Color-coded Doppler imaging of normal vertebral arteries

Using color-coded Doppler sonography, we studied the vertebral arteries of 42 persons without history or physical signs of vertebrobasilar disease. The intertransverse portion of the vertebral artery was visualized in all persons on both sides. Its origin was visualized in 37 persons (88.1%) on the right side and in 28 (66.7%) on the left; the atlas loop was visualized in 32 persons (76.2%) on the right side and in 36 (85.7%) on the left. Four vertebral arteries were hypoplastic. Peak systolic blood velocity ranged from 19 to 98 (mean 56) cm/sec and peak diastolic blood velocity ranged from 6 to 30 (mean 17) cm/sec. Resistive indices ranged from 0.62 to 0.75 (mean 0.69). Thus, color-coded Doppler sonography seems to be a promising noninvasive method for the evaluation of hemodynamics in the extracranial portion of the vertebral arteries.

Bone mineral density and parameters of bone metabolism in patients with acromegaly

To assess the effect of chronically elevated plasma growth hormone (GH) levels on bone metabolism and bone mineral density (BMD), 16 patients (10 females and 6 males) with a mean age of 49.1 +/- 13.2 years (range 33-68) with active acromegaly were studied and compared to a control group of 16 sex- and age-matched subjects. BMD of the lumbar spine and two different sites of the proximal femur were measured by dual-energy x-ray absorptiometry (Norland XR-26). In the acromegalic patients the mean plasma GH concentration was 30.1 +/- 11.1 micrograms/liter, and the mean plasma somatomedin C (SMC) concentration was 6.5 +/- 1.5 U/liter. Mean serum osteocalcin (OC) levels (14.3 +/- 1.1 versus 7.2 +/- 0.4 ng/ml, p < 0.001) as well as the urinary hydroxyproline excretion (OHP; 8.8 +/- 1.4 versus 2.7 +/- 0.3 mg, p < 0.0001) were significantly higher in the acromegalic patients than in the control subjects. In the acromegalic patients BMD was significantly elevated in the two examined regions of the proximal femur, that is, the femoral neck (1.06 +/- 0.05 versus 0.86 +/- 0.03 g/cm2, p < 0.05) and Ward's triangle (0.92 +/- 0.06 versus 0.76 +/- 0.03 g/cm2, p < 0.02), whereas the BMD of the lumbar spine was not significantly different from that of control subjects. Among the patients with acromegaly a significant positive correlation between serum OC concentrations, on the one hand, and urinary OHP excretion (r = 0.7, p < 0.004) as well as BMD in the proximal femur (r = 0.64, p < 0.007), on the other hand, could be observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Discrete lung involvement in systemic lupus erythematosus: CT assessment

PURPOSE

To study the computed tomographic (CT) appearance of early lung involvement in systemic lupus erythematosus (SLE).

MATERIALS AND METHODS

In a prospective study, 48 patients with serologically confirmed SLE but no prior clinical evidence of lung involvement underwent chest radiography, CT, and lung function tests. Radiographs and CT scans were compared, and CT scans were evaluated for signs suggestive of parenchymal and pleural disease. Extent and distribution of disease were determined. CT findings were correlated with clinical and functional data.

RESULTS

Of 45 patients with normal chest radiographs, 17 (38%) had abnormal CT findings. Extent of disease was statistically significantly correlated with duration of clinical history (r = .93) and decreased single-breath diffusing capacity for carbon monoxide (r = .8) and ratio of forced expiratory volume in 1 second to forced vital capacity (r = .77).

CONCLUSION

CT is superior to chest radiography for detection of functionally relevant pulmonary disease and is an important adjunct in early assessment of SLE.

Bronchial wall thickness: appropriate window settings for thin-section CT and radiologic-anatomic correlation

PURPOSE

To analyze the influence of computed tomographic (CT) window settings on bronchial wall thickness and to define appropriate window settings for its evaluation.

MATERIALS AND METHODS

Three inflation-fixed lungs were scanned with a section thickness of 1.5 mm by using a high-spatial-frequency algorithm. Wall thickness in 10 bronchial specimens was measured with planimetry. Window centers were altered in a range of -200 to -900 HU and window widths in a range of 400-1,500 HU. Relative and absolute differences between CT and planimetric values were calculated. CT and planimetric measures were correlated. Inter- and intraobserver variabilities were determined.

RESULTS

Window widths less than 1,000 HU resulted in a substantial overestimation of bronchial wall thickness, whereas widths greater than 1,400 HU resulted in an underestimation of bronchial wall thickness. There was no interaction between "width" and "center" regarding their influence on bronchial walls (F = 0.23; P = .99). Correlation between CT and planimetry was statistically significant (r = .85; P = .0001). Differences between the two observers were not statistically significant; results of the measurements of the two observers correlated well (r = .97; P = .001).

CONCLUSION

Bronchial wall thickness on thin-section CT scans should be evaluated with window centers between -250 and -700 HU and with window widths greater than 1,000 HU. Other than window settings, notably window widths less than 1,000 HU, can lead to substantial artificial thickening of bronchial walls.

123I-vasoactive intestinal peptide (VIP) receptor scanning: update of imaging results in patients with adenocarcinomas and endocrine tumors of the gastrointestinal tract

Recent data suggest that functional receptors (R) for vasoactive intestinal peptide (VIP) are expressed on various tumor cells. The high-level expression of VIPR on tumor cells provided the basis for the successful use of 123I-labeled VIP for the in vivo localization of intestinal adenocarcinomas and endocrine tumors. We here report an update of our imaging results using 123I-VIP (150-200 MBg/1 microgram/patient) in 169 patients. In patients with pancreatic adenocarcinomas without liver metastases, the primary/recurrent tumor was visualized in 16 of 18 patients (89%) and liver metastases were imaged in 15 of 16 patients. In 11 of 12 patients with colorectal adenocarcinomas, the primary/recurrent tumor (92%) was imaged by 123I-VIP. Also, in 21 of 25 patients, liver metastases (84%); in 3 of 6 patients, lung metastases (50%); and in 4 of 5 patients, lymph-node metastases (80%) were imaged by 123I-VIP. In 10 of 10 patients with gastric adenocarcinomas, the primary/recurrent tumor; in 3 of 4 patients, liver metastases; and in 2 of 2 patients, lymph-node metastases were visualized by 123I-VIP. 123I-VIP localized primary intestinal carcinoid tumors in 15 of 17 patients (88%) and 8 of 10 primary insulinomas (80%). We conclude that the 123I-VIPR scintigraphy localizes intestinal adenocarcinomas and endocrine tumors as well as metastatic tumor sites.

Update: abdominal tuberculosis--unusual findings on CT

To update our knowledge of abdominal tuberculosis as manifested on computed tomography (CT), we reviewed the CT scans of 12 patients with proven abdominal tuberculosis. The nature, range and extent of abdominal involvement was determined. The CT findings were compared to those reported in the literature. The aetiologic agent was Mycobacterium tuberculosis in all patients. One patient had an increased risk because of AIDS. In nine patients, tuberculosis was limited to the abdomen, and three patients had previously unknown thoracic tuberculous disease. Characteristic features in our patients included low density ascites and uncommon patterns of adenopathy. Findings reported to be typical in abdominal tuberculosis were present in only five of our 12 patients. Unusual findings in our patients included solitary and multiple pelvic, adrenal, splenic and hepatic lesions. In six of 12 patients, those findings mimicked malignancy. We conclude that knowledge and early recognition of these unusual manifestations of abdominal tuberculosis should help to optimize clinical management of the disease and avoid misdiagnosis.

Position of jugular oxygen saturation catheter in patients with head trauma: assessment by use of plain films

OBJECTIVE

The purpose of this study was to establish a plain radiographic technique for the assessment of the position of a jugular oxygen saturation catheter in patients with head trauma.

MATERIALS AND METHODS

In the experimental study, jugular oxygen saturation catheters were introduced into the internal jugular veins of four cadavers. Correct positioning of the catheter tips was monitored by CT. Concurrent anteroposterior radiographs of the skulls were obtained with the tubes angled in a transverse plane and in a sagittal plane at intervals of 5 degrees and within a total range of 70 degrees for each plane. Three radiologists judged the visibility of the catheter tips and measured the distance of the catheter tips to previously determined bony landmarks of the skull. Then, preliminary radiologic criteria for correct positioning of the catheters were defined. In the clinical study, we prospectively evaluated radiographs for 32 patients who received jugular oxygen saturation catheters. Eleven patients had digital radiographs done, and 21 patients had radiographs with a conventional screen film system done. Radiographs were analyzed for consistency of findings with the experimental results and for consistency of the suspected catheter position with laboratory data.

RESULTS

Results of the cadaveric study showed that catheter position is best assessed on strict anteroposterior radiographs with the orbitomeatal-basal line perpendicular to the plane of the film. A correctly positioned catheter tip should lie cranial to a line extending from the atlantooccipital joint space and caudal to the lower margin of the orbit. The catheter tip also should lie cranial to a line connecting the tips of the mastoid processes, with a catheter tip-to-line distance averaging 20% of the overall distance between the tips of the mastoid processes. According to these criteria, the catheter was properly positioned in 26 of 32 patients. In three patients, the catheter obviously was improperly positioned. Catheter position was equivocal in three other patients; in two of these patients, the catheter was looped within the internal jugular vein. Whereas for all 26 patients with properly positioned catheters values for jugular venous oxygen saturation were congruent with other laboratory data, incongruent saturation values were recorded for five of the six patients with equivocally or obviously improperly positioned catheters.

CONCLUSION

Accurate assessment of the position of a jugular oxygen saturation catheter can be made by use of specific bony landmarks seen on anteroposterior radiographs of the skull.

Renal allograft arteriovenous fistula due to needle biopsy with late onset of symptoms--diagnosis and treatment

A post-biopsy arteriovenous (AV) fistula in a renal allograft was diagnosed using color-coded Doppler sonography. Because the patient was asymptomatic, no specific treatment was initiated. 15 months after the diagnosis was established, severe hematuria with obstruction of the bladder occurred. Angiography revealed a connection of the fistula to the renal pelvis. The patient was treated successfully by transarterial embolization of the fistula. As a conclusion, we suggest periodical follow-up examinations of asymptomatic AV fistulas in renal allografts using color-coded Doppler sonography during 3-6 months. When no spontaneous regression of the fistula can be observed, embolization therapy should be performed even when the fistula is asymptomatic, in order to prevent late onset of complications.

Extra-CNS metastases of glioblastoma: CT and MR studies

The case of a 29-year-old man with glioblastoma and multiple metastases outside the CNS is presented. Cervical lymph node involvement was ascertained with CT and magnetic resonance (MR), and numerous bone metastases were detected with skeletal scintigraphy. The extent of the cervical tumor and its relationship to the carotid artery could be better assessed with MR than with CT. The patient died despite repeat operations, radiotherapy, and intraarterial systemic chemotherapy. The importance of radiological screening for detecting glioblastoma metastases in patients with long survival is discussed.

[Radiologic therapy of symptomatic lymphoceles following kidney transplantation]

During a four and a half year period ending in November 1988, we performed 13 percutaneous needle aspirations and 35 percutaneous drainages on 32 patients suffering from symptomatic lymphoceles (LC) following renal transplantation. Of 13 needle aspirations, 4 were therapeutic (31%); in 9 cases recurrent lymphoceles were observed within 3 days. 35 percutaneous catheter drainages were carried out on 29 patients. 16 of these (55%) did not require any additional therapy. In 8 cases recurrent lymphoceles were treated surgically by marsupialization, another 5 underwent repeated percutaneous drainage. One patient needed 3 percutaneous interventions until his symptoms ceased. In 8 patients 5 ml. of fibrinous glue was administered before the catheter was removed; nevertheless, 3 of them developed recurrent LC. In the group of patients without any symptoms after percutaneous drainage, 5 LC were infected, in the group of repeatedly drained LC, 2 had superinfection which was treated with antibiotics. All of the infected LC could be managed successfully by percutaneous drainage. The overall rate of success was 72%.

[Color Doppler ultrasound of kidney transplants. Does the resistance index facilitate diagnosis of chronic kidney failure?]

The retrospective study under report assessed the diagnostic capability of colour Doppler sonography (CDS) with measurement of the resistive index (RI) in the long-term follow-up of patients with renal allografts. 210 CDS examinations were performed in 115 patients. The time since transplantation ranged from 6 months to 22 years. The RI was correlated to laboratory parameters of renal allograft function (serum creatinine, urinary protein levels and serum-cyclosporine). In 97 of 210 examinations, serum creatinine was elevated (> 1.5 mg% or an increase of more then 0.3 mg% within the last 6 months). In 35 out of these examinations RI was > 70%, in 62 RI was < or = 70%. Thus, with a threshold RI of 70%, sensitivity of the RI in the diagnosis of renal allograft dysfunction is 36% and specificity 62%, respectively. There was no significant difference in the RI between examinations of allografts with normal function (68.2% +/- 7.5%) and those with dysfunction (68.5% +/- 8.5%). Furthermore, there was no significant correlation between the RI and any of the laboratory parameters. CDS with calculation of the RI cannot differentiate in the long-term follow-up between allografts with normal function and those with dysfunction.

[The screening of renal artery stenoses. The initial results with the value of color Doppler sonography]

The value of colour Doppler sonography in the diagnosis of renal artery stenosis has been studied retrospectively. 17 patients were examined (34 main renal arteries and 7 accessory renal arteries; ages 37 to 84 years; 7 males and 10 females). We studied 1) ability to study the main renal arteries, 2) visibility of accessory renal arteries and 3) the sensitivity and specificity of colour Doppler sonography for the diagnosis of renal artery stenosis. The results were compared with intraarterial angiography. Demonstration of the main renal arteries with colour Doppler sonography was possible in 23 of the 34 vessels. Not a single of the 7 accessory renal arteries was demonstrated by colour Doppler sonography. Of 8 angiographically demonstrated stenoses (more than 50% narrowing) 2 were missed by colour Doppler sonography. One stenosis was correctly diagnosed and 5 were incorrectly evaluated by sonography. 16 out of 18 angiographically normal main renal arteries were correctly evaluated by colour Doppler sonography but 2 showed a false positive finding. This results in a sensitivity of 17% and a specificity of 89% per kidney. Colour Doppler sonography cannot be recommended as a screening method for renal artery stenosis in view of its limited accuracy.

[Color-coded Doppler sonography of the carotid arteries]

Doppler colour flow imaging provides colour-coded visualisation of blood flow additional to the B-mode image. In this study, the carotid arteries of 92 patients were examined comparing duplex sonography with Doppler colour flow imaging. Efficiency of these methods was evaluated by angiography in 16 patients. Examination time was shorter by using Doppler colour flow imaging; evaluation of haemodynamics and anatomical changes was simplified.

[Color-coded Doppler sonography of kidney transplants]

A prospective study was carried out in 81 patients to compare the ability of colour coded Doppler sonography (angiodynography) and Tc bolus examination for demonstrating renal blood supply. In patients with normal transplant function both methods performed equally well. In anuric patients angiodynography was superior to the Tc bolus examination: In three cases angiodynography was able to provide important additional information such as absence of blood flow in peripheral intrarenal vessels or missing blood supply of a transplant pole. Angiodynography seems to be able to replace the Tc bolus examination; this statement excludes very obese patients until low-frequency probes for angiodynography will be available.

[Color-coded Doppler sonography in thyroid diseases: initial experiences]

The thyroid gland was investigated in 43 persons (12 healthy volunteers, 31 patients with diseases of the thyroid gland) with a new colour Doppler system (angiodynography). In euthyroid persons (normal thyroid gland, diffuse or multinodular goitre) only a few vessels were detected. In cases with Graves' disease however, hypervascularization was evident. Autonomous adenomas had a hypervascular periphery, whereas our two carcinomas showed a high vascularisation in the nodule. Angiodynography might become an important diagnostic tool for the evaluation of thyroid glands. The number of radionuclide studies and punctures might be limited.

Scarpa's fascia flap: anatomic studies and clinical application

Fascia and fascia-subcutaneous flaps are thin, pliable, and well-vascularized tissue with aesthetic and functional advantages, particularly for the extremities and in the head and neck region. Although various donor sites have been used for these flaps, there is an occurrence of unsatisfactory donor-site defects that are often complicated by conspicuous, widened scars or alopecia. In addition, flap elevation is sometimes prolonged because of the demanding operative procedures as well as the impossibility of a two-team approach. In this anatomic and clinical study we present a new fascial flap that results in a minimal donor-site defect and a short and easy operative procedure. Scarpa's fascia, which can be used as both a free and a pedicled flap, is a well-defined single membranous sheet within the subcutaneous tissue layer at the lower abdominal wall. We studied its distribution, structure, and vascular supply in 27 fresh cadaver specimens. In addition, computed tomographic (CT) and ultrasound studies were performed in 13 healthy volunteers and in 3 cadavers before and after injection of diluted contrast material in the superficial epigastric artery. Finally, histologic examinations were done with hematoxylin and eosin or with reticulum and elastin. Our studies showed that Scarpa's fascia provides a thin, pliable, and well-vascularized flap pedicled on the superficial epigastric artery. After successful application of the Scarpa's fascia flap as a free flap in 3 patients and as a pedicled option in 1 patient, we can recommend this flap as a valuable tool for the reconstructive surgeon.

[Color-coded Doppler sonography of the pelvis-leg arteries: an appraisal of the value of that method in comparison with angiography]

The aim of this study was to determine the accuracy of colour-coded Doppler sonography (CDS) and its advantages as compared with angiography and pulsed Doppler sonography. For this purpose, the arteries in the pelvis, thigh and knee of 42 patients were examined by CDS, the gold standard being angiography. In ten patients, pulsed Doppler sonography was performed as well and the length of the examination compared with that of CDS. It was shown that CDS is valuable in the investigation of peripheral vessels and that it can replace angiography after femoro-popliteal bypass operations or PTA. Compared with pulsed Doppler sonography, CDS has the advantage of being much quicker.

[The patency of the external and internal carotid arteries in patients with occlusion of the common carotid: detection using color-coded Doppler sonography]

Common carotid artery occlusion is not necessarily associated with thrombosis of the ipsilateral internal carotid artery. Noninvasive imaging of the carotid bifurcation with colour-coded Doppler sonography demonstrated patency of the external and internal carotid arteries distal to a common carotid occlusion in 4 patients which could be proven surgically. Identification of internal carotid artery patency could be demonstrated by angiography in two of the patients while in the other two cases angiography was inconclusive. Thus, CCDS provided a correct diagnosis of the internal carotid patency in these patients with common carotid occlusion.

[Sonography of benign skin tumors]

Evaluation of 62 pigmented skin tumors of unknown pathology showed that benign and malignant tumors can easily be separated. Benign skin tumors have many internal echoes whereas malignant melanomas show an almost echo-free structure. Superficial spreading melanomas (SSM) and very flat benign tumors were both recorded as thin echogenic layers. It is not possible to differentiate them by US. Real time US is a simple non stressful, reproducible procedure that should be established as a routine diagnostic tool in dermatology.

Automatic patient-instruction devices in thin-section CT of the thorax: impact on image quality

PURPOSE

To determine what influence automatic patient-instruction (API) devices have on image quality of chest computed tomographic (CT) scans and whether the qualitative outcome justifies their routine use.

MATERIALS AND METHODS

Thin-collimation CT scans of two age- and sex-matched groups of 64 patients each were evaluated prospectively for the presence of breathing artifacts and for concomitant deterioration of image quality. Breathing commands in group 1 were given with the API device and in group 2 with technologist-performed patient instruction. Cardiac motion artifacts were not evaluated. The frequency of scans repeated owing to breathing artifact was determined.

RESULTS

Image quality was worse in group 1 compared with that of group 2. The percentage of scans repeated was higher with API (38%) than without API (16%).

CONCLUSION

API devices cannot be recommended for thin-section CT of the thorax. The large number of scans that must be repeated leads to a considerable increase in patient irradiation, scanning time, and cost.

Comparison of Dual Energy X-Ray Absorptiometry of the Proximal Femur with Morphologic Data

Measurements of bone mineral density (BMD) of the proximal femur (including femoral neck, Ward's triangle and trochanteric region) were compared with the Singh index grading in 40 normal subjects (20 male, 20 female) and in 116 patients (18 male, 98 female) referred for assessment of possible osteoporosis. Additionally, the BMD and the Singh index of 12 cadaver specimens (6 male, 6 female) of the proximal femur were compared with each other and with the histomorphology of the femoral necks of the specimens. Although there was a good correlation of Singh index with BMD in the group of male patients with suspected osteoporosis and in the series of bone specimens, there was a poor correlation in the group of female patients as well as in the normal controls and in the patient population as a whole. There was also poor correlation of Singh index values with histomorphologic data, whereas the BMD measurements correlated well with the amount of calcified bone found histologically in the femoral necks of the bone specimens. We conclude that the Singh index cannot be used to predict BMD of the proximal femur accurately.

Renal Osteodystrophy

The parathyroid hormone concentration in the blood measured by the ‘two-site radioimmunoassay’, which is specific for the biologically active parathyroid molecule (parathyrine), was compared with the radiological manifestations of secondary hyperparathyroidism (HPT) on magnification radiographs of the phalanges in patients undergoing maintenance hemodialysis and in patients with renal allografts. Sensitivity of radiology for the diagnosis of HPT proved to be high (88%), whereas specificity was low (30%). Statistical analysis showed that there was a good correlation between the parathyrine levels and the intensity of radiological changes in the phalanges in patients with renal allografts (coefficient of Krueger-Spearman = 0.65). In patients undergoing hemodialysis the correlation between laboratory parameters and radiological changes was poor.

[Noninvasive follow-up by color-coded Doppler sonography after surgical interventions on the extracranial cerebral arteries]

By means of colour-coded Doppler sonography we studied retrospectively the incidence of postoperative changes in 54 patients following 58 carotid endarterectomies. The interval between operation and ultrasound varied from one to 41 months. The overall incidence of recurrent carotid disease was 50% with a 31% (18 of 58) of hemodynamically insignificant restenoses, a 13.8% (8 of 58) incidence of haemodynamically significant restenoses, and a 5.2% (3 of 58) of occlusions. The segment that had been endarterectomized showed a bulbous dilatation in 24.1% (14 of 58). In all of these cases extensive flow reversal zones could be demonstrated, the possible importance of which is discussed. Examinations in 9 patients with reimplantation of subclavian artery to the common carotid artery and grafting technique between these arteries and in 11 patients with reimplantation of vertebral artery to the common carotid artery demonstrated one occlusion of the ipsilateral vertebral artery.