A case of neuromyelitis optica (Devic's syndrome) in systemic lupus erythematosus. Clinicopathologic report and review of the literature.

An interesting case of systemic lupus erythematosus (SLE) is presented in which the clinical onset of myelopathy strongly suggested demyelinating disease. Later, intracranial hypertension developed on two occasions. Postmortem examination showed the systemic lesions of SLE. In addition, demyelinating lesions were found in the spinal cord and the optic nerve, the neuropathologic picutre of Devic's syndrome, a variant of multiple sclerosis. We question whether some of the cases showing necrotic myelopathy might have an autoimmune pathogenesis.

AUR Memorial Award 1992. Quantification of amino acids in human body fluids by 1H magnetic resonance spectroscopy. A specific test for the identification of abscess.

RATIONALE AND OBJECTIVES: When polymorphonucleocytes are incubated in proteinaceous fluid, they cause extensive protein degradation, which leads to accumulation of free amino acids. The authors tested whether these free amino acids, particularly valine and leucine, also accumulate in human abscess fluids, but not in other body fluids, and thus could be a specific and distinguishing marker for the presence of an abscess. METHODS: Thirty fluids, obtained by percutaneous drainage from 28 patients, were lyophilized and reconstituted in 2H2O before in vitro 1H magnetic resonance (MR) spectroscopy. Concentrations of valine and leucine were determined by comparison of spectra before and after addition of known amounts of valine and leucine. Two chart reviewers, blinded to the spectroscopic results, categorized cases as abscess (n = 14), non-abscess (n = 15), or infection but not abscess (n = 1). RESULTS: The concentration of valine and leucine was significantly higher in the abscess fluids, 2.57 +/- 1.90 mM than in the non-abscess fluids, 0.25 +/- 0.33 mM (P < .001). The one infected fluid which was not an abscess had no amino acids. Using 0.8 mM as the threshold concentration of valine and leucine necessary for the diagnosis of abscess resulted in a sensitivity rate of 86% and a specificity rate of 94%. CONCLUSION: The authors conclude that identification of high concentrations of valine and leucine by 1H MR spectroscopy may be a specific test for the diagnosis of abscess. This technique merits further investigation in vivo.

The role of interventional radiology for complications of cholecystectomy.

This report summarizes diagnostic and therapeutic radiologic procedures in 45 patients who suffered major complications from cholecystectomy. Complications were divided into (1) bile duct injury or ligation and (2) a variety of pathologic fluid collections. Specific lesions were bile duct injury (n = 6), accidental bile duct ligation (n = 12), ductal stricture (n = 12), abscess (n = 11), biloma (n = 7), hematoma (n = 5), infected pancreatic pseudocyst (n = 3), and stones (n = 2). Presenting problems were sepsis, jaundice, and intermittent cholangitis. The patients underwent 104 interventional radiologic procedures including 29 percutaneous transhepatic cholangiograms, 21 percutaneous biliary drainages, 12 balloon dilatations of strictures, drainage of 11 abscesses, 8 bilomas, 5 hematomas, and 3 pancreatic pseudocysts. Stones were removed by baskets in 2 patients; 12 pressure and perfusion studies were performed. One hundred of 104 procedures were successful; there was one failed biliary drainage, one unsuccessful stricture dilatation, one unsuccessful hematoma drainage, and one recurrent biloma. Thirty patients were spared another operation. The percutaneous procedures were beneficial although not curative in 14 of 15 patients who underwent reoperation; in those patients the procedures helped to establish a diagnosis, improve the patient's preoperative status, or serve as a landmark for the surgeon to locate and repair the ligated or injured duct. One patient died after reoperation, a 2.2% mortality rate. Sectional imaging studies combined with interventional radiologic procedures help to diagnose promptly and effectively treat major complications of cholecystectomy. These interventional procedures either cure the complication and obviate reoperation or aid the surgeon by relieving sepsis and jaundice before reoperation and providing an intraoperative guide for bile duct reconstruction.

Airway simulation to guide stent placement for tracheobronchial obstruction in lung cancer.

BACKGROUND: To effectively palliate large airway obstruction in advanced unresectable lung cancer (stage IIIB or IV), we developed an airway imaging technique to guide selective endobronchial metallic stent placement. METHODS: Fourteen consecutive patients with severe dyspnea (American Thoracic Society grade 4) had a combination of fiberoptic bronchoscopy, chest roentgenography, computed tomographic scanning, helical computed tomography with three-dimensional reconstruction, and intraluminal bronchography with selective bronchial guidewire placement under fluoroscopy to visually reconstruct and simulate the abnormal airway before and during stent placement. Wallstent or Gianturco intraluminal stents were used alone or in combination (up to five stents) to establish patency of the distal trachea and the major bronchi. RESULTS: All 14 patients had successful deployment with initial relief of airway stenosis (>75% predicted diameter). No procedural complications were noted. However, technical problems included stent foreshortening and imprecision of placement, misinterpretation of bronchography (mucous versus tumor), and airway maintenance during manipulation. Length of stay attributable to the procedure averaged 4 days. Stent placement initially improved the dyspnea score in 7 of 14 patients. Five of 14 died in less than 1 month, with the remainder alive at up to 8 months' follow-up. Of those surviving more than 1 month, the Karnofsky score improved in 4 and was unchanged in 5, with 2 dependent (Karnofsky score <50), 3 functional (Karnofsky score, 50 to 70), and 4 active (Karnofsky score >70). CONCLUSIONS: A protocol combining helical computed tomography with three-dimensional reconstruction, bronchography, and bronchoscopy allows accurate assessment of malignant airway obstruction to facilitate intralumenal stent placement for relief of stenosis. Patient selection to favor effective palliation and cost effectiveness has yet to be defined.

Ultrasound guided biopsy of nonpalpable and difficult to palpate thyroid masses.

We reviewed our experience with ultrasound-guided biopsies of masses of the thyroid gland that were either nonpalpable or difficult to localize by palpation to evaluate the technique and correlate the results. Thirty-two biopsies were performed upon 25 patients whose clinical presentations were palpable nodule (six patients), throat discomfort (two patients), postpartial thyroidectomy follow-up evaluation (two patients), incidental discovery of a mass--by ultrasound of the neck (two patients), roentgenogram of the chest (two patients), computed tomography of the chest (one patient) and during tracheostomy placement (one patient). Other presentations were eliminate infection (one patient), odynophagia (one patient), hoarseness (one patient), cold nodule on a nuclear medicine study (one patient), hyperparathyroidism (one patient), rule out metastasis from carcinoma of the colon (one patient), persistent cough (one patient), enlarged thyroid gland (one patient) or family history of carcinoma of the thyroid gland (one patient). Fifteen patients had nuclear medicine studies showing either a cold nodule (ten patients), multinodular goiter (one patient), normal examination (two patients), hot nodule (one patient) or no thyroid gland activity (one patient). The ultrasound examinations showed either a hypoechoic nodule (25 patients), inhomogeneous or mixed echogenic nodule (six patients) or a hyperechoic nodule with hypoechoic rim (one patient). The nodules ranged in size from 3 milliliters to 7 centimeters. Twenty-six lesions were less than 3 centimeters in diameter; of the other six, four were substernal goiters. Six patients had a previous nondiagnostic biopsy directed by palpation only. Biopsy was performed using real-time ultrasound guidance with various needles. One patient had a small hematoma, which was the only complication in the study. The results of the biopsies were diagnostic in 26 of 32 patients. The final diagnosis was benign follicular cells (ten patients), adenomatous nodule (seven patients), follicular neoplasm (three patients), colloid cyst (two patients), aspergillus (two patients), fibrosis (one patient) and papillary carcinoma (one patient). Six of the biopsies yielded unsatisfactory specimens. One of the patients with a diagnosis of benign follicular cells on biopsy had a follicular carcinoma after surgical pathologic factors were obtained; that was the only false-negative result. We conclude that ultrasound-guided biopsy of the thyroid is a safe and useful method of evaluating nonpalpable and difficult to palpate thyroid masses.

CT of diverticulitis. Diagnosis and treatment.

Diverticulitis can be detected accurately by computed tomography (CT) and staged according to an established system that is meaningful to both radiologists and surgeons. Diverticulitis limited to the wall of the sigmoid colon or small diverticular abscesses contained within the pericolic mesentery generally respond well to antibiotic therapy; larger abscesses must be drained. CT-guided catheter drainage is an effective method to treat these large diverticular abscesses. Overall management is simplified since one-stage sigmoid resection can be performed electively on a nonseptic patient. High-risk patients may be spared surgery entirely in selected cases.

Imaging and interventional radiology for pancreatitis and its complications.

Complications of pancreatitis are common, protean in their manifestations, and can be catastrophic. When complications occur, the morbidity and mortality are high. Expeditious radiologic detection of the complication, together with the plethora of nonoperative interventional techniques, offers new and improved methods for diagnosis and treatment. This article focuses on the essential role of radiology and the natural integration of imaging and interventional radiology for pancreatitis and its complications.

The uses of diagnostic ultrasound in the thorax.

Modern real-time gray scale ultrasonography has contributed new diagnostic and therapeutic information in patients with diseases of the lungs and pleura. This article will discuss the ways in which ultrasound is most clinically useful in patients with thoracic disease.

Preoperative percutaneous drainage of diverticular abscesses.

To define the role of percutaneous catheter drainage in the initial management of diverticular abscess, we reviewed 19 patients who were followed for an average of 17.4 months after drainage. All patients had large paracolic or pelvic abscesses with a mean size of 8.9 cm. There were no complications related to catheter placement, and 15 patients (79 percent) required drainage for less than 3 weeks. Sepsis resolved rapidly, and only two patients (11 percent) had persistent fever or leukocytosis beyond the third day of drainage. Routine sinography revealed fistulous communications to the colon in nine patients (47 percent), but only three (16 percent) had grossly feculent drainage. Fourteen patients (74 percent) completed the treatment plan of preoperative catheter drainage followed by single-stage sigmoid colectomy and primary anastomosis without complications. Two patients refused operation, one of whom died 16 days postoperatively from recurrent sepsis and end-stage pulmonary disease. The three patients with fecal fistulas all had inadequate control of infection, suggesting the need for early operation and fecal diversion in such cases. We conclude that preoperative percutaneous catheter drainage obviates the need for colostomy and multiple-stage surgery in approximately three-fourths of patients with large diverticular abscesses.

Image-guided needle biopsy of inaccessible head and neck lesions.

Fine-needle biopsy and large-needle core biopsy of inaccessible and deep-space lesions of the head and neck are difficult and sometimes hazardous to perform. Patients subsequently may have to undergo a major surgical procedure with exploration of the neck and open biopsy. We describe our experience with computed tomography and ultrasound-guided fine-needle and core-needle biopsy for 11 patients with inaccessible lesions in the head and neck. Carcinoma was diagnosed in three patients and nonmalignant pathologic findings in eight patients. Three of the needle biopsy findings were confirmed by surgical excision. The initial diagnoses made from the cytopathologic findings have remained unchanged in all patients. Compared with the alternative of open biopsy, we have found this method to be technically easy, diagnostically expeditious, and safe. Head and neck surgical oncologists should be familiar with image-guided biopsy techniques, since many of their patients may benefit from these diagnostic procedures.

Percutaneous drainage of infected and noninfected thoracic fluid collections.

Radiologically guided aspiration and drainage of thoracic fluid collections is an improvement on standard "blind" techniques for chest-tube insertion. Specific indications for radiologic drainage are broadening, and instead of failed surgical cases only, patients now are commonly referred for drainage. Most of these procedures are effective and the complication rate vis-à-vis alternatives is acceptable. Soft 12-F catheters suffice in most cases and are relatively comfortable to large-bore tubes.

Percutaneous drainage of thoracic collections.

Various infected and noninfected thoracic fluid collections may be diagnosed and treated by interventional radiologic techniques. The core procedure of ultrasound-guided thoracentesis has been expanded to allow catheter drainage of empyema, bronchopleural fistula, abscesses in the lung, mediastinum, pericardium, and infected tumors. Tailored use of guidance methods permits effective evacuation of most of these abscesses and noninfected collections. This paper details the authors' approach to each of these entities while highlighting the results and expected pitfalls of these techniques.

Percutaneous dissolution of gallstones.

Contact dissolution with MTBE is an effective and safe method to treat symptomatic patients with cholesterol gallstones. Personnel, time, and safety factors have limited widespread use of the procedure. With current competing methods to treat gallstones, it is likely that MTBE use will be reserved for those patients who elect percutaneous therapy due to fear of surgery or anesthesia and in those elderly patients who are compromised by underlying medical conditions.

Skin damage from acetylcysteine leak during percutaneous abscess drainage.

A patient experienced severe cutaneous pain and excoriation during acetylcysteine infusion at percutaneous abscess drainage. The mucolytic agent leaked back along the catheter track, causing the local reaction. Cessation of the acetylcysteine treatment, and catheter exchange resulted in improvement within a few days.

Simple apparatus to avoid inadvertent needle puncture.

Current heightened awareness and concern about accidental needle puncture prompted design of a device to reduce this risk. Holes are made in the top of a prepurchased film cannister; these allow placement of all sharp objects used for angiographic and interventional radiology procedures. This protective cannister is recommended for routine use on all instrument trays, since it lessens the likelihood of inadvertent puncture.

Bile duct obstruction in hepatocellular carcinoma (hepatoma)--clinical and cholangiographic characteristics. Report of 6 cases and review of the literature.

Direct cholangiography revealed 6 cases of hepatoma where tumor growth within the bile ducts caused obstructive jaundice. Characteristic features included bulky obstructing intraluminal masses in the proximal extrahepatic ducts. Distal common duct defects usually signify hemobilia and clots as tumor complication. Review of the literature disclosed only 22 cases in which common duct involvement was a predominant clinical feature. Hepatoma should be included in the different diagnosis of a cholangiographic filling defect in the proximal extrahepatic bile ducts. The recent widespread use of endoscopic and fine needle transhepatic cholangiography should aid in preoperative diagnosis.

Balloon techniques for percutaneous gastrostomy in a patient with partial gastrectomy.

Intragastric balloon techniques were used to achieve direct gastric distention and efferent loop obstruction in order to perform percutaneous gastrostomy on two occasions in a patient with a partial gastrectomy and Billroth II anastomosis. Previous attempts at percutaneous endoscopic gastrostomy and conventional radiologic percutaneous gastrostomy had been unsuccessful. Although a history of partial gastrectomy has been considered an impediment to both percutaneous gastrostomy and percutaneous endoscopic gastrostomy, this experience demonstrates that percutaneous gastrostomy can be performed safely in this setting with balloon assistance.

Radiologic management of hepatolithiasis.

We describe the diagnostic workup and therapeutic management of patients with hepatolithiasis from the viewpoint of the interventional radiologist. The diagnosis is best established by direct cholangiography such as percutaneous transhepatic cholangiography or endoscopic retrograde cholangiography. We consider percutaneous transhepatic stone removal a highly successful, minimally invasive, and safe procedure. Access can be gained to the biliary system in almost 100% of patients and complete stone clearance through percutaneous techniques, including stone fragmentation, removal of stones and fragments by baskets, and dilatation of underlying strictures in more than 90%. The role of these radiologic techniques is discussed vis-à-vis endoscopic and surgical alternatives.