Diffusion-weighted magnetic resonance imaging in ileocolonic Crohn's disease: validation of quantitative index of activity

OBJECTIVES

Magnetic resonance imaging (MRI) allows accurate assessment of Crohn's disease (CD), but requires gadolinium injection. Diffusion-weighted (DW)-MRI yields comparable performances in small bowel CD. We compared the accuracy of DW-MR enterocolonography (MREC) and the magnetic resonance index of activity (MaRIA), and performed an external validation of the Clermont score in assessing inflammation in CD.

METHODS

This was an observational prospective study of a single-center cohort. A total of 130 CD patients underwent consecutively MREC with gadolinium injection and DWI sequences between July 2011 and December 2012.

RESULTS

Of the 848 evaluated segments (small bowel=352, colon/rectum=496), 175 (20.6%) were active (small bowel=111, colon/rectum=64) defined as MaRIA ≥7. Using a receiver operating characteristic (ROC) curve, we determined an apparent coefficient of diffusion (ADC) threshold of 1.9 × 10(-3) mm(2)/s that yielded a sensitivity and a specificity in discriminating active from nonactive CD of 96.9% and 98.1%, respectively, for the colon/rectum, and 85.9% and 81.6%, respectively, for the ileum. ADC was better correlated to MaRIA ≥7 than related contrast enhancement obtained with injected sequences (P<0.001). The Clermont score (=1.646 × bowel thickness-1.321 × ADC+5.613 × edema+8.306 × ulceration+5.039) was highly correlated with the MaRIA (rho=0.99) in ileal CD but not in colonic CD (rho <0.80). Interobserver agreement was high with regard to ADC measurement (correlation >0.9, P<0.001, and concordance >0.9, P<0001).

CONCLUSIONS

DW-MREC is a reliable tool to assess inflammation in colonic (ADC) and ileal (Clermont score) CD and its use in daily practice would avoid gadolinium injection.

Abdominal complications following neutropenia and haematopoietic stem cell transplantation: CT findings

In haematology units, acute abdominal symptoms are common and often challenging for the clinician in charge. Two haematological conditions that may induce specific diagnoses are of particular concern: neutropenia and haematopoietic stem cell transplantation. Clinical and biological manifestations, including abdominal pain, fever, diarrhoea, hepatic cytolysis, or cholestasis are often non-specific. Computed tomography is often the primary imaging screening technique performed in such patients, as it is widely available, performs well for this indication, and may demonstrate evocative findings. The aim of this review is to provide the spectrum of specific diagnoses encountered and the corresponding key CT features in patients presenting with acute abdominal disorders following neutropenia and/or haematopoietic stem cell transplantation.

[Endovascular treatment of SVC syndrome from neoplastic origin: a review of 34 cases]

PURPOSE

To report our experience with the treatment of 34 patients with SVC syndrome from neoplastic origin using the Wallstent.

MATERIALS AND METHODS

Thirty-four patients were treated between January 2000 and February 2007: 21 males and 13 females, aged 44-81 years, with non-small-cell lung carcinoma in 27 cases (79%), small-cell lung carcinoma in 5 cases (15%) and metastatic breast adenocarcinoma to the mediastinum in 2 cases (6%). All patients were treated using the stainless steel self-expanding Wallstent. A dual brachial-femoral access was used in all cases.

RESULTS

Stent placement was possible in all cases. Per procedure acute respiratory distress occurred in 2 cases: 1 case of acute pulmonary edema and 1 case of tamponade. Symptoms resolved within 24 hours. Twenty-six patients died from disease progression, 8 during the first month, and 16 within 32-545 days post-procedure (mean: 213.4 days). Five patients with recurrent SVC syndrome underwent repeat treatment (restenosis in 3 cases, fracture in 1 case, thrombosis in 1 case), for primary and secondary patency rates of 81% and 100%.

CONCLUSION

Palliative stent treatment of neoplastic SVC syndrome is reliable, safe and provides long-standing improvement in quality of life.

Embolization of hepatic and adrenal metastasis to treat Cushing's syndrome associated with medullary thyroid carcinoma: a case report

We report functionally successful hepatic and left adrenal embolization with particles to treat Cushing's syndrome associated with a medullary thyroid carcinoma.

[Type III endoleaks at follow-up of covered descending thoracic aortic stent-grafts: report of 3 patients]

PURPOSE

To describe the imaging work-up and management of type III endoleaks detected after covered stent-graft treatment of descending thoracic aortic aneurysms.

PATIENTS AND METHODS

Retrospective study of circumstances surrounding the diagnosis, management and outcome type III endoleaks occuring in 3 of 18 patients following covered stent-graft treatment of descending thoracic aortic aneurysms between April 1998 and July 2005. The endoleaks were detected at a mean follow-up of 22 months (19-24 months) after stent-graft placement.

RESULTS

The type III endoleaks were detected on scheduled follow-up CT examinations in asymptomatic patients. Endovascular management was proposed at a mean interval time of 4.4 months (1 week - 11 months) after diagnosis of the endoleak, and was successful in all 3 cases. One patient died 1 month after endovascular repeai of the leak, 1 patient required surgical management at 14 months for new recurrence, and 1 patient had a favorable outcome at 2 months.

CONCLUSION

Follow-up of patients after covered stent-graft treatment of descending thoracic aortic aneurysms is required. Prompt endovascular repair of delayed complications may be possible, but surgical management may become necessary.

Centropontine myelinolysis after correction of hyponatremia: role of associated hypokalemia

BACKGROUND

Patients with severe hyponatremia have a high risk for centropontine myelinolysis (CPM) during treatment, but the incidence rate and risk factors have not been well-assessed.

METHODS

This study was conducted in a medical intensive care unit (ICU) of a university teaching hospital. All patients with a serum sodium concentration < 120 mmol/l and a serum osmolality level < 250 mosmol/kg upon ICU admission were enrolled in this prospective study and were included if they underwent a baseline brain computerized tomography scan (CT scan) and a follow-up brain magnetic resonance imaging 1 month after admission. The diagnosis of CPM was based on cerebral magnetic resonance imaging findings, i.e. T1-weighted images with T2-weighted images showing hyperintense signal in the corresponding areas which were not apparent on the initial cerebral CT scan. RESULTS. Of the 22 patients included, 12 were considered as having acute hyponatremia and 8 were chronic alcoholics. In 12 patients, the increase in serum sodium level was < 12 mmol/I in any 24-hour period. CPM was diagnosed in 7/22 patients (31.8%) and was asymptomatic in 4 of them. CPM was present in 4 patients with acute hyponatremia and in 4 chronic alcoholics. It was associated with a lower baseline potassium level (p = 0.05) and NaCl administration during the first 24 hours (p = 0.005). However, non-acute hyponatremia, chronic alcoholism and rapid correction of serum sodium did not appear as risk factors.

CONCLUSION

The incidence rate of CPM following severe hyponatremia is high and can develop even when there is a slow correction of serum sodium level. Hypokalemia is a predisposing factor.

[Impact of computed tomography on patient's care in nontraumatic acute abdomen: 90 patients]

OBJECTIVES

To determine the contribution of computerized tomography (CT) to the management of nontraumatic acute abdomen, to evaluate interobserver agreement and the contribution of CT to cost control, to look for the predictive factors of CT.

PATIENTS

and method. Ninety prospectively included patients, admitted for nontraumatic acute abdomen and examined by a surgeon, received CT examination. Diagnosis and treatment 1) envisioned before and 2) defined after CT, and 3) finally retained were compared, and the interobserver agreement was calculated after the second reading. The predictive value of the clinical and biological criteria as well as the radiological criteria characterizing these patients was sought.

RESULTS

CT was contributive in 68.9% of cases, with a reliable diagnosis and treatment strategy, defined after CT examination, for 92.2% and 90%, respectively. Interobserver agreement was 93.3%. CT contributed to reducing costs in 15.5% of patients, for an additional cost estimated at 104-139 euros. The positive predictive factors of the CT contribution were age over 70 years, localized symptoms, fever, and high CRP.

CONCLUSION

In agreement with the literature, in our study CT appears to be a choice examination to guide patient care in nontraumatic acute abdomen.

Preoperative Uterine Artery Embolization (PUAE) Before Uterine Fibroid Myomectomy

PURPOSE

To evaluate the potential of uterine artery embolization to minimize blood loss and facilitate easier removal of fibroids during subsequent myomectomy.

METHODS

This retrospective study included 22 patients (median age 37 years), of whom at least 15 wished to preserve their fertility. They presented with at least one fibroid (mean diameter 85.6 mm) and had undergone preoperative uterine artery embolization (PUAE) with resorbable gelatin sponge.

RESULTS

No complication or technical failure of embolization was identified. Myomectomies were performed during laparoscopy (12 cases) and laparotomy (9 cases). One hysterectomy was performed. The following were noted: easier dissection of fibroids (mean 5.6 per patient, range 1-30); mean intervention time 113 min (range 25-210 min); almost bloodless surgery, with a mean peroperative blood loss of 90 ml (range 0-806 ml); mean hemoglobin pretherapeutically 12.3 g/dl (range 5.9-15.2 g/dl) and post-therapeutically 10.3 g/dl (range 5.6-13.3 g/dl), with no blood transfusion needed. Patients were discharged on day 4 on average and the mean sick leave was 1 month.

CONCLUSION

Preoperative embolization is associated with minimal intraoperative blood loss. It does not increase the complication rate or impair operative dissection, and improves the chances of performing conservative surgery.

[Long-term MRI follow-up of aortic dissection in 56 patients: therapeutic impact]

PURPOSE

To retrospectively assess the value of MRI in long-term follow-up of aortic dissection (AD) and its impact on therapy.

MATERIALS AND METHODS

Comparison of clinical progression and analysis of 215 MRI examinations performed on 56 patients in our center from 1991 to 2002.

RESULTS

Twenty-six patients (46%) had AD complications: 14 (54%) were asymptomatic and eight (31%) had subsequent surgical repair (native aorta upstream prosthesis disease in three patients and aneurismal dilatation of false lumen in five cases). Of the eight patients with secondary surgery, five (63%) were clinically asymptomatic. The delay between initial dissection and secondary surgery was less than 5 years in five patients and exceeded 10 years in three cases. The remaining 30 patients (54%) had unmodified radiological findings after a mean follow-up of 3.5 years (6 months to 9 years).

CONCLUSION

MRI depicted AD complications in long-term follow-up of sometimes asymptomatic patients, allowing for adaptation of surgical treatment in 26 cases (46%).

Portal vein stenosis and occlusion stenting after liver transplantation in two adults

We report two cases of percutaneous transhepatic stenting of the portal vein to treat stenosis and occlusion disclosed 5 and 18 months, respectively, after orthotopic liver transplantation in two adult patients. If long-term patency is satisfactory, this technique should allow long-term management of portal vein stenosis and occlusion without the use of thrombolysis.

[Femoral superficial artery angioplasty: long term results, initial predictive factors. 101 patients]

OBJECTIVE

To evaluate immediate results, clinical improvement, long-term patency and predictive factors of long-term outcome after superficial femoral artery percutaneous angioplasty.

PATIENTS AND METHODS

Restrospective monocentric study of 101 patients (142 lesions: 105 stenoses and 37 occlusions) technical results, long-term patency (19 months), and clinical improvement (27,5 months) were analyzed. A multifactorial analysis was performed.

RESULTS

Technical success was obtained in 99%, complications and mortality rates were respectively 3% and 2%. At the end of follow-up, 55 patients were clinically improved (20 lost to follow-up), and femoral artery remained patent in 62 patients (10 to follow-up). Statistical analyses revealed 8 significant predictive factors of a good outcome (P<0.05): female gender, non-diabetic, at least one patent artery below the knee, AHA classification <2, no stent, treatment of an occlusion, number of dilatations<3, treatment by statins for hypercholesterolemia.

CONCLUSION

Femoral superficial artery angioplasty is usually achieved with low complication rate. We found eight factors predictive of long-term outcome, to keep in mind when indications are discussed.

Benign mature mediastinal dysembryoma with pulmonary extension revealed by recurrent hemoptysis in a young woman

We report one case of mature mediastinal teratoma with pulmonary extension surgically diagnosed in a 22-year-old woman complaining of recurrent hemoptyses for which no etiological explanation could be found. Thoracic surgery was only decided on after three embolizations proved ineffective.

Angioscanner hélicoïdal de l’aorte abdominale

The purpose was to illustrate that single or multirow spiral CT angiography has become the main modality for the examination of the abdominal aorta. Our multidisciplinary group investigates weekly 15 abdominal aortas, with a single slice spiral CT since 1995, and a 4 row detector spiral CT since 1999. CT scans protocols and parameters optimization for the 2 CT systems are described. Indications and results of CT to investigate the various abdominal aortic diseases are illustrated and discussed: aneurisms (pretherapeutic staging, selection of indications of endovascular stent-grafting); obstructive aorto-arteriopathies (pretherapeutic staging, follow up after endovascular revascularization); dissection (diagnosis, pretherapeutic staging, follow up); inflammatory diseases; normal patterns and principal complications after surgery. Situations where multislice CT is superior to single slice CT and compared advantages of MRI are discussed. CT is at the present time the main technique to image abdominal aorta. Multislice CT is especially interesting to explore the whole aorta, poly traumatisms, and to plan and follow up endovascular treatments.

Evolution of healthy thoracic aortic segment diameter during follow-up of patients with aortic aneurysm or dissection: a magnetic resonance imaging study

We studied the normal evolution over time of the diameter of the healthy descending aorta in patients suffering from aneurysm or dissection of the ascending aorta, in order to anticipate potential complications of endoprosthetic treatment in this aortic segment. During their follow-up (average 35.9 months), 52 patients suffering from aneurysm or dissection of the ascending aorta had 168 aortic MRI examinations (2-7; average 3). Measurements were taken according to conventional reference landmarks making it possible to study the evolution of the diameter of the supposed healthy descending thoracic aorta. The variations in diameter with time were on average 5 mm, and there was no significant variation in this diameter, either for early controls or for the controls carried out after more than 1 year or 3 years, whatever the age group. Thus according to our series it seems that patients with a descending aorta endoprosthesis are not exposed to graft endoleak due to inadequate contact of the prosthesis and aorta within the 5 years following its implantation.

Quand, comment et pourquoi réaliser une imagerie d’un anévrisme de l’aorte abdominale ?

Usually atherosclerotic in origin, aneurysms of the abdominal aorta (AAA) tend to involve the infrarenal aorta. Their biphasic exponential growth pattern, initially slow then accelerated, results in a risk of rupture. Surgical management is recommended for aneurysm diameters of 45-50mm or for growth rates more than 5mm in 6 Months. Imaging is useful for detection and follow-up of nonsurgical aneurysms, presurgical evaluation of aneurysms, and postsurgical follow-up. Frequently asymptomatic, AAA frequently is an incidental finding at the time of abdominal US. The size of the aneurysm sac, the presence of a neck and the size of the iliac arteries are assessed at the time of initial US detection. US is sufficient for follow-up of small aneurysms. Cross sectional imaging evaluation is necessary when surgery is contemplated. Readily available, multidetector row CT scanners with advanced image post-processing capabilities provide all the necessary information prior to surgical or endovascular management: evaluation of the aneurysm sac and neck, iliac and visceral arteries, and adjacent organs. Angiography with graduated catheters remains sometimes indicated. MR angiography provides results similar to CT but is less readily available and is usually reserved for patients with contraindication to iodinated contrast material. While follow-up imaging after surgical management is seldom performed, it is mandatory after endovascular management and includes KUB, Doppler US and CT or MR angiography.

Hypogastric arterial selective and superselective embolization for severe postpartum hemorrhage: a retrospective review of 36 cases

We report on embolization in 36 cases of postpartum hemorrhage (PPH). The 36 patients with severe PPH, including one patient who had undergone an emergency hysterectomy, were transferred to the regional interventional vascular radiology unit in a mean time of 6 hours 12 min. Bilateral occlusion of the anterior trunk of the hypogastric arteries was carried out using gelatin sponge. Immediate success was achieved in all cases. In 3 cases, however, a second embolization was necessary before day 2. In 17%, complementary nonvascular surgery was performed. Complications included one puncture site false aneurysm treated by compression, two cases of regressive lower limb paraesthesia, one femoral vein thrombosis, and nonsignificant puncture site hematomas (19.5%). Long-term follow-up was conducted in 23 patients: 91% resumed regular menstrual cycles, 8.7% dysmenorrhea. New pregnancy occurred in 13% (two full-term pregnancies and one voluntary termination). Immediate efficacy, low morbidity and preservation of fertility make embolization the technique of choice for severe PPH.

Traitement endovasculaire percutané des lésions oblitérantes du carrefour aorto-iliaque : résultats chez 28 patients

OBJECTIVE

We conducted a retrospective analysis of short- and mid-term results of endoluminal treatment of obstruction lesions involving the terminal aorta and the initial portions of the iliac arteries in 28 patients.

PATIENTS AND METHODS

Twenty-eight patients (9 women, 19 men, mean age 57.5 Years) presented 52 obstructive atheromatous lesions of the aorto-iliac bifurcation. The lesions were divided into three topographic groups (9 unilateral lesions, 19 bilateral ostial lesions, 5 widespread lesions of the terminal aorta) and identified as simple (44%) or complex (56%, more than 2 cm in length and/or calcified and/or eccentric).

RESULTS

Technical success was achieved in 93% of the cases with only one hematoma of the puncture site. Primary and secondary patencies were 78.9% and 93% after a mean follow-up of 50 Months (range 4-85). Clinical outcome remained good at this term for all cases of technical success but complete resolution of the symptoms was more frequent when a stent was used (84%) than for simple balloon dilatation (49%).

CONCLUSION

Percutaneous treatment of obstructive lesions of the aorto-iliac bifurcation may be proposed when possible as a first-line treatment.

IRM et dysplasie arythmogène du ventricule droit (DAVD)

PURPOSE

To retrospectively evaluate the contribution of MRI to the diagnosis of arrhythmogenic right ventricular dysplasia (ARVD).

PATIENTS AND METHODS

Thirty two men and 18 women (mean age: 48.7 years) were imaged using gated spin echo scans and short axis cine MR. References were McKenna criteria (gold standard), and also what we called "strong presumption" which may correspond to early or localized patterns, but correspond to negative McKenna scores.

RESULTS

One patient was claustrophobic; another one was lost to follow-up. In reference to McKenna score, diagnosis of ARVD was established in 12 patients (2 of whom had familial dilated biventricular cardiomyopathy with rhythmic expression). Sensitivity, specificity, positive predictive value, negative predictive value and prevalence were respectively: 75%, 75%, 50%, 90% and 25%. Using "strong presumption" criteria, we observed 14 true positives (with sensitivity of 82%, specificity of 87%, PPV of 78%, NPV of 90% and prevalence of 35%).

CONCLUSION

In our group, MRI was always performed before angiography. In our series, right ventricular wall T1W hyperintensity was the most frequent finding.

Management of splenic artery aneurysms and false aneurysms with endovascular treatment in 12 patients

PURPOSE

To assess the endovascular treatment of splenic artery aneurysms and false aneurysms.

METHODS

Twelve patients (mean age 59 years, range 47-75 years) with splenic artery aneurysm (n = 10) or false aneurysm (n = 2) were treated. The lesion was asymptomatic in 11 patients; hemobilia was observed in one patient. The lesion was juxta-ostial in one case, located on the intermediate segment of the splenic artery in four, near the splenic hilus in six, and affected the whole length of the artery in one patient. In 10 cases, the maximum lesion diameter was greater than 2 cm; in one case 30% growth of an aneurysm 18 mm in diameter had occurred in 6 months; in the last case, two distal aneurysms were associated (17 and 18 mm in diameter). In one case, stent-grafting was attempted; one detachable balloon occlusion was performed; the 10 other patients were treated with coils.

RESULTS

Endovascular treatment was possible in 11 patients (92%) (one failure: stenting attempt). In four cases among 11, the initial treatment was not successful (residual perfusion of aneurysm); surgical treatment was carried out in one case, and a second embolization in two. Thus in nine cases (75%) endovascular treatment was successful: complete and persistent exclusion of the aneurysm but with spleen perfusion persisting at the end of follow-up on CT scans (mean 13 months). An early and transient elevation of pancreatic enzymes was observed in four cases.

CONCLUSION

Ultrasound and CT have made the diagnosis of splenic artery aneurysm or false aneurysm more frequent. Endovascular treatment, the morbidity of which is low, is effective and spares the spleen.

[Alveolar echinococcosis of the liver. Mass ultrasound screening in the Haut Cantal area]

OBJECTIVE

Mass systematic screening for alveolar echinococcosis (AE) of the liver in the Haut Cantal endemic area.

MATERIAL AND METHODS

Targeted population was composed of the members of the Mutualité Sociale Agricole of the area, from 16 to 65 years old. 2077 notifications were sent, corresponding to 20% of the population of this area, defined by a triangle between Egliseneuve d'Entraigues, Riom ès Montagne and Saint Flour. Two screening tests were performed: Elisa serology test and liver ultrasound examination.

RESULTS

Participation levels were relatively low-ultrasound: 18.92%, serology: 17%. Among 350 liver examinations, 2 suspicions of AE were found: CT and serology confirmed the diagnosis in the first symptomatic patient; CT and biopsy confirmed the diagnosis in the other asymptomatic patient in whom serology was normal.

CONCLUSION

Ultrasound screening showed at least a 0.57% prevalence of AE, i.e., 2 cases out of 350. This low rate however confirms that Haut Cantal is an endemic area, but with a lower incidence rate than in other endemic areas.

[Thrombosis of the superficial dorsal vein of the penis (penile Mondor's phlebitis). The interest of Doppler examination]

INTRODUCTION

Thrombosis of the superficial dorsal vein of the penis (TSDVP) is a frequent and benign pathology that is often underestimated.

OBSERVATION

A patient consulted for acute erectile dysfunction and pain in the base of the penis due to a TSDVP, which was treated with non-steroidal anti-inflammatory agents and anticoagulants and was followed-up by Doppler ultrasound examination of the penis.

CONCLUSION

Essentially clinical, the diagnosis of TSDVP can benefit from Doppler ultrasound of the penis in difficult cases, because it is a useful tool for correct diagnosis and therapeutic management of the pathology.

Recurrent hemarthrosis following total knee arthroplasty. Report of a case treated with arterial embolization

Recurrent spontaneous hemarthrosis of the knee is common and often related to a detectable cause. In contrast, hemarthrosis after knee arthroplasty is rare and frequently unexplained. We report a case of recurrent hemarthrosis 6 years after total knee arthroplasty. The cause was hypervascularization about the joint, and embolization therapy was effective.

[Graves'ophthalmopathy: usefulness of T2 weighted muscle signal intensity]

OBJECTIVE

Immunosuppressive treatments may be usefull when Graves' ophthalmopathy is active. We evaluated the interest of hypertrophied muscle T2 weighted signal intensity as an argument of disease activity, to help for the therapeutic decision.

PATIENTS AND METHODS

46 MRI in 37 patients with Graves' ophthalmopathy were retrospectively studied.

RESULTS

During the active phase of the disease, centro-muscular hypersignal was always observed (6 cases); signal intensity was not so bright or even disappeared with immunosuppressive treatment (7 cases). We never observed hypersignal when the disease was inactive (4 cases). When there was no hypersignal on T2 weighted images, the disease was inactive in 70% cases, and of low activity in the other cases.

CONCLUSION

T2 weighted centro-muscular signal intensity analyse helps for the therapeutic decision in Graves' ophthalmopathy.

[Cost efficiency study of lacrimal canal obstruction treatment]

OBJECTIVE

To compare three methods used to clear the lacrimal canal.

PATIENTS AND METHODS

A total of 32 files (20 for the dacryocysto-rhinostomy by endoscopic way, 5 for the dacryocysto-rhinostomy by external way and 7 cases of percutaneous stenting) were reviewed. For each, costs of performed interventions were reviewed. An average of the total cost per patient was calculated for all three methods and was then correlated to the initial efficiency of the method.

RESULTS

Results show that the average cost for stenting is up to 1,366.80 EUR, for the endoscopic way is up to 2 001.53 EUR and for the external way is up to 2,220.46 EUR. ANOVA (Analysis of Variance) gives significant results when comparing stent to endoscopic way (p=0.000007) and to the external way (p =0.02). The analysis of sensitivity concerning the success rate of various treatments shows that the stent was potentially the most cost-effective and that a failure rate of 35.1% is rather acceptable by comparison to the endoscopic method. If the stent is considered as an outpatient intervention, then, a failure rate of 50% is acceptable.

CONCLUSION

If the failure rate stays under 35.1%, the stent may be considered as a short-term cost-effective method.

[Idiopathic epiphoras in adults treated with lacrymal-nasal stents]

Fluoroscopic nonsurgical placement of an expandable polyurethane stent is less invasive than surgery for the treatment of epiphora due to obstruction of the nasolacrimal duct. It needs to be performed with the collaboration of an ophthalmologist, using a high resolution digital subtraction imaging unit.

[CT dacryography without selective lacrimal duct catheterization: review of 39 patients]

OBJECTIVES

Dacryographies and CT dacryographies are usually performed after catheterization of a lacrimal canaliculus. We evaluated the quality of opacification on CT scan after simple instillation of contrast medium, without any catheterization.

PATIENTS AND METHODS

39 patients (78 nasolacrimal ducts) were examined for lacrimal pathways obstruction by CT scan after instillation of diluted contrast medium. Additional CT scan imaging was performed after catheterization when the first study did not provide adequate opacification.

RESULTS

CT dacryography after instillation is a well tolerated technique. In our study, it allowed detection of all pathologic lacrimal ducts; 7 normal lacrimal pathways (after catheterization) were not opacified after instillation (false positives). The sensitivity of the method was 100%, its specificity 84%.

CONCLUSION

CT dacryography after instillation is a physiologic, simple and sensitive method to evaluate lacrimal obstruction. We propose it as a first step, catheterization being used only in the absence of opacification after instillation.

[Effect of pelvic member abduction on the kinematics of the thoracic and lumbar spine]

The motion of thoracic and lumbar spine segments has been analysed by mean of the skin landmarks method on 14 volunteers (7 males, 7 females). Results demonstrate that: There is no significant difference between male and female. There is either facilitation, or limitation of the motion of the characteristic landmarks of the spinal segments during trunk motion in perpendicular planes. The mobility of the spinal segments is associated with pelvic girdle motion in order to obtain the planed amplitude, and varies with hips abduction. The analysis of the precise mechanisms of relaxing or stretching of the pelvi-spinal musculo-ligamentous structures constitutes a large field of investigation that necessitates the study of other pelvic limbs postures and needs the use of robotic techniques.

[Prevalence and morphology of pineal cysts discovered at pituitary MRI: review of 1844 examinations]

PURPOSE

To evaluate the frequency, morphology and clinical long term evolution of pineal cysts depicted on MRI.

PATIENTS AND METHODS

one thousand eight hundred and forty four (1 532 women and 126 men) MRI examinations were retrospectively reviewed. Coronal and sagittal spin echo T1 weighted sequences without and with gadolinium injection were performed, completed with spin echo T2 weighted images when a cystic sellar lesion was suspected. A pineal cyst was diagnosed as a rounded well defined lesion, with fluid signal in an enlarged pineal gland. Follow-up examinations were performed to evaluate the efficacy of the treatment of the sellar lesion.

RESULTS

Twenty one epiphyseal cysts (1.27%) were diagnosed in 20 women (1.31%) and one man (0.79%). Their size was 1,2 +/- 0,4 cm (0,3 to 2 cm). They were asymptomatic. In 10 patients, follow-up MRI examinations did not show any change in size. During the clinical follow-up, these twenty-one patients remained asymptomatic (6 months to 5 years).

CONCLUSION

The incidental detection of a pineal cyst at MRI is not exceptional. This lesion's pattern appears characteristic and their reputation of benignity is confirmed in our study.

Percutaneous transluminal renal angioplasty in atheroma with renal failure: long-term outcomes in 99 patients

The aim of this study was to evaluate renal function changes after percutaneous transluminal renal artery angioplasty (PTRA) done to treat atheromatous renal artery stenosis with renal failure. Between 1990 and 1995, PTRA was performed in 99 renal failure patients (creatinine clearance less than 80 ml/min) with atheromatous stenosis of one or more native renal arteries. Indications for PTRA were chronic renal failure with poorly controlled hypertension (group A, 67 patients) or rapidly deteriorating renal function (group B, 32 patients). Renal function changes after PTRA were evaluated based on the percentages of patients with improved, stabilized, and worsened serum creatinine and creatinine clearance values, and on mean differences between final and baseline creatinine clearances. At the end of follow-up (19+/-10 months), group A had a significantly smaller creatinine clearance gain (42.9 ml/min before PTA to 44.5 ml/min after PTA, D=1.6 ml/min, in group A, vs 24.1-28.4 ml/min, D=4.3, in group B, p=0.03), and a significantly smaller percentage of improved patients (36 vs 62%) than group B. Most stenoses in group B either were bilateral or occurred on a solitary kidney ( p=0.001). Percutaneous transluminal renal artery angioplasty combined with aggressive medical treatment may be useful in maintaining or improving renal function, particularly in patients with a recent, sharp deterioration in renal function.

[Complicated polycystic liver disease with intracystic hemorrhage and obstructive jaundice]

Polycystic liver disease, which is generally part of the autosomal dominant polycystic kidney disease, is often asymptomatic. We report a case of obstructive jaundice caused by compression of the biliary tract by a large haemorrhagic liver cyst. The patient was a man with sporadic polycystic liver disease without polycystic kidney disease and with normal renal function for his age. Ultrasound combined with cholangio-MRI provided non-invasive confirmation of intracystic bleeding and intrahepatic biliary dilatation. Obstructive jaundice was confirmed by cyst puncture-aspiration which resolved symptoms and normalized biology. The initial treatment of haemorrhagic liver cyst complicating polycystic liver disease must be medical with cyst aspiration-drainage and sclerotherapy to avoid surgery in these fragile patients.

Visualisation of the portal flows by porto-scanner

This study presents a retrospective analysis of 15 portal vein CT scans, conducted for the evaluation of hepatic metastasis in patients suffering from colorectal cancer, with the aim of verifying in vivo the presence of laminar flow as reported by Pironcof. After selective catheterization of the superior mesenteric artery, CT scans were performed during opacification of the portal vein. Different flows were identified by the incomplete opacification they induced in the portal vein. Splenic flows could always be identified, however right colic and superior mesenteric flows were only seen in 3 cases (20%) and gastrocolic flow in 2 (13.6%). Even though incremental (i.e. slower than helical) the CT acquisitions allowed the flows to be viewed by modifying the visualisation window. In vivo evidence of laminar flow is provided which supports Pironcof's experimental observations.

Influence of the mode of load carriage on the static posture of the pelvic girdle and the thoracic and lumbar spine in vivo

The influence of various modes of carrying a load of 16 kg (15.69 DaN) on the static positioning of the pelvic girdle and the thoracic and lumbar segments of the spine was examined in seven male subjects. The displacement of cutaneous markers attached to easily palpable skeletal landmarks was recorded using 4 CCD cameras; the data acquired were analysed using an optoelectronic technique (SAGA3). The subjects stood upright on an AMTI biomechanical force platform, from which the ground reaction forces enabled displacements of the centre of gravity axis and thus the moment of the mass carried to be determined. The modes of load carriage examined were: 1) in a case in the left hand; 2) in a case in the right hand; 3) equally in two cases; 4) on the head; 5) in a rucksack; and 6) in an anterior bag. The results showed displacements of the pelvic girdle, the caudal and cranial lumbar segments, and the caudal and cranial thoracic segments in the three orthogonal planes (sagittal, frontal and transverse). The influence of the moment created by the load was seen in the statokinesigrams. The use of external markers using an optoelectronic technique, in association with the ground reaction forces, enables the mode of load carriage to be determined. The results show that the influence of the moment exerted by the mode of load carriage on the gravity axis has important ergonomic consequences.

Origin and initial course of the renal arteries a radiological study

The aim of this study was to determine the topography of the origin, implantation angle and initial course of the renal arteries in the transverse and frontal planes, from a prospective analysis of angiograms and helical CT-scans of 40 patients. In the frontal plane, the implantation angles of the right and left renal arteries were 73.8 +/- 17 degrees and 65.6 +/- 16 degrees respectively; 17.9% of the right renal arteries were straight compared with only 5% of the left ones. The first sinuosity was observed to be at a distance greater than the aortic diameter for 43.6% of right renal arteries and at a distance less than the aortic diameter for 62.5% for the left renal a. In the transverse plane, the right renal a. had an implantation angle of 65.6 +/- 15.7 degrees compared with 95.7 +/- 16.85% for the left renal a. The artery was rectilinear in 2.6% of the cases on the right side, and in 2.5% of the cases on the left. The first sinuosity occurred before the lateral margin of the spine was reached in 60.5% of right renal arteries and after the margin of psoas major muscle for 55% of left renal arteries. A knowledge of the anatomy of the origin and initial course of the renal arteries is important when considering vessel dilatation and the implantation of stents in the renal arteries. No correlation was observed between the origin, sinuosity or angulation of the renal arteries which could aid interventional procedures.

Role of hip abduction in the kinetics of the thoracic and lumbar spine

The motion of the thoracic and lumbar spine segments was analysed by mean of the skin landmarks method in 14 volunteers (7 males, 7 females). The results demonstrated that there was no significant difference between men and women and there was either facilitation or limitation of the motion of the characteristic landmarks of spinal segments during trunk motion in perpendicular planes. The mobility of spinal segments was associated with pelvic girdle motion in order to obtain the planned amplitude, and varied with hip joint abduction. The analysis of the precise mechanisms of relaxing or stretching of the pelvivertebral musculo-ligamentous structures constitutes a large field of investigation that necessitates the study of other lower limb postures and the use of robotic techniques.

[Percutaneous recanalization of occluded renal arteries]

Acute embolic renal artery occlusion is usually clinically typical. In case of early diagnosis, an in situ thrombolysis may be effective. As thrombosis often progressively completes a severe renal artery stenosis, the classical clinical description of renal infarction (lumbar pain, hematuria) is frequently not present. The kidney parenchyma downstream from the renal arterial occlusion is not always irreparably lost: collateral circulation may preserve nephron viability, which requires a lower perfusion pressure than glomerular filtration. An iodine, isotopic, or MR gadolinium nephrogram may prove this viability. Over the last 10 years, we attempted 21 percutaneous recanalizations of renal artery occlusion. Mean patient age was 62 years (44-85). All were hypertensive. Serum creatinin level of 17 patients was above 130 micromoles/ml. Three patients were previously hemodialysed. We observed 8 failures, without any complication. Thirteen immediate technical successes occurred, but one rethrombosis occurred at Day 1. Immediate complications were seen in 2 patients: 1 acute pulmonary edema, 1 puncture site false aneurysm. The mean follow up of the 12 technical successes was 26 months (18-60). One rethrombosis occurred at 6 months. Hypertension was unchanged in 4 patients and improved in 8. In all patients with renal insufficiency, a significative improvement of serum creatinine level was observed. It was possible to discontinue hemodialysis in the 3 patients previously hemodialysed. One predictive factor of success was recognized: a short delay (shorter than 90 days) between occlusion and recanalization. Percutaneous recanalization must be proposed in case of renal artery occlusion, especially to avoid vascular azotemia and dialysis, even if the kidney fed by the occluded artery is small.

[Comparative assessment of helical CT-angiography, 2D TOF MR-angiography and 3D gadolinium enhanced MRA in aorto-iliac occlusive disease]

PURPOSE

To compare helical CT-angiography (CTA) and two techniques of MR angiography (MRA) to conventional angiography in aorto-iliac occlusive disease.

MATERIALS AND METHODS

The abdominal aorta and iliac arteries in 22 patients (4 for preoperative assessment of abdominal aortic aneurysm and 18 for peripheral vascular disease) were imaged using four techniques: digital subtraction angiography ("gold standard"), 2D TOF MR angiography, 3D Gd-enhanced MR angiography and helical CT angiography. Source (CTA and 2D TOF MRA) and MIPed images (after subtraction measures before and after gadolinium injection for 3D Gd-MRA) were reviewed.

RESULTS

Sensitivity, specificity and accuracy for the detection of significant (>50%) stenosis and occlusion of aorto-iliac arteries were respectively: 38%, 89%, 77% for 2D TOF MRA; 75%, 71%, 72% for 3D Gd-MRA and 95%, 90%, 92% for CTA. Excluding the internal iliac arteries, results were 54%, 96%, 88% for 2D TOF MRA; 96%, 80%, 83% for 3D Gd-MRA and 92%, 93%, 95% for CTA.

CONCLUSION

3D Gd-MRA, a technique with potential for further improvement, is superior to 2D TOF MRA for detecting significant stenosis and occlusion of aorto-iliac arteries. Results at Gd-MRA are nearly similar to those at CTA (after excluding internal iliac arteries). Results at Gd-MRA are not affected by calcified plaque.

[Aneurysm of the duodeno-pancreatic arcades. Diagnostic imagery and therapeutic indications]

BACKGROUND

Aneurysms of the duodenopancreatic arcades account for 2 to 3% of all aneurysms of the digestive arteries. Mortality is high due to the risk of rupture and the difficult diagnostic situation.

CASE REPORTS

The first case involved a short wide collar aneurysm implanted on the first centimeter of the superior mesenteric artery, associated with tight stenosis of the celiac trunk. The patient complained of diffuse abdominal pain and was treated surgically. In the second case, there was a false aneurysm of the gastroduodenal artery which developed a few months after acute biliary pancreatitis. The aneurysm was treated by exclusion using a transcutaneously delivered endovascular coil prosthesis.

CONCLUSION

These cases illustrate the importance of imaging (magnetic resonance angiography) both for diagnosis and treatment monitoring, allowing early care with very limited morbidity and mortality.

A comparison of the efficacy and safety of ioxaglate and iobitridol in renal angioplasty

PURPOSE

To compare ioxaglate and iobitridol for percutaneous transluminal renal angioplasty (PTRA) as regards thromboembolic complications, the quality of diagnosis, and renal and general safety.

METHODS

One hundred and eighty-nine patients were prospectively studied, 98 of whom received ioxaglate, and 91, iobitridol. Twenty-two were secondarily excluded from the evaluation of thromboembolic complications as they did not undergo PTRA.

RESULTS

Two hundred and two PTRAs were performed. The total volumes of contrast medium administered and the procedure durations were the same for each patient. In the ioxaglate group, four dissections (3 stents), one occlusive dissection, and two spasms occurred; in the iobitridol group, there were three dissections (all stented), one occlusive dissection (stented), and two spasms. The final angiograms showed four renal infarctions with ioxaglate (2 of which were in patients who were not anticoagulated), two with iobitridol. No significant difference was seen in the incidence of thromboembolic complications when the PTRA was performed after anticoagulation (n = 150; 3.9% vs 4%, p = 0.78); in the whole population, thromboembolic complications were more frequent in the ioxaglate group but the difference was not significant (5.7% vs 3.7%, p = 0.74). The quality of the diagnosis and the general and renal safety were the same in the two groups.

CONCLUSION

Regarding the clotting phenomenon, we recorded as many thromboembolic complications with ioxaglate as with iobitridol.

Spiral CT quantification of aorto-renal calcification and its use in the detection of atheromatous renal artery stenosis: A study in 42 patients

PURPOSE

To investigate whether a correlation exists between aortic and renal arterial calcifications detected with spiral CT and significant angiographic renal artery stenosis (RAS).

METHODS

Forty-two patients (mean age 67 years, range 37-84 years), of whom 24 were hypertensive, prospectively underwent abdominal helical CT and aortic and renal arteriography. The 3-mm thickness CT scans (pitch = 1) were reconstructed each millimeter. A manual outline of the renal artery including its ostial portion was produced. Calcific hyperdensities were defined as areas of density more than 130 HU. CT data were compared with the presence or absence of RAS on angiography (24 cases); hypertension and age were taken into account (Mann-Whitney U-test).

RESULTS

CT detection and quantification appeared to be reliable and reproducible. We did not find any correlation between aortic and renal arterial calcifications and RAS, even for the patients above 65 years, with or without hypertension. There was no correlation either between calcifications and hypertension in patients without RAS.

CONCLUSION

In this population, aortic and renal arterial calcifications have no predictive value for RAS.

Infrapopliteal percutaneous transluminal angioplasty for limb salvage

PURPOSE

To evaluate long-term results of infrapopliteal percutaneous transluminal angioplasty (PTA) for limb salvage.

MATERIAL AND METHODS

A retrospective study of 71 consecutive infrapopliteal PTAs in 49 patients with rest pain (n = 20) or ulceration (n = 29) was conducted. In 18 patients, surgical minor amputation or debridment was also performed.

RESULTS

Technical success was achieved in 45 patients. Four failures necessitated 2 amputations. One patient died in the postoperative course. Global morbidity rate was 16%, including minor complications in 5 patients and major vascular complications in 3 patients. After technical success during the follow-up (median duration 21 months), restenoses occurred in 4 patients, of whom 3 had a successful re-PTA (clinical success rate 72%). Survival, primary patency, secondary patency and limb salvage rates were, respectively, 75%, 81%, 88% and 87% after 3 years. The only positive predictive factor for primary patency was the presence of diabetes mellitus.

CONCLUSION

Infrapopliteal PTA is a safe and effective procedure, allowing good patency and limb salvage rates with low mortality and morbidity.

[Abduction of pelvic members and pelvic girdle kinematics]

The analysis of the displacement of the pelvic girdle, during movements of the trunk in the anatomical orthogonal plans, was carried out by the technique of the cutaneous markers on two series of 7 male subjects and 7 female. The photographs made it possible to objectify angular displacements of reliable singular points and to observe that the abduction of hips determines, according to movements carried out, either a facilitation, or a limitation of displacements observed similar in the two series. The precise mechanism of these variations will have to be analyzed by later studies.

[Radio-anatomic study of the angle of origin of dysplastic renal arteries]

PURPOSE

To compare the angulation at the origin of dysplastic renal arteries compared to atherosclerotic renal arteries, in order to improve the technique for percutaneous transluminal angioplasty of FMD.

MATERIALS AND METHODS

Retrospective analysis of 40 aortograms in patients who underwent renal angioplasty for dysplastic stenosis, with comparison with 45 control aortograms (with or without atherosclerotic lesions of the renal arteries). The angle of implantation of the renal arteries was measured relative to the aortic axis in the frontal plane, taking into account only the angulation of its proximal segment. We identified three types of kidneys with regard to their position relative to the renal artery ostium.

RESULTS

The angle of implantation of dysplastic renal arteries is significantly sharper compared with the control group (63.8 degrees vs 80.9 degrees, p = 0.0001), irrespective of the side. The angulation did not correlate with the position of the kidney or the direction of the renal artery, suggesting a congenital origin.

CONCLUSION

The angle of implantation of the dysplastic renal arteries relative to the aortic axis in the frontal plane is sharper than the angle measured in non dysplastic renal arteries.