase), glutamic pyruvic transaminase (GPT; EC 2.6.1.2, L-alanine:2-oxoglutarate aminotransferase), and lactate dehydrogenase (EC 1.1.1.27; (S)-lactate:NAD+ oxidoreductase) peaked 24 to 48 h after TAE and returned to the base lines in 7 to 10 days. Mitochondrial GOT (mGOT) and glutamate dehydrogenase (GLDH; EC 1.4.1.2, L-glutamate:NAD+ oxidoreductase) also peaked at the same time after TAE. alpha-Fetoprotein peaked 2 h after TAE and decreased to half of the baseline on day 7. Carcinoembryonic antigen peaked at 24 h and fell at 48 h only in the patients with colon cancer. The total amount of cytosolic GOT, GPT, mGOT, and GLDH released was correlated to the volume of the necrotic mass estimated by computed tomography scans. The correlation coefficients for mGOT and GLDH were r = 0.919 and r = 0.939 (both p less than 0.001), respectively. Assays of mGOT and GLDH may be useful to estimate the volume of the necrotic mass of a hepatoma or metastatic carcinoma in the liver.

[The availability of digital subtraction angiography using continuous intra-arterial infusion tubes founded various malignancy]

DSA was employed using continuous intraarterial infusion tubes for various malignancies (73 cases) which were examined a total of 135 times. In head and neck malignancy (50 cases), the general position of the infusion tube had been determined beforehand by dye infusion, but DSA from the tube showed that the tubes in 24 cases (48%) were located in the wrong position, especially in tongue cancer (21 cases) where many tubes were discovered to be in an erroneous position (71%) such as the common carotid artery. We were unable to determine the effect of chemotherapy and radiation using DSA only. In 9 cases of breast cancer for which fixation of the tube was not attempted under X-ray fluoroscopy, 7 (78%) showed an unusual tube position such as the intraaortic arch. In 5 cases of abdominal malignancy, only the tube position for sigmoid colon cancer was unusual. We were able to observe the effect of chemotherapy by DSA in 2 cases. For DSA in one out of 3 hepatomas using a Port-A-Cath, we observed that infusion of anticancer drug with degradable starch microspheres caused a reduction in tumor size. However, in the two remaining cases, we were unable to observe any effect of infusion of these drugs by DSA for various mechanical reasons. DSA from an infusion tube revealed not only the location of the tube accurately and promptly, but also the effect of chemotherapy.