[Iopentol in varix radiography. Double blind comparison with iohexol]

This trial was aimed at comparing the tolerance and the safety of Iopentol, a new nonionic monomeric contrast agent, with Iohexol, a reference compound already on the market and commonly used in similar trials. Sixty adult patients (41 women and 19 men, aged 23 to 76 years, mean age: 51.4 years) referred to our Department of Radiology for varicography 24 hours before surgery were examined; the trial was designed as a double-blind, parallel two-group comparison of Iopentol 300 mg/ml and Iohexol 300 mg/ml with 30 patients in each treatment group. No adverse reactions were observed in our series of patients. Only slight and not clinically significant changes were observed in heart rate and blood pressure values. The immunohistochemical parameters were studied for postvaricography anatomopathologic complications of the injected veins (A-Actin ML, Vimentin, Factor VIII, CD31, CD68, CK, Ulex Europaeus I, Lecitin, Desmin, Laminin) and no statistically significant differences were observed between the two groups. The histologic specimens showed only venous wall changes, as diagnosed on admission. All radiographs were classified as technically adequate and contrastographic efficacy was defined as "good" in all patients by two independent radiologists. To conclude, our trial on the efficacy and safety of the two nonionic monomeric radiographic contrast agents Iopentol and Iohexol proved the two contrast agents to be equally effective and well tolerated, which makes Iopentol a good alternative to Iohexol in varicography.

[Color Doppler and phlebography in the Paget-Schroetter syndrome]

The authors compared the adequacy of phlebography and color-Doppler US in the diagnosis of subclavian-axillary thrombosis, or Paget-Schroetter syndrome. Ten patients with subclavian-axillary thrombosis (8 men and 2 women, aged 16 to 55 years, mean age: 30 years) were examined over a two-year period. All of them underwent color-Doppler US and conventional phlebography in the same session. US findings were in agreement with phlebographic results in all cases as to thrombosis presence and site. The thrombosis involved the subclavian-axillary vein in 8 cases, the subclavian-innominate vein in 1 case and both veins in 1 case. Color-Doppler US, however, yielded no information relative to the superior vena cava; these data were always obtained with phlebography even though in 4 cases that segment had to be studied with phlebographic opacification via contralateral route. Furthermore, US failed to clearly demonstrate the thrombosis involving the last axillary valve; preserving this valve is indeed the main aim of fibrinolysis since its integrity, at this level, prevents venous reflux independent of subclavian-axillary trunk recanalization, thus reducing the severe symptomatologic sequelae following postphlebitic damage. Phlebography showed the valve and its possible involvement in all cases. In 4 cases phlebography also demonstrated compressive thoracic inlet syndrome, which had been missed by US, yielding the main anatomic elements for following surgery. To conclude, the authors suggest noninvasive color-Doppler US as the screening method of choice, while phlebography remains the gold-standard technique to be performed in all Doppler positive cases: in fact, the latter method yields more pieces of information and is more panoramic than the former, besides allowing fibrinolysis effects to be studied and the possible presence of an associated thoracic inlet syndrome to be investigated.

[Full computerization of a radiology service. A 5 years' experience at a centralized system]

Even though the problem of collecting and processing information is of paramount importance in any radiology department, the choice of the best information system--as for organization and effectiveness--largely depends on specific and different local situations and is therefore still largely debated. In the ULSS 18 in Veneto (Dolo, Venezia), all patients are referred to the only existing hospital radiology. Therefore, a central computer system has been be realized and used also by the radiology department, for completely computed procedures, since January 1, 1988. We describe the computer configuration of both the ULSS and the radiology department and report on our 5-year experience with full computerization within a central information system. As for department organization, any information system--with appropriate hardware and software--can be equivalent to others, since it largely contributes to both management (programming, booking, filing, accounting) and reporting (automatic reporting with memorized texts and/or voice recognition; reprinting; immediate correction at the video-terminal). Thanks to more rational exploitation of human and technological resources, any information system makes a radiology department more functional and efficient. However, some peculiarities of the central computer system must be stressed, as they allow: 1) to use pre-existing and updated patients files (unequivocal identification in the whole ULSS); 2) to gain access to the databanks of different specialties and to patients' clinical histories (complete data collected from many sources); 3) to intervene in booking and ticket collection centers with none of the relative loads; 4) to have no limits of memory, storage or speed for complex programs (automatic reporting also with the recognition of the dictating voice, accounting and statistical analyses, ecc.); 5) to profit by continually updated and fitted hardware and software, with the relative expenses and benefits shared by the whole ULSS. Within the possibilities given by a double role-ruled password, all different menus and programs are accessible from any video-terminal, even while other programs are running, thus allowing cost-effective hardware to be available in the radiology department.

[Percutaneous neurolysis of the celiac plexus. Description of a new CT-guided technique and preliminary results]

June 1991 to June 1992, twelve CT-guided percutaneous celiac plexus neurolyses were performed by a new simplified technique with the patient in left-hand side decubitus and a single right lumbar needle access. CT guidance allows the interventional radiologist to locate the best access point on the skin, to give the needle the appropriate depth and inclination to avoid passing through pleura, parenchyma and vessels, and finally to check the correct position of the needle tip and the spread of neurolytic solution. In left-hand side decubitus, fat and loose connective tissue around ganglia and vessels expands much more, thus allowing the alcohol-contrast medium solution to spread easily and evenly getting to both celiac ganglia by gravity. The analgesic value of celiac plexus neurolysis has been proved complete and lasting. The technique is quick and safe (apart from inevitable hypotension due to splanchnic vasodilatation).

[Deep venous thrombosis of the legs. Diagnostic results comparing the duplex and the color-Doppler methods]

Thirty-eight patients (45 limbs on the whole) with clinical suspicion of deep venous thrombosis in the lower limbs were examined with duplex US and color-Doppler flow mapping. The results were compared with those of ascending phlebography used as a reference. Disease sites included distal localizations, limited to the leg, with no involvement of the popliteal vein, and proximal localizations, involving the popliteal vein to the iliac segment. In case of proximal thrombosis, duplex US had 81% sensitivity, 93% specificity, 86% positive and 90% negative predictive values. Color-Doppler flow mapping had 87% sensitivity, 96% specificity, 93% positive and negative predictive values. In case of distal localizations, the results were poorer with both methods; duplex sensitivity decreased to 60% and specificity to 83% with 64% positive and 80% negative predictive values. Color-Doppler results were slightly higher, with 80% sensitivity, 93% specificity, 85% positive and 90% negative predictive values. Thus, the authors believe color-Doppler flow mapping to be adequate as the imaging method of choice when deep venous thrombosis is suspected. Color-Doppler imaging yields better results in distal localizations and makes the examination easier, quicker and more panoramic. Phlebography should be employed in questionable cases and is required for the diagnosis of limited thromboses, which are at risk for embolism, as those we observed in the adductor canal, which are difficult to diagnose with US.

[Small-cell lung tumors: is a more accurate staging possible and useful?]

Small cell lung cancer is generally staged as a localized or diffuse disease due to its great invasiveness and quick spread. The authors investigated the advantages of a more accurate staging by TNM system applied to small cell lung cancer. Sixteen patients (12 males and 4 females, mean age 54 years, max 66, min 48) were submitted to a treatment protocol consisting of 6 cycles of chemotherapy over an 18-month period. All patients underwent CT before and after the third and sixth cycles. Disease evolution was evaluated by means of the TNM system; relative to the N parameter, the American Thoracic Society criteria were followed. After completion of the third chemotherapy cycle, CT demonstrated reduction in T in 7/16 cases, while in the extant patients T was unchanged. N decreased too in 7 patients and remained unchanged in the others. CT examinations at the end of the whole treatment protocol demonstrated no changes in T. As for N, CT showed evolution from N0 to N2 in one case and from N3 to N0 in another one, while no changes were observed in the extant patients. The M parameter was constantly negative in all cases. Our results demonstrate that this approach to small cell lung cancer permits a more accurate characterization of the disease, thus making it easier to monitor the positive/negative response to treatment and allowing the latter to be personalized.

[Duplex study of primary venous insufficiency of the legs. First results and methodologic comparison]

Primary venous insufficiency is a pathologic condition characterized by reflux in the deep venous system not secondary to phlebothrombosis. The authors compare the diagnostic capabilities of duplex and Doppler US in the evaluation of this condition. At present, Doppler US has a more widespread use than the duplex method. Both lower limbs were examined in 46 patients known to be affected with mono/bilateral primary venous insufficiency thanks to previous retrograde phlebography. Ten patients with different phlebopathies and 10 healthy volunteers were also studied as a control group, duplex US had 92% sensitivity and 90% specificity, while Doppler had 86% and 75%, respectively. Duplex US appeared to be more accurate than Doppler in locating and quantifying the reflux. Finally, the authors draw attention to the segmentary reflux phenomenon they observed in asymptomatic patients and suggest the possibility of recognizing the preclinic stage of this condition by duplex US, which is a non-invasive and relatively inexpensive method. The latter could become, thanks to its intrinsic characteristics, the method of choice for monitoring.

[The Duplex system in the follow-up of sclerosing therapy of the greater saphenous vein. First results and considerations]

The authors evaluated the long-term results of sclerosing therapy as an alternative to surgery by means of high-resolution US and Doppler dynamic fluximetry (duplex system). Seventy patients (53 females and 17 males) were examined, all of whom fulfilled the clinical criteria of recovery and efficacy of sclerosing therapy. Average follow up was 20 months (range: 6-26). The results, compared with duplex findings before sclerosing therapy, demonstrated: a) persistence of reflux and absence of US signs of sclerosis (9/70 patients); b) evident sclerosis with persistent residual lumen and reflux of variable entity at the thigh (33/70) cases; c) incomplete sclerosis sparing the crosse, with physiological flow and disappearance of reflux (8/70 patients); d) nearly complete sclerosis with vasal lumen obliteration (20/70 cases). No changes were observed in the deep venous system after sclerosing therapy. The authors stress the advantages of the duplex system they employed as an instrumental support to clinics for a complete monitoring of sclerosing therapy.

[Duplex-sonography in the preoperative evaluation of the small saphenous vein]

The authors analyze the results obtained by means of Doppler US, duplex examination and venography in the preoperative evaluation of venous vascular anatomy and flow dynamics in the popliteal fossa for short saphenous vein surgery. As a whole, 50 legs were examined in 34 patients who subsequently underwent surgery. The confluence of the short saphenous vein in the deep system proved to be very variable. Doppler results were compared with contrastographic ones: Doppler US had 10% accuracy in locating the confluence of the short saphenous vein and the figure rose to 62% with a +/- 2 cm tolerance. Duplex US had 30% and 98%, respectively. The latter always correctly demonstrated the reflux, while Doppler US in 5 cases (10%) ascribed gastrocnemius vein incompetence (4 cases) and Giacomini vein incompetence (1 case) to the short saphenous vein. The above findings demonstrate the total reliability of duplex US versus Doppler US and venography in recognizing the anatomic confluence and in allowing the fluximetric evaluation in a noninvasive, riskless and inexpensive way.

[First experience with the combination of ultrasonics and pulsed Doppler (Duplex system) in the study of venous pathologies of the legs]

Over a 2-year period the authors examined 400 patients affected with different types of phlebopathies with combined real-time US and pulsed Doppler (Duplex system). Ninety-eight patients had deep phlebothrombosis, 45 had superficial phlebothrombosis, and 110 primitive or secondary vein insufficiency. The obtained data, supported in 171 cases by contrastographic findings, allowed both the semeiological study and the evaluation of the indications for Duplex US in the various phlebopathies. The combination of high-resolution US morphological data, dynamic tests, and the functional data from pulsed Doppler have particular interest in the study of: a) the diagnostics of superficial or deep thrombosis and adhesive or floating thrombi; b) post-thrombotic syndrome; c) primitive or secondary vein insufficiency; d) the ostium of the superficial venous system (location, morphology, functionality). Duplex US is a non-invasive technique for the examination of the superficial and the deep venous systems, which reduces the indications for phlebography, an exam which requires radiation exposure, and is not always safe or possible. Duplex US is however limited by the difficult assessment of the venous system below the knee, because of too many trunks and variants.

[Torsional defects of the lower limb: an evaluation of the reliability of the results obtained by CT]

The torsional angle was calculated goniometrically of 9 femurs and 2 tibio-peroneal groups, and then compared to the values obtained from CT scans of the corresponding bones. The results show how the methods adopted up to now have been inaccurate and have yielded only gross definitions of the axis of the femoral neck. As far as this feature is concerned, an error of +/- 6.5 degrees can be estimated, with limits of confidence of 95%, after applying a more accurate system of measurement to the images and considering statistical interferences. After pointing out the advantages of this method, we suggest that the test performed in vivo be systematically proposed to all those patients in whom a more accurate diagnosis would lead to a different medical/surgical therapy considering that: 1) the inevitable error such a measurement bears can be contained between acceptable limits; 2) the radiation dose sufficient to distinguish the bone from the other surrounding tissues is much reduced with respect to the dosage necessary to perform a common CT of the inferior limbs. It comprises one topogram and four tomograms, with a total dose to the patient of approximately 10-20 mGy.

CT appearance of generalized von Recklinghausen neurofibromatosis

Two cases of von Recklinghausen neurofibromatosis (VRN) with thoracic and abdominal involvement are described. Computed tomography demonstrated the typical lesions of this disease: meningoceles, neurofibromas, and skeletal alterations. In both cases lesion morphology and location were similar and characteristic, in particular in the pelvic region. Computed tomography findings in generalized VRN are sufficiently characteristic to be considered diagnostic for this disease.

Evaluation of post-pneumonectomy space by computed tomography

Twenty-two patients who had undergone pneumonectomy for various reasons were evaluated by computed tomography (CT) in order to study the post-pneumonectomy space (PPS). In 13 of 22 cases, the residual PPS contained fluid, even years following surgery. In 9 of 22 cases, the PPS was obliterated. Obliteration of the PPS, one of the events that may follow pneumonectomy, is significantly correlated with the expansion of the nonoperated lung (coefficient, 0.84). Obliteration of the PPS does not present a significant coefficient of correlation with the following parameters, also considered in this study: time interval between surgery and CT, presurgical tests of respiratory function, hemidiaphragm elevation, and retraction of operated hemithorax. The fluid contained in the PPS does not organize but persists or is reabsorbed. Mediastinal shift depends on the expansion of the residual lung. The mediastinum rotates following right pneumonectomy and shifts following left pneumonectomy. The usefulness of CT in the follow-up of the pneumonectomized patient is stressed.

[Thymus gland scan in myasthenia gravis: experience in 52 patients]

A firm relationship has been established between thymus gland pathology and myasthenia gravis. The most frequent changes observed in this gland consist in simple hyperplasia of germinal centers or thymoma. In order to detect these alterations it is necessary to have a suitable reliable technique, beside routine radiological exams: thymus scan has been proposed as an useful tool. Since 1968 we submitted 52 patients to this procedure; we used as a tracer 75Se-Seleniomethionine in most cases, 57Co-bleomycin and 67Ga-citrate in a few cases. The scan was found positive in 22 cases (42%) showing either localized or diffuse uptake in the region of the sternum. Thymus changes were subsequently examined in 26 cases: 22 cases after thymectomy in 4 cases at autopsy. We found a good correlation between positive scan and pathological changes of the gland such as thymoma or germinal center hyperplasia. However in 4 patients with negative scan that previously received radiation therapy or immunosuppressive therapy such pathology was missed: 3 cases of hyperplasia and 1 residual thymoma. We conclude that thymic scan an useful and highly specific diagnostic procedure and should be done before any kind of treatment which affects thymus.