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Biomedical subjects

E K Fishman

Publications and source records attributed to E K Fishman.

At least 631 records · Page 35Linked to original sources
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CT evaluation of renovascular disease.

Computed tomography (CT) plays an important role in evaluation and management of primary renovascular disease. Nonenhanced CT is useful for demonstrating renal hemorrhage, renal parenchymal or vascular calcifications, and masses. Contrast material-enhanced CT is essential to identify global or regional nephrographic abnormalities resulting from the vascular process (eg, renal infarcts, ischemia secondary to renal artery stenosis, arteriovenous communications). In addition, renal manifestations of a systemic disease (eg, vasculitis, thromboembolic disease) can be seen at CT. In trauma, occlusion of the main renal artery can be accurately diagnosed with contrast-enhanced CT. In cases of spontaneous renal hemorrhage without an apparent cause (eg, vasculitis, coagulopathy), a careful CT study should be performed to exclude renal cell carcinoma. The presence of fat in a hemorrhagic renal mass larger than 4 cm in diameter is characteristic of angiomyolipoma complicated by hemorrhage. Acute renal vein thrombosis appears as a clot in a distended renal vein, whereas renal vein retraction with collateral vessels is highly indicative of chronic thrombosis. Helical CT, especially with multiplanar two-dimensional and three-dimensional reconstruction following an intravenous injection of iodinated contrast material, has greatly improved our ability to directly image the proximal renal arteries and detect vascular lesions.

Diagnosis, Differential↗
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Dynamic MR imaging of pelvic organ prolapse: spectrum of abnormalities.

Pelvic organ prolapse is a relatively common condition in women that can have a significant impact on quality of life. Pelvic organ prolapse typically demonstrates multiple abnormalities and may involve the urethra, bladder, vaginal vault, rectum, and small bowel. Patients may present with pain, pressure, urinary and fecal incontinence, constipation, urinary retention, and defecatory dysfunction. Diagnosis is made primarily on the basis of findings at physical pelvic examination. Imaging is useful in patients in whom findings at physical examination are equivocal. Fluoroscopy, ultrasonography, and magnetic resonance (MR) imaging can be useful in evaluating pelvic organ prolapse. Advantages of MR imaging include lack of ionizing radiation, depiction of the soft tissues of the pelvic floor, and multiplanar imaging capability. Dynamic imaging is usually necessary to demonstrate pelvic organ prolapse, which may be obvious only when abdominal pressure is increased. Treatment is more likely to be successful if a survey of the entire pelvis is performed prior to therapy. Therapy is usually undertaken only in symptomatic patients. In all patients, imaging findings must be interpreted in conjunction with physical examination findings and the patient's symptoms.

Female↗
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Three-dimensional volume-rendered CT angiography of the renal arteries and veins: normal anatomy, variants, and clinical applications.

Three-dimensional volume-rendered computed tomographic (CT) angiography represents an increasingly important clinical tool that, in many institutions, is replacing conventional angiography in the depiction of normal vascular anatomy and the diagnosis of vascular disorders. Evaluation of conditions affecting the renal vasculature constitutes a major focus of volume-rendered CT angiography, which has documented utility for demonstrating both arterial and venous disease. Arterial disorders include renal artery stenosis, renal artery aneurysms, and dissection. Venous disorders include splenorenal shunts, thrombosis, and intravascular tumor extension. In addition, volume-rendered CT angiography accurately displays the normal and variant renal vascular anatomy, which is crucial to detect before surgery, especially partial nephrectomy and laparoscopic nephrectomy. CT angiography is also useful in the evaluation of the renal vasculature following renal transplantation. Familiarity with proper CT protocols and data acquisition techniques are crucial for accurate diagnosis.

Angiography↗
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Neurofibromatosis type 1: a diagnostic mimicker at CT.

Neurofibromatosis type 1 (NF1) is the most common of the phakomatoses and has a variety of localized or, more frequently, systemic manifestations throughout the thorax, abdomen, pelvis, and extremities. Classic computed tomographic (CT) findings in NF1 with thoracic involvement include small, well-defined subcutaneous neurofibromas, focal thoracic scoliosis, posterior vertebral scalloping, enlarged neural foramina, and characteristic rib abnormalities due to bone dysplasia or erosion from adjacent neurofibromas. However, more atypical manifestations are occasionally seen, and magnetic resonance (MR) imaging can be useful in equivocal cases. NF1 with abdominopelvic involvement tends to arise in the retroperitoneal, mesenteric, and paraspinal regions; it may be quite extensive and therefore difficult to distinguish from adenopathy at CT. The multiplanar capabilities of MR imaging, particularly with T2 weighting, make this modality helpful in evaluating affected patients and making the diagnosis. The classic peripheral manifestations of NF1 include limb hemihypertrophy, pseudarthrosis, peripheral nerve neurofibromas, and subcutaneous common and plexiform neurofibromas. In some cases of NF1, imaging findings are inconclusive, and biopsy and subsequent pathologic analysis are required. Familiarity with the various manifestations of NF1 in different anatomic locations is important in making the diagnosis and optimizing postdiagnostic treatment.

Diagnosis, Differential↗
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Imaging of renal trauma: a comprehensive review.

Computed tomography (CT) is the modality of choice in the evaluation of blunt renal injury. Intravenous urography is used primarily for gross assessment of renal function in hemodynamically unstable patients. Selective renal arteriography or venography can provide detailed information regarding vascular injury. Retrograde pyelography is valuable in assessing ureteral and renal pelvic integrity in suspected ureteropelvic junction injury. Ultrasonography is useful in detecting hemoperitoneum in patients with suspected intraperitoneal injury but has limited value in evaluating those with suspected extraperitoneal injury. Occasionally, radionuclide renal scintigraphy or magnetic resonance imaging may prove helpful. Renal injuries can be classified into four large categories based on imaging findings. Category I renal injuries include minor cortical contusion, subcapsular hematoma, minor laceration with limited perinephric hematoma, and small cortical infarct. Category II lesions include major renal lacerations extending to the medulla with or without involvement of the collecting system and segmental renal infarct. Category III lesions are catastrophic renal injuries and include multiple renal lacerations and vascular injury involving the renal pedicle. Category IV injuries are ureteropelvic junction injuries. CT is particularly useful in evaluating traumatic injuries to kidneys with preexisting abnormalities and can help assess the extent of penetrating injuries in selected patients with limited posterior stab wounds. Integration of the imaging findings in renal injury with clinical information is critical in developing a treatment plan.

Angiography↗
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Multi-detector row CT of thoracic disease with emphasis on 3D volume rendering and CT angiography.

Multi-detector row computed tomography (CT) with three-dimensional (3D) volume rendering provides a unique perspective on thoracic anatomy and disease. Multi-detector row CT allows shorter acquisition times, greater coverage, and superior image resolution. Three-dimensional volume rendering now permits real-time, interactive modification of relative pixel attenuation in an infinite number of planes and projections. In vascular imaging, this technique provides image quality that equals or surpasses that of conventional angiography. Its use has expanded to aid in diagnosis and surgical planning, often obviating conventional or digital angiography and reducing costs. It is reliable in depicting clot and the pulmonary vasculature and may also be used to evaluate thoracic venous anomalies (eg, pulmonary arteriovenous malformations) and to plan therapy. Airway imaging with multi-detector row CT with 3D volume rendering is particularly useful in the planning and follow-up of stent placement. In diffuse lung disease, this technique can increase nodule detection and help differentiate between small nodules and vessels. It is also helpful in imaging the musculoskeletal system and the thoracic cage. Multi-detector row CT with 3D volume rendering has enhanced the conventional roles of thoracic CT and challenged the supremacy of other imaging modalities. It will likely play a leading role in future radiologic research and practice.

Angiography↗
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CT evaluation of cervical cancer: spectrum of disease.

Invasive cervical cancer is the third most common gynecologic malignancy. The prognosis is based on the stage, size, and histologic grade of the primary tumor and the status of the lymph nodes. Assessment of the stage of disease is important in determining whether the patient may benefit from surgery or will receive radiation therapy. The official clinical staging system of the International Federation of Gynecology and Obstetrics has led to errors of 65%-90% in stage III and IV disease; the result has been unofficial extended staging with cross-sectional imaging modalities such as computed tomography (CT). CT is useful in staging advanced disease and in monitoring patients for recurrence. The primary tumor is heterogeneous and hypoattenuating relative to normal stroma on contrast material-enhanced scans. Obliteration of the periureteral fat plane and a soft-tissue mass are the most reliable signs of parametrial extension. Less than 3 mm separation of the tumor from the pelvic muscles and vascular encasement are signs of pelvic side wall invasion. Lymphatic spread is along the external and internal iliac nodal chains and the presacral route to the paraaortic nodes. Distant metastases are seen with primary or recurrent disease and can involve the liver, lung, and bone.

Female↗
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Multi-detector row CT of mesenteric ischemia: can it be done?

Mesenteric ischemia is a complicated disorder whose prevalence in the United States is increasing as the population ages. It is often difficult to diagnose, both clinically and radiologically. In the past, computed tomography (CT) has allowed only limited success in the early detection of ischemia. However, with the introduction of multi-detector row CT and three-dimensional (3D) imaging, it is now possible to perform a detailed CT examination of the small bowel and mesenteric vessels. Multi-detector row CT allows routine studies to be performed much faster than with single-detector CT scanners and makes available new applications, especially in the field of CT angiography. Its increased speed and narrower collimation, coupled with the use of water as an oral contrast agent, improve visualization of the bowel wall and mesenteric vasculature. Multi-detector row CT with 3D reformatting may improve the ability to make an early diagnosis and identify the cause of disease in patients with suspected acute or chronic mesenteric ischemia. In many cases, this examination has eliminated the need for additional imaging studies such as Doppler ultrasonography or angiography. Further investigation will be needed to determine the scope of the utility of multi-detector row CT in this clinical setting.

Acute Disease↗
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Complications of endoscopic retrograde cholangiopancreatography: spectrum of abnormalities demonstrated with CT.

Endoscopic retrograde cholangiopancreatography (ERCP) is an invasive procedure that is performed to diagnose and treat pancreatic and biliary disease. In approximately 5%-10% of cases, the procedure itself causes adverse events. Diagnosis and management of ERCP-induced complications are performed with clinical, laboratory, and radiologic procedures. Evaluation of the type and severity of the complication is necessary and is successfully performed with computed tomography (CT). The most common causes of post-ERCP pain are acute pancreatitis and duodenal perforation. In severe pancreatitis, the pancreas is enlarged and enhances heterogeneously at CT. Pancreatic enhancement is diminished in areas of glandular necrosis. In duodenal perforation, CT may reveal extraluminal air or fluid. CT findings of acute duodenal hemorrhage are duodenal wall thickening and a high-attenuation mass in the duodenal wall. In infection, the bile ducts can be dilated and the attenuation of the bile can be increased at CT. Abscesses appear as hypoattenuating masses with enhancing capsules. CT findings of stent migration are an atypical location of the stent and bowel impaction. Other complications of ERCP are those related to endoscopy and include esophageal, liver, and splenic injury.

Cholangiopancreatography, Endoscopic Retrograde↗
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Acetabular and pelvic fractures in the pediatric patient: value of two- and three-dimensional imaging.

Pediatric trauma is a significant source of morbidity and mortality in pediatric patients. Prompt and accurate assessment of injuries is necessary for the best outcome. Computed tomography (CT) has become a well-accepted, rapid, relatively noninvasive way to assess the trauma patient. In certain cases of pelvic trauma, two- and three-dimensional CT (2D/3D CT) adds detail not otherwise obtainable or appreciated. Although the benefits must be balanced against the slight increase in delivered radiation dose, we believe that 2D/3D CT is often an important part of patient management.

Acetabulum↗
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Wegener granulomatosis: CT features of parenchymal lung disease.

Chest CT from eight patients with pulmonary Wegener granulomatosis were reviewed. The CT features of parenchymal lung involvement included multiple nodules or masses (seven of eight; 88%), ranging in size from 0.3 to 5.0 cm. Lung nodules demonstrated distinct feeding vessels in seven of eight patients (88%); and lesions similar to pulmonary infarcts, i.e., peripheral wedge-shaped lesions abutting the pleura, were identified in seven cases (88%). Scarring, spiculation, and pleural tags emanating from pulmonary nodules were prominent features (seven of eight; 88%). Other findings included cavitation (four of eight; 50%), air bronchograms through nodules (two of eight; 25%), and pleural effusions (two of eight; 25%). One patient on immunosuppressant therapy also demonstrated scattered ground glass infiltrates due to complicating pneumocystis pneumonia. In comparison to corresponding conventional chest radiography, CT examinations revealed more parenchymal lesions in five of eight cases (63%) and bilateral disease instead of unilateral disease in one of eight cases (13%). Feeding vessels were only identified on CT. Wegener granulomatosis is a primary necrotizing granulomatous vasculitis, and when it affects the lung it demonstrates CT features that are similar to other vessel-related disorders of the lung such as septic emboli, pulmonary infarcts, and tumor emboli of hematogenous metastases. We believe that these CT features--nodules with feeding vessels and wedge-shaped lesions abutting the pleura--are related to the necrotizing angiitis that affects pulmonary arteries and veins in this disease.

Adult↗
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Inflation-fixed lungs: pathologic-radiologic (CT) correlation of lung transplantation.

Pulmonary infections and lung rejection are the two major complications of lung transplantation. Although the therapies for these two processes differ greatly, they often cannot be differentiated using standard radiography. We applied high resolution CT (HRCT) to seven lung specimens that were obtained from patients who had received a heart-lung transplant. The lungs were fixed by a method that allows for direct one-to-one pathologic-radiologic correlation. We found: (a) that in contrast to the extensive changes present microscopically, acute lung allograft rejection was characterized by only minor changes on HRCT; (b) that bronchiolitis obliterans, the hallmark of chronic lung allograft rejection, was not reliably identifiable on HRCT; (c) that bronchiectasis with associated peribronchial inflammation and fibrosis, a common finding in lung allograft rejection, was identifiable on HRCT, but that the HRCT appearance of this lesion was not specific for rejection; and (d) that pulmonary infections were often identifiable as a mixed airway-interstitial process on HRCT.

Adult↗
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CT of inflation-fixed lungs: wedge-shaped density and vascular sign in the diagnosis of infarction.

To evaluate the role of high resolution CT (HRCT) in the diagnosis of pulmonary infarcts, we selected 83 postmortem lung specimens with subpleural densities from a collection of 180 lungs that had been prepared by a method which allows for a direct radiologic-pathologic correlation. Twelve of the lungs had pulmonary infarcts and 71 lungs had other disorders that had produced a subpleural shadow on HRCT. Lungs were evaluated for the presence of wedge-shaped pleural-based densities and for the presence of an associated vascular sign. There was no significant difference in the incidence of wedge-shaped densities on HRCT between lungs with pulmonary infarcts and lungs with pulmonary hemorrhage, pneumonia, tumor, or edema (p greater than 0.05). A vascular sign associated with a subpleural density was, however, more common (p less than 0.01) in lungs with pulmonary infarcts. We suggest that the vascular sign associated with a wedge-shaped density may be of importance in diagnosing pulmonary infarcts by HRCT.

Humans↗
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Pulmonary infarction: CT appearance with pathologic correlation.

The CT appearance of 12 proven pulmonary infarcts in 10 patients was analyzed and correlated with pathologic appearance. The diagnosis of pulmonary infarction was clinically suspected in only 2 of the 10 patients. A pleural based parenchymal density with convex, bulging borders and linear strands directed from the apex of the density toward the hilum was noted in each case (n = 12). Other features were a truncated apex (n = 10), a broad pleural base (n = 10), and scattered areas of reduced attenuation within the lesions (n = 7). This distinctive complex of findings on CT should raise a strong suspicion of pulmonary infarction.

Adult↗
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Chondromyxoid fibroma of the fibula.

A 3 1/2-year-old girl presented with a lytic lesion in the diametaphyseal region of the right fibula. In addition to plain roentgenography, radiological evaluation consisted of bone scintigraphy and computed tomography. The radiological features suggested a benign lesion. Pathological examination revealed a chondromyxoid fibroma.

Bone Neoplasms↗
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Multiplanar imaging of the hip: a systematic approach.

Computed tomography has become an invaluable adjunct for the evaluation of musculoskeletal pathology. Although the transaxial image presentation has distinct advantages over conventional radiography, the ability to reformat the acquired data into coronal, sagittal, or oblique planes contributes to a more thorough understanding of complex anatomy such as that of the hip joint. This article reviews our experience with a series of over 500 hip cases using the multiplanar reformatting and display [MPR/D] package developed for use on the Siemens Somatom DR-3 scanner.

Acetabulum↗