Biomedical subjects
Publications and source records attributed to D M Nichols.
Posterior "iliac horns" are a common finding in nail-patella syndrome and when present are considered pathognomonic of the disease. We have had an opportunity to study a patient with these iliac horns and describe their appearance on computerized tomography.
Nine patients with 10 episodes of acute axillary-subclavian vein thrombosis were treated with local low-dose streptokinase infusion. All patients except one were heparinized during the procedure with conversion to oral anticoagulation upon completion of the infusion. Recanalization was achieved in 7 patients (70%). Thrombosis recurred in 1, and in 2 patients the procedure was unsuccessful. No major complications were encountered. We concluded that local low-dose streptokinase infusion is a safe, simple, and effective method for treating acute axillary-subclavian vein thrombosis.
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Ultrasound-guided surgical cholecystostomy with local infiltration anesthesia was combined with radiologic removal of gallstones in 36 elderly patients with acute calculous gallbladder disease who were considered to be at high risk due to multiple coexisting diseases. At cholecystostomy, the fundus of the gallbladder was sutured to the anterior abdominal wall resulting in a short surgical track to the gallbladder. This permitted early percutaneous stone removal through the cholecystostomy track under fluoroscopic guidance. All gallstones were removed in 31 of 36 patients, for an overall success rate of 86%. The success rate was 97% for gallbladder stones, 86% for cystic duct stones, and 63% for common bile duct stones that were removed by traversing the cystic duct. The treatment in the five patients in whom radiologic stone removal was incomplete or unsuccessful consisted of elective cholecystectomy in three, with common bile duct exploration in two of these; endoscopic sphincterotomy and stone extraction in one; and expectant management in one. There were no deaths or serious complications. This technique has thus proved safe and effective in these 36 high-risk patients.
Detection of aortopulmonary window lymph node enlargement by chest radiography was assessed in 67 patients with bronchogenic carcinoma. All patients underwent computed tomography (CT). Surgical confirmation of the radiographic and CT findings was available in all patients with lymph node size smaller than 2.5 cm in diameter on CT (47 patients) and in 6 of 20 patients with nodes greater than 2.5 cm in diameter. Forty-one had normal-sized and 26 had enlarged (greater than 1.5 cm diameter) aortopulmonary nodes. Lymphadenopathy was detected on the chest radiograph in 21 of the 26 patients with enlarged nodes. It was wrongly suspected in one of the 41 patients with normal-sized aortopulmonary nodes on CT. Three patients with lymphadenopathy had a normal aortopulmonary window on the chest radiograph. In these patients, the nodes measured 1.6-2.6 cm in diameter. In two patients with enlarged nodes and in two with normal-sized nodes, the aortopulmonary window could not be assessed on the radiograph because it was obscured by concomitant atelectasis and obstructive pneumonitis of the left upper lobe. We conclude that in the absence of left upper lobe atelectasis, chest radiography has a high sensitivity (87%) and specificity (97%) in detecting aortopulmonary lymph nodes larger than 1.5 cm in diameter. In only one patient was metastatic disease detected at surgery in a node smaller than 1.5 cm diameter.
Interventional radiologists are being asked more frequently to evacuate stones from the gallbladder. In order to facilitate such evacuation in patients with a large number of small gallbladder stones, a readily available medical suction machine was adapted for this purpose, and we describe here the adaptation and its successful use in six patients.
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Nine high-risk patients with endoscopic evidence of bleeding from the left gastric artery territory without angiographic extravasation were embolized to prevent rebleeding. Three were embolized with Gelfoam particles, 1 with Gianturco coils, and 5 with Gelfoam plus coils. Three patients rebled; 2 were embolized with Gelfoam only, and the third with coils only. No rebleeding occurred in the 5 patients treated with Gelfoam plus coils. No ischemic complications occurred. We conclude that embolization of the left gastric artery, despite absence of extravasation, is effective in preventing rebleeding in high-risk patients and that both Gelfoam and coils be used.
To assess the accuracy of computed tomography (CT) in the diagnosis of emphysema, we performed CT on 32 patients prior to surgery for removal of suspected tumors. The CT scans were assessed visually for emphysema by 2 independent radiologists and 1 chest physician. Intraobserver and interobserver variation were assessed. Pathologic emphysema was graded on the resected lung specimens. These grades were correlated with the CT scores and with pulmonary function tests obtained prior to surgery. Significant correlation was found between the pathologic grade on resected lung specimens and the preoperative CT score of both the resected lobe (r greater than or equal to 0.57, p less than 0.001) and the whole lung (r greater than or equal to 0.63, p less than 0.001). Compared with pulmonary function tests, CT was a better predictor of emphysema and distinguished patients with moderate emphysema from patients with normal lungs. We conclude that CT is a useful adjunct in assessing the presence and severity of emphysema.
We report the angiographic and magnetic resonance imaging findings of an aneurysm of the ductus arteriosus in a woman with Marfan syndrome. This is the first reported ductus aneurysm diagnosed in an adult with Marfan syndrome.
Fracture-dislocation in the tarsometatarsal region (Lisfranc) may be subtle and difficult to recognize on standard radiographic projections. Computed tomography (CT) was used to study the normal anatomy of the forefoot and to evaluate three patients with suspected tarsometatarsal fracture dislocation. The advantages of CT in the evaluation of forefoot trauma are emphasized.
Severe coarctation proximal to both subclavian arteries, a rare entity previously reported only once in an adult, was successfully diagnosed preoperatively using intravenous digital subtraction angiography (DSA). The significance of this rare condition and the value of intravenous DSA for aortography in a patient with no peripheral pulses is discussed.
Computed tomographic (CT) findings in a case of surgically proven acute mesenteric vein thrombosis are described. Gross symmetric edema of bowel wall over a long segment of jejunum was present, associated with a very edematous mesentery. Previous reports have described radiography, barium studies, angiography, and nuclear scintigraphy in the investigation of this condition. The use of CT has not been previously described and appears extremely helpful.
The computed tomographic (CT) findings in a young man with bilateral popliteal entrapment are presented. CT may be the procedure of choice in young adults with intermittent claudication.
Six serious pleural complications (three empyemas, two hemothoraces, and one bilious effusion) have occurred after use of the right intercostal approach to the upper abdomen in 230 interventional radiologic procedures performed over the last 3 years. The anatomy of the pleural reflection in the right costophrenic sulcus is reviewed and correlated with a dissection study of the course of right intercostal needle punctures in three cadavers. The pleural reflection reaches the level of the 10th rib in the midaxillary line, and in the cadaver study, all 9th- 10th interspace punctures clearly traversed pleura, diaphragm, and peritoneum to reach the liver. The widely held belief among radiologists that the pleura can be deliberately avoided in transhepatic cholangiography and biliary drainage is shown to be false. It is believed that most needle punctures traverse the costophrenic sulcus, through pleura but below lung, despite the low incidence of reported pleural complications. a left subxiphoid approach avoiding the pleura is recommended in patients with abscesses, ascites, emphysema, anxiety, and, in the case of biliary drainage, benign or purely left-sided disease. When using the intercostal approach, the minimum number of needle passes, careful route planning, antibiotic prophylaxis, and postprocedural chest radiography are strongly recommended.
The degree of magnification in radiographic imaging of the bile duct has not been sufficiently emphasized. Differences in magnification account for much of the considerable discrepancy among various radiographic and nonradiographic measurements of size. In measuring a series of 22 freshly extracted common bile duct stones, an average magnification factor of 1.43 (43%) was found on fluoroscopic spot films; this compares with the 1.3 (30%) magnification generally accepted as being present in conventional intravenous cholangiography using the overhead-tube technique. The large magnification factor must be remembered in interpreting fluoroscopic images of the bile duct. Most published dimensions are meaningless unless accompanied by a statement of technique and magnification factor.
To assess the accuracy of computed tomography (CT) in the recognition of bronchiectasis, CT was performed in 11 patients with clinical findings strongly suggestive of this diagnosis. In two patients, CT showed extensive bilateral cystic and varicose bronchiectasis, and bronchography was considered unwarranted. In four patients, bilateral, and in five, unilateral bronchograms were obtained. Correlation was made between the CT and bronchographic findings in these 13 lungs. In only six bronchograms did CT give an accurate assessment of the presence and extent of disease. In five, the diagnosis of cylindrical and varicose bronchiectasis was missed on CT. In two, CT suggested the diagnosis of cylindrical bronchiectasis but the bronchogram was normal. It was concluded that CT may be useful in the diagnosis of cystic bronchiectasis, but is unreliable in detecting cylindrical and varicose changes. Bronchography, therefore, remains the definitive method for establishing the diagnosis, extent, and severity of bronchiectasis.