Percutaneous drainage of abdominal abscesses.

Abdominal abscesses carry high morbidity and mortality unless properly drained. In recent years, percutaneous drainage has become an accepted alternative to surgery. A brief overview of diagnostic principles, selection of patients, percutaneous drainage catheters and technique, contraindications, and post-drainage follow-up is presented. In experienced hands, more than 80% of abdominal abscesses can be drained successfully by this method and with lower rates of morbidity, mortality, and complications than by surgery.

Computed tomography of the pancreas: the use of intravenous contast to define the dorsal surface of the pancreas.

After a non-selective review of 80 abdominal CT examinations, it was found that the use of intravenous contrast markedly improves the recognition of the superior mesenteric vein and the splenic vein. These veins lie adjacent to the posterior surface of the pancreas. When the pancreas is poorly seen due to inadequate retroperitoneal fat, when pancreatic size is borderline, or when pancreatic ductal obstruction is suspected on scans prior to intravenous contrast administration, the use of contrast may resolve the uncertainty.

Monitoring the response of lymphoma patients to therapy: correlation of abdominal CT findings with clinical course and histologic cell type.

A review was made of 365 abdominal computed tomographic (CT) examinations in 125 patients with a histologic diagnosis of lymphoma who had undergone CT before and after therapy. Clinical correlation immediately preceding the follow-up CT examination was obtained in 100 patients. In these 100 patients, five distinct subgroups emerged: (a) reduction in extent of disease without changes in internal nodal characteristics; (b) reduction in extent of disease with change in internal nodal characteristics; (c) no change in extent of disease and no change in internal nodal characteristics; (d) no change in extent of disease but change in internal nodal characteristics; and (e) disease progression. Changes in internal nodal architecture consisted of diminished attenuation or mesenteric "stranding." A 91% correlation existed between the CT findings and the clinical course. Of those patients with a worsening clinical course, and follow-up CT studies suggesting a stable or improved response to therapy, relapse in the majority (57%) involved the central nervous system. The authors conclude that limited abdominal CT examination is satisfactory in the posttherapy follow-up of lymphoma patients.

Basal ganglia calcification as a late radiation effect.

Basal ganglia calcification following radiation therapy has rarely been documented in the literature. A case of diffuse bilateral basal ganglia calcification developing 6 years after irridiation of a hypothalamic glioma is presented. Review of previous reports and other causes of basal ganglia calcification are discussed.

Femoral percutaneous catheterization in infants and small children for cerebral angiography.

An improved technique of selective cerebral angiography for infants and small chicken is described. The needle is inserted approximately 45 degrees to the skin in order to avoid subintimal placement of the tip. After good backflow is established, the guidewire is advanced to a position in the descending aorta. A No. 3 polyethylene catheter and 21-gauge scalp vein needle were most successful.

The detection of inferior vena caval thrombosis with computed tomography.

Two cases are reported in which computed tomography demonstrated inferior vena caval thrombosis following intravenous administration of contrast material. This observation appears to have its greatest application in the staging of abdominal neoplasms, particularly renal-cell carcinoma.

Focal nodular hyperplasia of the liver in children: a report of three new cases.

Three cases of focal nodular hyperplasia of the liver in children are presented. The angiographic findings of a hypervascular mass with dense, delayed capillary stain in combination with increased uptake of 99mTc sulfur colloid on radionuclide scans were present in two cases. Computed tomography, utilized in one case, demonstrated a well-circumscribed mass with an irregular stellate area of low density which corresponded to the central collagenous scar described pathologically. The ultrasonographic finding was that of a mass slightly less echogenic than surrounding normal liver tissue.

Liver lesions: comparative accuracy of scintigraphy and computed tomography.

Of 84 cases with both radionuclide and computed tomographic studies of the liver, in 54 the results of the two examinations agreed, in 14 results disagreed, and in 16 cases one of the two tests gave equivocal results. Overall accuracy in detecting or ruling out focal liver disease was 79% for scintigraphy and 98% for computed tomography. In 13 of the 14 patients in whom studies did not agree, the scintigram was falsely negative. In 10 of these 13 false-negative scintigrams, small (less than 2 cm) solitary or multiple lesions were detected on computed tomography in patients who had normal liver function studies. In seven patients in whom both studies agreed, computed tomography provided additional, extrahepatic information that altered clinical management. Scintigraphy was 86% accurate in detecting liver disease when the patient had a gastrointestinal neoplasm, but only 74% accurate for nongastrointestinal neoplasm. Computed tomography was over 94% accurate in both situations. These data indicate an advantage of computed tomography as the initial screening examination for space-occupying lesions of the liver, especially in patients with a primary diagnosis of nongastrointestinal neoplasm.

Arthroscopy and arthrography of the knee: a comparison study.

Between 1975 and 1978, over 200 knee arthroscopies were performed at the Emory University Hospitals; the findings were totally correct in 91%. During the same period, arthrograms were performed on 79 different patients, 39 of whom had confirming arthrotomies. The arthrograms were totally correct in 38%. Fifteen totally incorrect arthrograms were reviewed without knowledge of the operative findings; 12 were considered by the radiologist to be technically acceptable for review. Of these, five correlated partially, but none completely, with findings at arthrotomy. We discuss the difficulty in arthrographic reading of lateral meniscus tears, anterior cruciate tears, and osteochondral loose bodies. We conclude that, although arthroscopy and arthrography can be complementary, arthrography must be used only with the best equipment and technic by a motivated, experienced, and enthusiastic radiologist.

Gas in the pancreatic bed without abscess.

A series of 259 patients from the Emory University Affiliated Hospitals with clinical suspicion of pancreatic inflammatory or neoplastic disease was reviewed. Seven of the patients had documented gas in a pancreatic mass; three of the cases were proved subsequently not to be pancreatic abscess formation. Two of the seven patients had proven fistulae from pseudocyst to bowel documented either by surgery or on an associated radiologic examination which accounted for the gas. In one additional patient, no fistula was identified at preoperative radiologic examination or at surgery. The awareness of this entity is important in the avoidance of unnecessary surgery. Since patients with spontaneous cystoenteric fistulae improve after rupture into the gastrointestinal tract, this entity should be kept in mind, particularly in the patient who is not toxic. Radiologic evaluation of the gastrointestinal tract to detect fistulous communication, percutaneous aspiration, and culture may prevent unnecessary surgery.

Evaluation of the left renal vein in candidates for splenorenal shunts.

The authors describe 4 patients who had functioning distal splenorenal shunts despite obstruction of the left renal vein at its insertion into the inferior vena cava. The angiographic technique and findings of left renal vein evaluation in 40 shunted patients are reviewed. There were two important findings. First, no correlation existed between the degree of portal hypertension and the degree of filling of collateral tributaries of renal veins. Second, obstruction of the left renal vein does not impair a splenorenal shunt if good collateral pathways are present.

Management of stenosis of distal splenorenal shunt by balloon dilation.

Stenosis of a distal splenorenal shunt may lead to inadequate variceal decompression with the risk of rebleeding. We report this complication in three patients at five, 16 and 17 months after DSRS, with successful management by balloon dilation. One patient had rebled from varices and the other two showed roentgenologic evidence of inadequate variceal decompression. All of the shunts were patent but showed a mean pressure gradient of 15 millimeters of mercury which was reduced to a mean of 7 millimeters of mercury by dilation. Angiography at 15 months showed no restenosis and sustained reduction of the pressure gradient in one patient. The other two patients await long term follow-up observation. Rebleeding or reappearance of varices are indications for repeat angiography after DSRS to determine the cause. The risk of dilating a venous anastomosis must be weighed against the risk of rebleeding; the results of this report demonstrate that this can be done with a satisfactory outcome.

CT directed hepatic biopsies: increased diagnostic accuracy with low patient risk.

A technique for computed tomography directed percutaneous liver biopsy using small gauge (18-20) needles is described. In 51 procedures performed on 50 patients tissue specimens adequate for diagnosis were obtained 49 times (96%). There was one false negative diagnosis. The correct diagnosis was made in 48 of 51 (94%) procedures on 48 of 50 (96%) patients. There were no significant complications.

Biopsy of the right adrenal gland by the transhepatic approach.

A transhepatic computed-tomographic-guided biopsy of a right adrenal mass is described. This method is simpler to perform than the usual posterior biopsy carried out with the patient prone and is less likely to cause a complicating pneumothorax. In seven of eight patients with right adrenal masses, adrenal tissue was obtained and an accurate diagnosis was possible. No complications resulted.

67Ga scintigraphy in postoperative synthetic graft infections.

Postoperative infections of synthetic vascular grafts are seldom diagnosed by conventional radiographic methods, leading to high morbidity and mortality. Gallium-67 scintigraphy was included in the diagnostic evaluation of five patients with suspected vascular graft infections. Abnormal accumulation of the radionuclide around the graft was present in all of these patients who were later determined to have paraprosthetic infections. Gallium-67 citrate scintigrams seem to be diagnostically effective in the difficult problem of paraprosthetic infection.

Portal pseudoperfusion: an angiographic illusion.

Much confusion regarding the hemodynamics following interposition mesosystemic shunts prevails. Many authorities have claimed that portal venous perfusion continues following interposition mesocaval shunts. In 1971, a prospective, randomized trial comparing the distal splenorenal shunt with a variety of interposition mesosystemic shunts (primarily mesocaval or mesorenal) was begun. Visceral angiography was utilized to assess the early and late postoperative hemodynamic changes following both selective and nonselective shunts. None of the patients with patent interposition shunts retained portal perfusion present preoperatively. Searching for an explanation for this hemodynamic discrepancy, we examined two patients of the randomized trial angiographically. Both patients had excellent portal perfusion preoperatively, yet following interposition shunting (one mesocaval and one splenocaval), neither maintained portal perfusion of the liver. Celiac artery injections produced opacification of the entire splenoportal axis; however, it is shown that such portal venous opacification occurred in a retrograde direction by selective hepatic arterial injections demonstrating hepatofugal portal venous flow. Additionally, two nonrandomized patients received interposition mesorenal shunts and exemplify this phenomenon, entitled "portal pseudoperfusion". The explanation for conflicting literature reports lies in the misinterpretation of venous phase celiac and non-selective SMA arteriography in determining the direction of portal flow. A narrative of preoperative and postoperative angiograms of four patients will clarify the mechanism of "portal pseudoperfusion" and demonstrate that interposition shunts totally siphon portal venous perfusion. Clues to the detection and techniques to avoid this phenomenon will be presented.

Varicoceles: a coaxial coil occlusion system.

A modified transfemoral technique for testicular venography and occlusion of the testicular vein (TV) was used to treat 30 patients with a total of 43 varicoceles (17 left-sided and 13 bilateral). Occlusion was satisfactory in all left varicoceles and 90% of right varicoceles. This coaxial technique facilitates subselective catheterization of the TV and its collaterals and enables coils to be placed deep within these vessels, either alone or in combination with detachable balloons.