Hemorrhagic arachnoid cyst with third nerve paresis: CT and MR findings.

We report the CT and MR appearance of a nontraumatic hemorrhagic arachnoid cyst presenting with a third nerve paresis in a 37-year-old man. The cyst, located in the left suprasellar area, contained a fluid-blood level with stigmata of subacute hemorrhage on both CT and MR studies.

Unusual location of an intracranial chondroma.

We describe the MR findings in a case of chondroma arising from the falx. At MR imaging, the mass appeared well defined, lobulated, hypointense to isointense on T1-weighted images, and very heterogeneous with marked hyperintense areas on T2-weighted images. After contrast administration, this tumor enhanced slightly on delayed images.

An early MR observation of carotid involvement by retropharyngeal abscess.

We report early carotid involvement by retropharyngeal abscess in a 4-year-old boy. MR imaging showed enhancement of the wall and narrowing of the lumen of the internal carotid artery, which were thought to reflect spasm and/or arteritis. Prompt treatment may have prevented hemorrhagic and neurologic complications.

Unusual occipitoatlantal fracture dissociation with no neurological impairment. Case report.

The authors describe an unusual case of a complex traumatic fracture-dissociation injury of the craniovertebral junction, which the patient survived with no neurological damage. This case featured the rare combination of an avulsion of both the right occipital condyle and clivus and a fracture of the left lateral mass of the atlas. Because of the craniocervical ligament injury and the slight anterior occipitoatlantal dislocation, the lesion was considered to be unstable and was treated successfully with a cervical collar. The authors emphasize that thin-slice computerized tomography scanning with multiplanar reconstructions is essential to visualize these fractures, whereas magnetic resonance imaging is useful to assess soft tissues.

Anatomical variations of the carotid bifurcation: implications for digital subtraction angiography and ultrasonography.

Intravenous digital subtraction angiography was used to determine prospectively the positional variations of the common carotid bifurcation in 100 consecutive patients with clinically suspected arteriosclerotic disease. The most common position (97/200, 48.5%) of the external carotid artery was anteromedial to the internal carotid artery. Position of the external carotid artery anterolateral to the internal carotid artery was noted in 26/200 (13%) bifurcations, but this anatomical variant was more common on the right (21/100) than on the left (5/100) (p less than 0.01). Practical implications may be drawn from this study. For digital subtraction angiography, the left anterior oblique view has to be considered the projection of choice and the right common carotid bifurcation is less likely to be adequately displayed than the left one; for duplex ultrasonography, optimal visualization is obtained from a posterolateral orientation of the transducer.

Comparative study of two iodinated contrast media containing 20% iodine in lower-limb phlebography: ioxaglate versus a conventional product.

Forty-eight patients were examined by bilateral ascending phlebography in a crossover, prospective, randomised, double-blind study. A low-osmolar agent (Hexabrix) (ioxaglate, 200 mg iodine/ml) and a dilute conventional contrast medium (Angiografin) (meglumine diatrizoate) with the same iodine concentration were used for each limb alternately. The adverse reactions and the quality of diagnostic data were recorded: the Student paired-t-test showed statistically that ioxaglate containing 200 mg iodine per ml was better tolerated and that diagnostic information was equally good for the deep and ilio-caval systems, but seemed better with diatrizoate for superficial veins with extensive varicosity. The authors conclude that ioxaglate 200 is advantageous overall in lower-limb phlebography from the standpoints of tolerance, diagnostic data and cost.

Pitfalls of digital angiography in the diagnosis of right aortic arch.

The authors describe the difficulties using intravenous digital subtraction angiography, in diagnosing on a left anterior oblique view a right aortic arch with aberrant left subclavian artery and left descending aorta. The proximal topography of the left common carotid artery ostium is a useful sign in the diagnosis of this kind of abnormality.

Is a lung perfusion scan obtained by using single photon emission computed tomography able to improve the radionuclide diagnosis of pulmonary embolism?

Planar pulmonary scintigraphy is still regularly performed for the evaluation of pulmonary embolism (PE). However, only about 50-80% of cases can be resolved by this approach. This study evaluates the ability of tomographic acquisition (single photon emission computed tomography, SPECT) of the perfusion scan to improve the radionuclide diagnosis of PE. One hundred and fourteen consecutive patients with a suspicion of PE underwent planar and SPECT lung perfusion scans as well as planar ventilation scans. The final diagnosis was obtained by using an algorithm, including D-dimer measurement, leg ultrasonography, a V/Q scan and chest spiral computed tomography, as well as the patient outcome. A planar perfusion scan was considered positive for PE in the presence of one or more wedge shaped defect, while SPECT was considered positive with one or more wedge shaped defect with sharp borders, three-plane visualization, whatever the photopenia. A definite diagnosis was achieved in 70 patients. After exclusion of four 'non-diagnostic' SPECT images, the prevalence of PE was 23% (n =15). Intraobserver and interobserver reproducibilities were 91%/94% and 79%/88% for planar/SPECT images, respectively. The sensitivities for PE diagnosis were similar for planar and SPECT perfusion scans (80%), whereas SPECT had a higher specificity (96% vs 78%; P =0.01). SPECT correctly classified 8/9 intermediate and 31/32 low probability V/Q scans as negative. It is concluded that lung perfusion SPECT is readily performed and reproducible. A negative study eliminates the need for a combined V/Q study and most of the 'non-diagnostic' V/Q probabilities can be solved with a perfusion image obtained by using tomography.

Sciatic neuropathy at the popliteal fossa: clinical, ultrasonographic and computed tomographic diagnosis.

A 22-year-old female had been suffering from sciatica-like pain in the left leg for four years. Clinical findings strongly directed further investigations to the popliteal fossa. Ultrasonography located a hypoechogenic mass in the upper lateral popliteal space. Guided by these data, computerized tomography (CT) with vertical reconstructions made the tentative diagnosis of a common peroneal nerve tumor, which was confirmed at operation. Microscopic examination showed a neurinoma of the mixed neurilemmoma-neurofibroma type. In the presence of atypical features of sciatica, a high index of suspicion seems advisable. Emphasis is laid on the complementary contribution of ultrasonography and CT in this type of ill-defined lower limb pain.

Occurrence of thyroid papillary carcinoma in young patients. A Chernobyl connection?

The risk of thyroid papillary carcinoma is increased by external radiation particularly in children under 15 years of age as shown by a marked increase in those exposed to radiation after Chernobyl. We were recently confronted in Belgium over a short period with four patients (3 F, 1 M) with papillary thyroid carcinoma who were aged 10 years, 2 months, 2 years and 6 years when the Chernobyl accident occurred. We thus raise the question of a possible relationship. The patients were aged 17, 11, 10, 19 years at presentation. They all presented fortuitously over 3 years which was a very unusual increase in our extensive experience in thyroid surgery (62 cases of thyroid cancer among 1014 thyroidectomies in adults vs 4 cases in 18 children since the Chernobyl accident in 1986). Two out of the four patients had psammoma bodies (identifiable on CT scanning and ultrasound) and thyroglobulin autoantibodies (TgAb). The first patient had positive lymph nodes at the time of surgery. The incidence of thyroid cancers in Belarus and Ukraine rose just 4 years after the Chernobyl disaster; because radioactive clouds passed over Belgium, we wonder whether the occurrence of thyroid cancer in our patients could be related to this irradiation. The mechanism of increased incidence of radiation-induced thyroid cancer is thought to be due to rearrangement of the tyrosine kinase domains of the RET and TTK genes. The other important similarities in our patients are the presence of psammoma bodies that can be visualized on radiological examination and the presence of TgAb that are more frequent in differentiated thyroid cancers. Whether or not these cases reflect an increased incidence in the population as a whole, clinicians must remain vigilant for this rare but curable cancer in young patients, especially if suggestive radiological features or TgAb are present.

Radiologic findings of normal and compromised thoracic venous catheters.

We review the radiologic findings of normal positioning, malpositioning, and complications related to the more commonly used thoracic venous catheters. These include central venous catheters, long-term central venous access catheters, and pulmonary artery catheters. The radiologist plays an important role in the early recognition of the complications of these catheters. The daily practice of chest radiology is intimately related to the evaluation of the integrity and correct placement of thoracic venous catheters. The purpose of this pictorial essay is to review radiologic findings of normal positioning, malpositioning, and complications related to the more common devices used, including central venous catheters, long-term central venous access catheters, and pulmonary artery catheters. Many of the complications described are serious and may remain unrecognized for a long time; this may cause incorrect diagnosis and delayed treatment. The radiologist plays an important role in the early recognition of these complications. Malpositioning and complications often are more easily diagnosed with contrast-enhanced studies and computed tomography.

Spiral computed tomography with three-dimensional reconstructions for severe blunt abdominal traumas: a useful complementary tool?

Spiral computed tomography (CT) has proved to be a valuable tool by providing three-dimensional (3D) images of the studied structures. We hypothesized that a more realistic depiction of lesions by 3D CT could be of interest for surgeons who are treating blunt abdominal traumas and lead to less inappropriate triage. A good working relationship between surgeons and radiologists allowed us to perform a 3D CT examination in six patients. In the first patient, the 3D CT accurately demonstrated spleen fragmentation without devascularized fragment. The second patient had complete devascularization of the spleen upper pole. Conservative treatment was pursued for both patients. For the third patient, 3D CT helped us to differentiate peritoneal-perisplenic fluid from subcapsular fluid. The fourth patient had minor spleen injury associated with severe lacerations of the left kidney. 3D CT showed a complete separation of the kidney lower pole. A delayed partial lower nephrectomy was performed. The fifth patient presented a fragmented spleen and transient massive haematuria related to a well-contained laceration of the kidney upper pole that were amenable to nonoperative management. The sixth patient was emergency operated for active bleeding from a fragmented spleen. 3D CT performed 2 months after spleen repair allowed the assessment of the amount of devascularized tissue, as well as the status of the upper abdomen arteries. For haemodynamically stable patients, 3D CT could be a helpful addition to conventional axial CT for quantifying blunt abdominal traumas, for making the choice between nonoperative and operative treatment, but also between emergency and delayed surgical strategy.

Cerebrovascular circulation "steal" syndrome secondary to a voluminous retrotracheal goiter.

A case of recurrent transient ischaemic attacks in the brain resolved after removal of a voluminous retrotracheal goiter is presented. The presence of congenital atretic left vertebral artery, associated with impairment of left carotid artery blood flow by a very large inferior thyroid artery, probably caused the episodes to transient ischaemic attack.

Blunt renal traumas: contribution of spiral CT with three dimensional reconstruction to the surgical decision process?

Spiral CT has proved to be a valuable tool by providing various kinds of three-dimensional (3D) images of the studied structures. Such 3D images, which offer a more realistic depiction of the lesions, could be of interest for surgeons who are attempting to treat conservatively blunt abdominal traumas and lead to less inappropriate triage between conservative and operative management particularly for renal trauma. A good working relationship between surgeons and radiologists allowed us to perform an early follow-up 3D spiral CT on a commercially available spiral CT scanner. In the first adult patient, the 3D CT demonstrated minor spleen injury associated with severe lacerations of the left kidney with complete separation of the kidney lower pole. A delayed partial lower nephrectomy was performed. For the second 12-year-old patient presenting with severe spleen trauma and macroscopic hematuria, the 3D CT accurately documented the spleen and renal lesions that were safely amenable to nonoperative treatment. For hemodynamically stable patients, 3D CT is a potentially helpful addition to conventional axial CT for quantifying blunt renal traumas and for making the strategic choice between nonoperative, emergency or delayed surgical treatment.

[Liver abscess and appendicular foreign body]. / Abcès du foie et corps étranger appendiculaire.

We report a case of liver abscess secondary to appendicitis which was due to a wire within the appendix. Appendicitis was asymptomatic, probably because of its retrocaecal position and/or previous antibiotic treatment. The abscess was treated with broad-spectrum antibiotics and percutaneous drainage, followed by a second stage appendicectomy. This case illustrates the value of gastrointestinal radiological investigations before considering the abscess as cryptogenetic.

[Hepatic abscess complicating ileal Crohn disease in remission. Efficacy of antibiotherapy]. / Abcès hépatiques compliquant une maladie de Crohn iléale en rémission. Efficacité de l'antibiothérapie.

Liver abscess is a rare complication of Crohn's disease. The authors describe a case of liver abscess associated with inactive regional enteritis which recovered completely under antibiotic treatment alone.

[Pneumatosis cystoides intestinalis associated with Steinert disease]. / Pneumatose kystique intestinale associée à une maladie de Steinert.

We report the case of a 63-year-old patient suffering from myotonic dystrophy, complicated with respiratory insufficiency, who presented a pneumoperitoneum without sign of peritonitis. Diagnosis of pneumatosis cystoides coli was based on CT scan evidence. Given oxygenotherapy and antibiotherapy, the patient rapidly improved. The association between the two affections has, to our knowledge, not been previously described.

Discrepancy between diffusion and perfusion imaging in a patient with transient ischaemic attack.

We report paradoxical and ambiguous imaging findings in a patient with transient ischaemic attack (TIA). Perfusion-weighted (PW) MRI obtained 2 hours after symptoms onset showed a hypoperfused area in a region compatible with the focal deficit, while diffusion-weighted (DW) MRI was considered negative. Despite the complete resolution of the symptoms which had already begun at the end of the first MR examination, follow up DW MRI at 3 days showed partial conversion to hyperintensity of the initially hypoperfused area. This case illustrates that PW and DW MRI have to be used in combination and at different time points to correctly diagnose and manage ischaemic stroke because PW MRI is more sensitive than DW MRI for very early detection of ischaemia and delayed DW MRI provides the final signature of brain damage even in case of complete clinical recovering.

[Value of varicography in the preoperative assessment of lower limb varicosities (author's transl)]. / Intérêt de la varicographie dans le bilan préopératoire des varices des membres infériurs.

The author's experience of a 100 pilot cases revives the role of varicography for the preoperative evaluation of varicose veins in the lower limbs. This procedure consists of directly injecting the contrast medium into the varicose network. The technique is described in full details, also with several recommendations aimed at preventing potential side effects. The main advantages of direct varicography over "downstream" ascending phlebography include: 1 degrees clearer opacification of the connections between the varicose plexuses, the deep venous line and the paraaxial surface routes; 2 degrees more reliable detection of any deep- seated incompetence. Varicography seems to be particularly useful for the reevaluation of varicose veins after surgical failure; for studying perineal varicosities; and for finding out the source of external varicose veins at the thigh or lower leg.

['Sciatic" artery and vein. Apropos of 3 cases]. / Artère et veine "sciatiques". A propos de 3 observations.

Three cases of sciatic axis are reported: one case, documented by arteriography, of bilateral persistant sciatic artery, which is a rare but well known embryologic abnormality and two cases, documented by varicography, of sciatic vein. Vascular embryology of lower limb is briefly related; the usefulness of arteriography for pulsatile buttock masses and of varicography concerning some leg's varicose veins are developped.