[Endovascular stent grafting for chronic proximal thoracic aortic pseudoaneurysm]. / Faux anévrysme chronique de l'aorte thoracique descendante proximale: traitement endovasculaire percutané.

Chronic descending aortic pseudoaneurysm generally result from traumatic and can spontaneously progress to rupture. We report the case of a 70-year-old patient presenting a chronic pseudoaneurysm of the thoracic aorta treated by endovascular stent-grafting. The patient underwent imaging evaluation for endoluminal repair: thoracic aorta was evaluated by contrast-enhanced CT scan and supra-aortic and iliac vessels were evaluated by MRI-imaging. Stent-graft was deployed under fluoroscopic guidance across the aneurysmal defect. The left sub-clavian artery was covered, but no ischemic symptoms appeared and transposition of the left sub-clavian artery was not necessary. Clinical and radiological follow-up at 6 and 30 months showed total exclusion and thrombosis of the pseudoaneurysm. Chronic pseudoaneurysm of the thoracic aorta do benefit from endoluminal repair, which is adapted to patients with high surgical risk.

Pulmonary arteriovenous malformations.

OBJECTIVE: Helical CT scan (HCT), a noninvasive method, can detect pulmonary arteriovenous malformations (PAVMs). Its sensitivity is superior to that of global digitalized angiography, but patients receive a significant dose of radiation during diagnostic HCT. We compared HCT to contrast-enhanced pulmonary magnetic resonance angiography (CEMRA), a new noninvasive radiation-free method, in the diagnosis of PAVMs. PATIENTS AND METHODS: Five consecutive patients with PAVMs underwent HCT, CEMRA, and pulmonary artery digital subtraction angiography (PADSA). CEMRA was performed during the pulmonary arterial phase of an IV bolus of gadolinium. PADSA was performed during the embolization procedure. All images were examined for PAVMs. The site and size of aneurysms were specified, as well as the diameter of the vascular pedicles. RESULTS: Thirty PAVMs were detected by CEMRA and 38 by HCT. All 20 PAVMs at least 5 mm in diameter and 10 of the 18 PAVMs < 5 mm in diameter identified on HCT were also identified by CEMRA. Whatever the site, all PAVMs with a feeding artery diameter of at least 3 mm (ie, PAVMs with clinical consequences) were detected by CEMRA. No false-positive results were obtained with CEMRA. CEMRA therefore had a sensitivity of 78% and a specificity of 100%. CONCLUSIONS: CEMRA, a nonionizing and noninvasive procedure, has high sensitivity and specificity for the diagnosis of clinically relevant PAVMs.

Primary pulmonary AIDS-related lymphoma: radiographic and CT findings.

STUDY OBJECTIVES: To describe the radiographic and CT findings of primary AIDS-related lymphoma (ARL) of the lung (ARLL), and to evaluate percutaneous transthoracic needle biopsy (PTNB) in the diagnosis of primary ARLL. MATERIALS AND METHODS: Seven chest radiographs and seven CT scans of HIV-infected patients with histologically proved primary pulmonary non-Hodgkin's lymphoma (PPL) were reviewed at our institution. All of the patients had fibroscopy with BAL. The diagnosis of PPL was established histologically by means of PTNB (n = 4), open-lung biopsy (n = 2), or autopsy (n = 1). RESULTS: All but one patient had multiple peripheral well-defined nodules of various sizes on the chest X-ray film and CT scan. One patient had a subpleural parenchymal infiltrate and another had a main peripheral mass with spontaneous cavitation. Hilar/mediastinal adenopathies and pericardial/pleural effusion were never associated with the parenchymal abnormalities. Fibroscopy with BAL was always negative. PTNB, done in six cases, was diagnostic in four cases and suggested primary ARLL in two cases. No complications occurred during these procedures. CONCLUSION: After excluding infectious causes, multiple peripheral nodules and/or masses without hilar or mediastinal adenopathies and without pleural effusion are suggestive of primary pulmonary ARL. A specific diagnosis can be obtained by means of PTNB.

Intrathoracic Kaposi's sarcoma. CT findings.

AIM: To describe the thin CT scans findings in AIDS patients with intrathoracic Kaposi's sarcoma (KS). MATERIAL AND METHODS: Fifty-three CT scans of patients with KS were retrospectively reviewed. The diagnosis of intrathoracic KS was established histologically (n = 17) or on the association of skin KS and the visualization of characteristic endobronchial lesions (n = 36). CT scans were performed with thin slices (2 mm) obtained at 10-mm intervals, and a 512 x 512 reconstruction matrix. No patients had Pneumocystis carinii pneumonia within the 3 months preceding the CT scan examination. RESULTS: Numerous nodules (n = 42), tumoral masses (n = 28), bronchovascular pathways thickening (n = 35), and pleural effusions (n = 28) were the most frequent patterns. Septal lines (n = 15), ground-glass opacities (n = 3), and mediastinal adenopathies (n = 8) were not frequent. CONCLUSION: Numerous nodules, tumoral masses, bronchovascular pathways thickening, and bilateral pleural effusions were the main signs of intrathoracic KS; their association (66%) is very characteristic. An opportunistic infection or mycobacteriosis must be sought if the thin CT scans reveal ground-glass opacities and/or mediastinal adenopathies.

Computed tomographic diagnosis of bronchogenic carcinoma in HIV-infected patients.

PURPOSE: To describe the features of bronchogenic carcinoma (BC) on plain radiography and computed tomography (CT) in human immunodeficiency virus (HIV)-infected patients; to evaluate percutaneous transthoracic needle biopsy (PTNB) in this setting; and to assess outcome. PATIENTS AND METHODS: We reviewed the medical charts, radiographs and chest CT scans in 15 AIDS patients with histologically proven BC. All but one of the patients were young men (mean age 48 years) with a long history of smoking (mean 40 pack-years). Adenocarcinoma was the predominant cell type (46.6%). The stage of the malignancy did not correlate with the CD4 cell count (mean 189 per mm(3)). The diagnosis was obtained by means of PTNB (n=7), bronchoscopy (n=4), thoracotomy (n=2), pleural biopsy (n=1) or extrathoracic biopsy (n=1). RESULTS: Parenchymal masses and nodules were the most common features (66.6%) on chest radiographs and CT. BC was peripheral in 11 cases (73%) and was located in the upper lobe in ten cases (66.6%). Enlarged lymph nodes were present in 60% of patients and metastases in 30%. PTNB was diagnostic in seven of the eight patients who underwent the procedure; complications included two pneumothoraces and one secondary implantation of tumor cells along the needle tract. Three lobectomies and one pneumonectomy were performed for stage I disease. The mean survival time among the patients who underwent surgery was 14 months. These survivals are more encouraging than some of those previously reported in the literature, furthermore, patients die of competing illnesses. CONCLUSION: BC in HIV-infected patients is similar to that in the general population. Early diagnosis can be achieved by means of PTNB. Surgical resection, when feasible, significantly improves survival.

A new model of endovascularly induced renal artery stenosis in normocholesterolemic versus hypercholesterolemic rabbits.

RATIONALE AND OBJECTIVES: The authors determine the feasibility of creating renal artery stenosis by overdilatation and deendothelialization and compare the model in normocholesterolemic versus hypercholesterolemic rabbits. METHODS: Thirty male New Zealand White rabbits were randomized into two groups: group A (n = 15) was fed a normal diet and group B (n = 15) was fed a cholesterol-rich diet 4 weeks before stenosis induction. An aortogram was performed, then the right renal artery was overdilated with an angioplasty balloon-catheter, and deendothelialized. After 6 weeks, groups A and B were compared by angiographic and pathologic study. RESULTS: Comparison of group A versus group B showed that 12 arteries (80%) versus 6 (40%) were angiographically stenotic (P < 0.05); 14 (93%) versus 12 (80%) contained neointima (NS), 12 (80%) versus 3 (20%) showed medial disorganization (P < 0.01), and 9 (60%) versus 2 (13%) presented adventitial fibrosis (P < 0.01). CONCLUSIONS: A new model of endovascularly induced renal artery stenosis has been developed in rabbits. Medial proliferation and adventitial fibrosis are more frequent in normocholesterolemic rabbits.

Comparison of magnetic resonance imaging and computed tomography in the preoperative staging of rectal cancer.

Nineteen patients with middle and lower rectal carcinomas were operated on, with abdominoperineal resection in 10 patients, lower anterior resection with coloanal anastomosis in 6 patients, and colorectal anastomosis in 3 patients. The distance of the lower margin of the tumor to insertion of the levator ani on the rectal wall was correctly evaluated by computed tomography in 12 (63%) of 19 patients and by magnetic resonance imaging in 13 (68%) of 19 patients, while digital examination correctly assessed the distance in 15 (79%) of 19 patients. Computed tomography and magnetic resonance imaging were unable to assess extension through the rectal wall. No significant difference was observed between computed tomography and magnetic resonance imaging in assessing extension to the perivesical fat, adjacent organs, pelvic side wall, or lymph nodes. According to the TNM classification, magnetic resonance imaging correctly staged 74% (14/19) of carcinomas, while computed tomography correctly staged 68% (13/19).

Magnetic resonance imaging in adults presenting with severe acute infectious cellulitis.

BACKGROUND AND DESIGN: Early categorization of some acute soft-tissue infections, such as severe infectious cellulitis (IC) without or with secondary abscess formation, necrotizing fasciitis (NF) or pyomyositis, is frequently difficult. The first one requires only medical treatment, the remaining ones require either surgery or closed drainage. To determine the presence and the extent of these infections early, we have prospectively studied the value of magnetic resonance imaging in patients admitted for IC with local or general criteria of severity. Images were analyzed on a blind basis. Definite diagnosis was obtained by reviewing clinical records and, in most patients, the results of an invasive procedure. RESULTS: Twenty-six patients (56 +/- 23 years old) were included in this study. Among them, 13 received gadolinium-diethylene-triaminepenta-acetic acid intravenously. The final diagnosis was pyomyositis (five patients), NF (three patients), or IC with (seven patients) or without (11 patients) subcutaneous abscess. Images specific for these diseases were best outlined with T2-weighted sequences. In patients with pyomyositis or subcutaneous abscess(es), we observed spindle-shaped or round, well-defined areas of high signal intensity within the muscles or subcutis, respectively. Patients with NF exhibited numerous homogeneous, well-defined dome-shaped areas of hypersignal in the deep hypodermis. In patients with uncomplicated IC, these dome-shaped areas of hypersignal appeared ill-defined, heterogeneous, smaller, thinner, and less numerous than those in patients with NF. CONCLUSIONS: In patients presenting severe IC, magnetic resonance imaging provided an early clue in the diagnosis of pyomyositis, NF, and abscess-complicated IC. By precisely defining the extent of these infections, it helped to plan surgical treatment.

[Congestive cardiac failure secondary to hepatico-portal arteriovenous fistula. Apropos of a case and review of the literature]. / Insuffisance cardiaque globale secondaire à une fistule artério-veineuse hépatico-portale. A propos d'une observation et revue de la littérature.

A 66 year old man with mild hypertension developed congestive cardiac failure of rapid onset associated with a continuous epigastric murmur suggesting an arteriovenous fistula. Doppler ultrasonography, computed tomography, magnetic resonance imaging and abdominal arteriography showed the fistula to arise from a large thrombosed aneurysm of the hepatic artery which had ruptured into the portal vein. Echocardiography and radionuclide angiography showed normal left ventricular systolic function. The patient underwent aneurysmorrhaphy and suture of the portal vein without any complications and the murmur and signs of cardiac failure disappeared. Histological examination showed the arterial lesion to be due to atherosclerosis. The authors underline the rarity of aneurysms of the hepatic artery and, above all, of their rupture into the portal system as there have only been 7 previously reported cases. Fistulae of the portal system are usually well tolerated, the commonest complication being portal hypertension. Cardiac failure is an exceptionally rare occurrence: it may be observed when the fistula develops suddenly and has a high flow rate, and in patients with abnormal myocardial function.

[Treatment of jaundice caused by neoplastic obstruction of the bile ducts with percutaneous placement of endoprostheses: 53 cases]. / Traitement des ictères par obstruction néoplasique des voies biliaires par mise en place percutanée d'endoprothèses: 53 cas.

From October 1983 to October 1985, 53 patients with malignant biliary obstruction were referred to our institution for a transhepatic biliary stent. One or two endoprostheses were inserted in 46 patients (87 p. 100). Stent insertion was usually performed in two sessions, after two or three days of external drainage. There were 23 men and 23 women. Their mean age was 70.6 years +/- 12 years (m +/- DS). Fourty-two patients (91 p. 100) were referred after failure of an endoscopic or surgical drainage procedure; fourty-four p. 100 of the patients had stage II or III high periportal obstruction. Five cases of severe early complications (11 p. 100) and 8 delayed complications requiring in-hospital treatment (17 p. 100) were observed. Among the latter, 7 were due to plugging of the endoprosthesis. All patients were unfit for surgery either because at a high operative risk or because of the extent of the cancer. Our results showed that percutaneous biliary drainage can be achieved in a high percentage of cases following failure of a surgical or endoscopic drainage procedure. The endoscopic transpapillary approach, which allows the insertion of 12 French endoprostheses in one session should be tried first. Percutaneous biliary drainage should be performed as a complementary procedure when endoscopic drainage has failed or in stage II or III high periportal obstruction associated with persistent jaundice or cholangitis.

[Magnetic resonance imaging in the exploration of abdominal and anoperineal fistulas in Crohn's disease]. / L'imagerie par résonance magnétique dans l'exploration des fistules abdominales et ano-périnéales de la maladie de Crohn.

In a twelve month period, ten patients with fistulas related to Crohn's disease were explored by magnetic resonance imaging performed with a high-field supraconductive magnet. This technique demonstrated 3 cases of peri-anal abcesse invisible by other imaging modalities, and in 8 cases, fistules tracts, including 5 complex fistules, and one communicating with the bladder. This examination defined the extension of these lesions relative to the elevator plane, and demonstrated diffusion to the inferior space in 4 cases, to the superior space in 2 cases, and to both spaces in 2 cases. This method seems to be efficacious and does not expose the patient to X-rays.

[Percutaneous drainage of intra-abdominal abscesses guided by real-time ultrasonography]. / Drainage percutané des abcès intra-abdominaux guidé par échographie en temps réel.

From October 1982 to October 1984, a percutaneous drainage under realtime ultrasound guidance was performed in 53 patients with abdominal abscesses. The location of the abscesses was subphrenic (23), retroperitoneal (16), and intrahepatic (14). A safe access route was found by using ultrasound and fluoroscopy in 53 out of 55 patients (96 p. 100). Percutaneous drainage failed in 8 patients and 3 of these patients died. The causes of death were: cerebral abscess (1), renal failure after surgery for correction of a duodenal fistula (1), and pancreatic abscess (1). The other five patients were cured by surgical drainage. Two complications were observed: one case each of pneumothorax and purulent peritonitis. Forty-five patients were healed by percutaneous drainage without operation. The duration of the catheter drainage was 14 days +/- 13 (m +/- 1 SD). Our results suggest that percutaneous drainage under realtime ultrasound guidance is an efficient and safe way to treat abdominal abscesses.

[Vascular investigation of impotence (author's transl)]. / Explorations vasculaires dans l'impuissance.

Approximately 25% of patients with impotence have erectile dysfunction of vascular origin, which requires systematic investigation in patients under 60 years of age because of the possibility of surgical treatment. Diagnosis is based on clinical findings, confirmed by two tests that are simple to conduct in ambulatory patients, doppler and plethymography. Arteriography of the sexual organs enables precise definition of the lesions, and surgery is indicated when there is strong clinical evidence, no other cause for the lesions can be found, and operative correction appears possible. Many unknown factors still exist in relation to the physiopathology of impotence of valvular origin. Current-research is directed towards detection and possible treatment of disorders of venous origin.

[Glomus tumor of the extremities]. / Tumeur glomique des extrémités.

Glomus tumor is a neuro-myo-arterial benign tumor accounting for 1 to 5% of hand tumors which occurs principally in young adult females. It may be unique or multiple. Acute, focalized, pain is the main sign, the pressure of a small trigger zone induces a syncopal pain and immediate hand withdrawal. Differential diagnoses includes neurinoma, melanoma, hematoma, osteoid osteoma, fibrokeratoma, mucoid cyst, angioma, and exostosis. The diagnosis is suspected on clinical grounds, and X rays exhibits a bone erosion in one third of the cases. Magnetic resonance angiography is now the first line non invasive tool for both diagnosis and precise localization. Treatment consists in complete surgical tumor resection (J Mal Vasc 1999; 24: 364-367).

[Hypoxic cerebral lesions. X-ray computed tomography and MRI aspects. Apropos of 20 cases. Selective vulnerability of the striatopallidum]. / Lésions cérébrales hypoxiques. Aspects TDM et IRM. A propos de 20 cas. Vulnérabilité sélective du striatopallidum.

Brain lesions following hypoxic-ischaemic injuries are known from autopsy studies, but their appearance in live patients has been only occasionally described, and only sporadic reports have been published on their CT and MRI images. Over a 2-year period (1991-93) we studied the clinical, MRI and CT features in 20 patients shortly after a severe hypoxia. Clinical examination showed motor extrapyramidal signs in 13 cases and coma in 7 cases. MR with inversion recovery (IR) and T2-weighted spin echo (SE) sequences was performed in 17 patients and CT in 15. Bilateral lesions were found in 11 cases, but in 13 of them CT was normal. Radiological lesions were always symmetrical and bilateral, located in the pallidum in 10 cases, the striatum in 4 cases and the thalamus in 2 cases. Additional white matter lesions were present in only 4 MRI examinations. No relationship was found between the mechanism of hypoxia and the severity of clinical signs. The course of the clinical signs was correlated with the presence of radiological lesions. In comatous patients there was a relation between parkinsonism and abnormalities of basal ganglia. None of the patients who had perinatal asphyxia had radiological lesions. The presence of pallidal or striatal confirmed the hypoxic origin of neurological symptoms, especially in patients with parkinsonism. MRI, particularly in IR sequences, makes it possible to detect small lesions in basal ganglia after hypoxic injuries.

[Non-palpable breast lesions: radio-pathologic correlations on open excisional biopsies. Significance of the choice of technique for minimal excisional biopsy]. / Lésions infracliniques mammaires: corrélations radiopathologiques sur les pièces d'exérèse chirurgicale. Intérêt pour le choix des techniques d'exérèse a minima.

OBJECTIVE: To decrease the number of open excisional breast biopsies, percutaneous breast biopsies have been developed to perform the histologic diagnosis of non-palpable breast lesions. Some techniques allow a complete removal of small radiologic lesions. To evaluate the accuracy of a pathologic analysis performed only on the radiologic findings, we studied the radiologic and histologic correlation on open excisional biopsy (OEB) specimens. The aim of our study was to determine how many carcinomas were found distant from the radiologic findings. MATERIAL AND METHODS: Non-palpable breast lesions have been excised after preoperative localization. The radiologic findings were classified in microcalcifications, masses, architectural distortion and in sonographic masses. The correlation between the radiologic and pathologic findings was studied and all the lesions incidentally discovered on histology with no correlation with the imaging findings or distant from the radiologic findings were described. One hundred and twenty-nine lesions have been evaluated in 99 patients. Radiologic findings included 79 clusters of microcalcifications, 30 masses, six architectural distortions and 14 sonographic lesions. RESULTS: The histopathological results were benign in 41.9%, malignant in 49.6% and atypical hyperplasia lesions were discovered in 8.5%. All benign lesions were correlated to radiologic findings. No malignant lesion was found at a distance. In three cases atypical hyperplasia lesions were coexistent with the radiologic findings correlated with benign lesions and in three cases they were found at a distance. All but two malignant lesions were correlated with radiologic findings. In two cases a microinvasive carcinoma and foci of labular carcinoma in situ were found coexistent with benign lesions. The subgroup of small lesions lesser than 10 mm included 31 benign lesions. A complete removal of these lesions should be obtained with percutaneous biopsies. CONCLUSION: A pathologic analysis targeted on radiologic findings is accurate. Numerous open excisional biopsies performed for benign pathology should be avoided.

[Ultrasono-hysterography: techniques and indications]. / La sono-hystérographie: techniques et indications.

Sonohysterography consists in injecting a saline solution into the uterine cavity and performing transvaginal sonography. The purpose of this procedure is the pre-operative assessment of intracavitary anomalies, especially polyps, myoma, adhesions, congenital abnormalities such as septate uterus. Technical aspects are shown. This procedure is painless, atraumatic and no adverse effect is seen if the usual precautions before hysterography are taken. The right place of this exam is between hysterography and hysteroscopy, but more widespread use is required before a final opinion can be reached.

[Diluted barium contrast agent for digestive opacification in abdominal x-ray computed tomography]. / Apport des barytes diluées dans l'opacification digestive en TDM abdominale.

Computed tomography is the gold standard technique for abdominal examination with a sliced-imaging modality, because actually US and MRI are not as available for studying hollow viscera. Oral opacification is necessary to analyze bowel loops, and complete iodinated venous injection which is indispensable to examine intra-abdominal organs. Oral administration of a barium diluted contrast agent, is discussed in terms of tolerance, efficacy and administration mode.

[Imaging of digestive involvements after irradiation]. / Imagerie des atteintes digestives après irradiation.

The main limiting factor of the abdominal and pelvic radiotherapy is radiation damage of the digestive organs. The intestinal abnormalities resulting from irradiation are due to damaged blood vessels and connective tissue. Radiation changes in the small bowel and the recto-sigmoid are frequent and often symptomatic. Imaging is able to detect the induced radiation damage, even the asymptomatic scars. It is relevant to differentiate them from tumoral recurrence. The lesion location within the irradiated volume is important in the evaluation of post-radiotherapy imaging. Computerized tomography (CT) and magnetic resonance imaging (MRI) detect asymptomatic lesions in the liver, spleen and pancreas. We insist on the CT-imaging of induced radiotherapy changes, which are of major importance during the follow-up of irradiated patients.

[Radiological aspects of the duodenum and small intestine in severe strongyloidiasis. Apropos of 4 cases]. / Aspects radiologiques du duodénum et du grêle dans l'anguillulose sévère. A propos de 4 observations.

Four cases of severe strongyloidiasis in Martinique patients are reported. Clinical features were typical of the affection, and the outcome was fatal in two cases. Fibroscopy findings were negative but larvae were demonstrated in biopsy specimens in 3 out of the 4 cases. A barium meal follow-through examination showed the different radiological images of the infestation: non-specific parasitic duodenitis and pseudo-stenosis of D3 with duodenal dilatation, barium reflux into the main bile duct, and absence of jejunal folds, these images being very suggestive of strongyloidiasis.