An undiagnosed pleural effusion with surprising consequences.

We present the case of a 43-year-old Italian woman with a left undiagnosed pleural effusion, which in subsequent months presented a clinically unexpected evolution with the appearance at first of a right wrist tenosynovitis and subsequently a bilateral lung involvement caused by M. Tuberculosis. With this case report, we would like to underline the importance of making a correct diagnosis of any pleural effusion as soon as possible by at least a thoracocentesis. If untreated, tuberculosis may easily disseminate to other organs. Some considerations and suggestions for antibiotic treatment of pleural effusion will also be given, since many antibiotics have some anti-tuberculosis effect and may delay the diagnosis of this infectious disease.

Cerebral atrophy in patients on long-term regular hemodialysis treatment.

The presence of Cerebral Atrophy in the form of cortical damage (Cortical Atrophy) or subcortical damage (enlargement of ventricular cavities) was explored by computed tomography (CT) scans in 30 patients maintained on regular hemodialysis treatment (RDT) for not less than 10 years, and less than 50 years of age. Whereas a group of 50 normal subjects of the same age, used as control, gave no evidence of cerebral atrophy, 46.6% of the patients maintained on RDT showed cortical atrophy, evenly diffuse in half the cases and predominantly frontal in the other half. In addition 16.6% of the patients showed subcortical atrophy, even in the absence of evident central neurologic or neuropsychic symptoms. In a search for the possible causes of this high incidence of cerebral atrophy in chronic hemodialysis patients we reviewed the last five years' profiles of clinical and blood biochemistry parameters known or suspected to produce brain damage when altered, as stored in a computer system available to our Hemodialysis Unit: these were mean blood pressure before and after hemodialysis, blood cholesterol and triglyceride assays, and mean daily oral intake of A1(OH)3. The status of arterial blood vessels in terms of vascular calcification in soft tissue roentgenograms was also defined; then we correlated these clinical and biochemical indices with the findings of cerebral CT scans by the Fisher test and Discriminant Analysis. The Fisher test revealed a decreasing correlation of cerebral atrophy with mean blood pressure, A1(OH)3 intake, blood cholesterol content, arterial calcifications and blood trygliceride assay in that order.(ABSTRACT TRUNCATED AT 250 WORDS)

Peripheral arteriography with a new nonionic agent: comparison of iomeprol with iopamidol.

Aim of this randomized, double-blind, parallel group study was to compare the safety, tolerance and diagnostic efficacy of iomeprol and iopamidol, both at iodine concentration of 150 mgI/ml, in 100 adult patients undergoing peripheral intra-arterial digital subtraction angiography (IA-DSA). All patients underwent extensive pre- and post-contrast clinical, instrumental and laboratory evaluation for safety assessments. The tolerance to the test compounds was evaluated in terms of discomfort associated with the injection of the test compounds. Image quality was prospectively graded by two independent readers according to a five-point scale as 1, insufficient; 2, sufficient; 3, good; 4, excellent; or E, excessive. At the end of the study, two experienced radiologists working at institutions other than the study centre and not aware of patients identity, clinical profile or results of other imaging procedures, jointly evaluated study images using the same ordinal scale. The procedure was always well tolerated. None of the studied patients experienced adverse events. All angiographic examinations were rated as diagnostic. The quality of the radiographs was judged as excellent or good in most individual patient studies, without significant differences between the two study groups. No significant differences between the results of prospective on-site assessment and retrospective external assessment were detected. The results of our study show that iomeprol and iopamidol are equally effective, well tolerated and safe contrast agents when used for peripheral IA-DSA.

Diastematomyelia in adults.

The authors report two cases of diastematomyelia in adults. One patient had a congenital kyphoscoliosis; the other had undergone surgery at birth for a myelomeningocele. The occurrence of diastematomyelia in patients with congenital scoliosis and myelomeningocele is discussed. Diastematomyelia is regarded as one of the causes of late deterioration of neurological function in such cases.

[Controlled clinical study of the treatment of chronic bronchitis with guacetisal]. / Studio clinico controllato sul trattamento della bronchite cronica con guacetisal.

Controlled clinical research has been carried out on the activity and tolerance of a new active principle, guacetisal (Broncaspin) obtained from the esterification of acetylsalicylic acid with guaiacol, in the treatment of chronic bronchitis. The drug's therapeutic response was evaluated with respect to that of bromexine. Guacetisal was generally well tolerated. It had no unwanted side-effects on the main haematochemical parameters or on the function of organs and systems. It was found to have considerable therapeutic effectiveness, at times even superior to that of the control drug, with respect to general symptomatology and at respiratory system level. It produced early, lasting reduction in temperature, heart frequency, dyspnoea, duration of expirium and in the intensity and number of coughing attacks. It also led to an appreciable improvement in thoracic objectivity and the X-ray picture. Variations in respiratory functional parameters were of considerable interest and from these it is concluded that guacetisal exerts its polyvalent activity to a proportionately higher extent in the bronchial districts more seriously involved in the inflammatory process, inducing an elective improvement in bronchial permeability, a reduction in total pulmonary resistances--with consequent tendency for ventilation-perfusion relations to normalise--as well as an improvement in gas exchanges and patient oxygenation.

[Physiopathology, clinical aspects and prevention of renal insufficiency caused by contrast media]. / Fisiopatologia, clinica e prevenzione dell'insufficienza renale da mezzi di contrasto.

Contrast-media associated nephropathy (CMAN) consists in a sudden impairment of glomerular filtration rate following exposure to radiographic contrast materials. Damage may be limited to an asymptomatic mild increase of blood creatinine, or reach the highest levels of nitrogen retention compatible with acute renal failure. Some preexisting clinical conditions or pathologies may lead to CMAN: not only renal insufficiency, diabetes mellitus, multiple myeloma, congestive heart failure and severe hypertension, but also simple dehydration and a growing series of immunologic diseases are recognized as predisposing condition. The exact mechanism responsible for renal injury is still doubtful but recently animal models have shown substantial ischemic changes that may be added to the traditional presumed pathogenesis of direct tubular toxicity and intra-tubular obstruction. As renal ischemia stimulates both endogenous vasoconstrictor and vasodilator substances, it is now supposed that CMAN acts similarly to non-steroidal anti-inflammatory agents, selectively inhibiting the vasodilatory prostaglandin phase and therefore causing a derangement of the physiologic vasoconstriction/vasodilatation balance of renal circulation. The role of oxygen free radicals to contribute to renal dysfunction is considered. Low osmolality non ionic contrast media when compared to conventional high osmolality ionic contrast media have reduced but not eliminated CMAN. Simple but effective lines of prevention include the previous selection of patients predisposed to CMAN for concomitant pathology, suspension of FANS or any other recognized nephrotoxic substance, the least amount of contrast media compatible with radiologic visualization of the patient's problem, careful hydration of the patient before contrast injection and sustained diuresis afterwards. The usefulness of pre-treatment with Ca-channel blockers or atrial natriuretic factors remains sub judice.

[Hyperselective angiography in the study of spinal diseases (author's transl)]. / Sulla validità dell'arteriografia superselettiva nella patologia midollare e del canale vertebrale.

We report about a new angiographic technique, spinal angiography, its indications and complication. Spinal angiography is clearly essential for the diagnosis in retro or intramedullary arterio-venous malformations and for metameric angiomatosis with neurological involvement.

Cerebral computed tomography in uremic and hemodialyzed patients.

Sixty-nine uremic patients, 19 on conservative and 50 on regular hemodialysis treatment (RDT), showing no clinical symptoms attributable to central nervous system impairment, were examined by cerebral CT to discover morphological modifications in brain structure and determine their incidence. A CT picture indicative of cortical atrophy was observed in 56.5% of the cases, associated with ventricular atrophy (15.9%), especially in patients on long-term RDT. In addition, CT revealed areas of low density related to past episodes of cerebral ischemia in 10.1% of the cases and some small calcifications in the brain parenchyma in 4.5% of the patients. The degree of these lesions seems to correlate with the duration of uremia.

[Presentation of a case of spinal osteoid osteoma causing dorsal scoliosis. Role of high resolution CT]. / Presentazione di un caso di osteoma osteoide vertebrale causa di scoliosi dorsale. Ruolo della TC ad alta definizione.

A case of vertebral osteoid osteoma in a 19 years old female is described. The tumor was located at D7 right peduncle and was responsible for a mild left convex curve dorso-lumbar scoliosis. The patient had been complaining for 3 years because of a stablike pain at medio-dorsal level. The symptomatology was exacerbated by erect position, during the night and was relieved by salicylic acid. Diagnosis was suspected on the basis of scintigraphic and computed tomographic features and confirmed at surgery. Limited value of plain films and the importance of bony scintigraphy and high resolution computed tomography to establish the localization and nature of the lesion are stressed.

[The role of computerized tomography in the diagnosis of osteoid osteoma]. / Ruolo della tomografia computerizzata nella diagnosi dell'osteoma osteoide.

Radiological diagnosis of osteoid-osteoma is based upon conventional radiographic techniques, i.e. plain film and tomography, scintigraphy and Computed Tomography (CT). The authors report on the use of CT in 13 patients affected by histologically verified osteoid-osteoma, in different locations, as related to their main clinical and epidemiological signs. A comparison is made of the diagnostic contribution of the different techniques, including scintigraphy and tomography, when available. CT results were evaluated referring to fundamental semiologic elements, such as the presence of the nidus--with or without calcifications--of perilesional sclerosis, hyperostosis and periosteosis. As a rule, we can affirm that CT allows a better spatial location in the metaphysodiaphyso-epiphyseal areas, the only exception being represented by location in the metacarpal and phalangeal bones, which are better evaluated in the axial plane due to their thinness. CT is otherwise indispensable for a correct evaluation of the posterior vertebral arch.

[Correlations between Doppler velocimetry, arteriography and intraoperative findings in the study of carotid vascular diseases]. / Correlazione fra la velocimetria doppler, l'arteriografia ed i reperti intraoperatori nello studio delle vasculopatie carotidee.

The present paper reports the results obtained in 54 patients who underwent a non invasive cerebral vascular examination by doppler technique, followed by a cerebral angiography: a total of 86 carotid arteries were compared. An overall accuracy between arteriographic and ultrasonographic results was found in 69 arteries whereas in 15 arteries there was a discordance; and in only 3 cases ultrasonographic findings resulted false negative. The Authors have also considered the emodinamic and anatomo pathological results obtained in 23 carotid arteries operated on, in order to evaluate ophthalmic test accuracy and noninvasive evaluation of Willis's circle. The Authors have reached the conclusion that doppler technique appears to be inadequate in case of turbulent flow due to arterial dilatation or to non significant stenosis. In addition they have noticed a better reliability of emodinamic findings and a poor accuracy of the ophthalmic test.

High resolution O2 computed meatocisternography in the differential diagnosis of internal auditory canal pathology.

Recent introduction of O2 computed tomography cisternography and imaging with high resolution program have greatly improved the detection and preoperative evaluation of acoustic neuromas and other possible pathologies of the internal auditory canal. Sixty patients have been evaluated following the diagnostic protocol given in the text. Based on our results and on the experience as reported in literature HRO2CTC proved to be the most reliable method for detection and exclusion of intracanalicular and small extracanalicular acoustic neuromas and other pathologies at the internal auditory canal level.

[Upper cervical spine fracture: sources of misdiagnosis]. / Fratture dei primi due metameri cervicali. Cause di errore diagnostico.

PURPOSE: Missing cervical spine fractures during the initial plain film study may lead to severe neurological complications for patients and to medicolegal responsibilities for the physician. The upper cervical spine tract (C1-C2) is considered to be at high risk for misdiagnoses. We decided to investigate the possible causes of mistake in the cases of missed fractures on the initial plain film, performed in the emergency room. MATERIAL AND METHODS: We retrospectively reviewed the radiological reports, the original plain films and the CT findings, of 32 patients with upper cervical (C1-C2) fractures, admitted January 1994 to December 1998. Twenty-eight of these patients (87.5%) had multisystem trauma, 4 (12.5%) had minor craniocervical trauma. None of these patients had neurological signs correlated to the cervical injuries, 30 of them had normal consciousness and reported only neck pain, 2 of them were unconscious for the associated head trauma and were hospitalized in the intensive care unit. All the patients with normal consciousness underwent conventional three-view cervical spine radiography; the two unconscious patients in the intensive care unit were submitted to bedside examination with an anteroposterior and a lateral views of the cervical spine. All patients underwent spiral CT of the upper cervical tract. RESULTS: In 9 of 32 patients (28%) a cervical fracture was missed on the plain film and CT was performed only because of persistent neck pain. We found 2 Jefferson's fractures, 2 type II dens fractures, one type I dens fracture and 4 hangman's fractures. In 8 of the 9 patients (89%) the fracture was potentially unstable. Misdiagnoses resulted from overlapping bone structures (3%), suboptimal film quality (3%), satisfaction of search phenomenon (3%), missed mild tilting of the dens (6%), missed double cortex sign (16%), missed C1-C2 lateral subluxation (6%) and marked osteoporosis (3%). Prevertebral soft tissue swelling was not seen in any of the 9 cases of missed fractures. Considering the group of patients with C1-C2 fractures separately, the false negative rate is 28%, which corresponds to 10.7% of the total number of patients with cervical fractures and dislocations examined during the same period. CONCLUSIONS: Among the causes of false-negative interpretation, osteoporosis, suboptimal film quality due to associated fractures and overlapping bone structures must be considered unavoidable. On the other hand these possibilities should be indicated on the X-ray report because, if painful symptoms persist, a CT exam is strongly advised. Subtle alterations like dens tilting, double cortex sign, lateral subluxation of C1 and prevertebral soft tissue swelling should be regarded as highly suspicious for fracture. Missing these lesions might be considered a true diagnostic mistake with possible legal consequences, which may also expose the patient to the risk of neurological complications. The satisfaction of search phenomenon can be avoided only by trying to use a search pattern for every film, which includes checking all the visible anatomical structures even in the presence of a particularly evident lesion. In all questionable cases or high-risk fracture patients, even with an apparently negative plain film, it is advisable to perform CT instead of additional plain films. Finally, in all the patients treated in the intensive care unit for head trauma, an upper cervical CT scan should be routinely carried out at the same time as the brain scan.

Progression of cerebral atrophy in patients on regular hemodialysis treatment: long-term follow-up with cerebral computed tomography.

Fifteen patients (10 males, 5 females) on regular hemodialysis treatment (average age 43.6 +/- 4.0 years, average time on dialysis 100.7 +/- 62.8 months) underwent cerebral computed tomography between 1981 and 1984. Ten patients showed mild cerebral atrophy (CA) on the basis of cortical sulci exceeding 3 mm in breadth and an Evans ratio exceeding 0.31, for a total of 14 degrees of CA (mean 0.9 +/- 1). The same 15 patients underwent a second cerebral computed tomography during 1991/92 (101 +/- 23.7 months later). At that time, the patients exhibited a degree of CA of 2.6 +/- 1.4, for a total of 39 degrees with an overall increase of 25 degrees. Since CA is not detected before the age of 55 years in the normal population, we conclude that the CA in this patient group can only be attributed to uremia-related pathology and that it tends to worsen as regular hemodialysis treatment continues. Nevertheless, no evident cognitive, affective, or behavioural changes were verified in these patients. To our knowledge, this is the first presentation of radiologically documented progression of CA in the same patient population over time.

Cerebral imaging changes in patients with chronic renal failure treated conservatively or in hemodialysis.

BACKGROUND: Nonuremic patients with apparently normal memory and behavior, studied by means of cerebral computed tomography and found to have cerebral atrophy (CA), evidenced functional intellectual deficits when they underwent psychometric testing. The finding of CA has been repeatedly reported in limited case groups of uremic patients who also demonstrated functional intellectual deficits on the basis of the same tests. This retrospective study considered all diagnostic cerebral computed tomography scans done in our department between 1981 and 1998. Fifty-five uremic patients in conservative treatment (CT) and 111 patients in hemodialysis treatment (HT) were selected on the basis of the following two criteria: primary nephropathy as the cause of uremia and an age < or =55 years to exclude involutive brain changes occurring with age. AIMS: The aims of the study were to determine the percent of uremic patients with CA, the characteristics of their CA (cortical or subcortical), and eventual associated morphological lesions. RESULTS: CA was detected in 50.9% (cortical atrophy in 47.3% and subcortical atrophy in 3.6%) of the uremic patients in CT and in 77.5% of those in HT (cortical atrophy in 65.7% and subcortical atrophy in 7.7%). The average degree of CA was 0.872 in the patients in CT and 1.765 in the patients in HT. Thirty-four of the patients in the CT group and 46 in the HT group were hypertensive: these patients had a more severe degree of CA than the nonhypertensive subjects. In the CT group, the degree of CA in the hypertensive patients was 1.205 versus 0.428 for the nonhypertensive subjects. In the HT group, the degree of CA was 2.087 for the hypertensive patients versus 1.538 for the nonhypertensive patients. Of the overall population, 7.8% had ischemic lesions, 9.6% had endocranial calcifications, and 5.4% evidenced periventricular white matter hyperintensities. CONCLUSIONS: The high percent of CA found in young uremic patients increased in subjects in HT and, even more so in hypertensive patients. Vascular calcifications, focal ischemia and leukoaraiosis, well-known expressions of a chronic state of cerebrovascular insufficiency, were also found in HT patients; hypertension alone is a recognized accelerator of vascular damage. Thus, early and severe atherosclerosis and related hypoperfusion can be considered as the paramount causes of parenchymal cerebral damage in uremia.

MR findings in Meige syndrome.

A 65-year-old woman was diagnosed clinically to have Meige syndrome in the oromandibular dystonic clinical variant of Marsden. On magnetic resonance imaging a reduced signal intensity in the head of the caudate nuclei, more prominent on the right, and in both putamina was shown.

[Dissection of the internal carotid artery. Personal case reports and a review of the literature]. / Dissecazione dell'arteria carotide interna. Casistica personale e revisione della letteratura.

The clinical and angiographic features of 20 patients affected by internal carotid artery dissection are reported. In one patient the neurological signs were related to a traumatic event, in two cases the symptoms presented after hyperextension of the neck during athletic events, while their onset was apparently spontaneous in the remaining 17 patients. Plain CT was normal in 14 cases and positive for ischemic necrosis in 6 patients. Angiography demonstrated extensive/segmental stenosis of the internal carotid lumen in 12 cases (60%), pseudoaneurysmal dilatation in 3 cases (15%), and complete carotid occlusion in 5 patients (25%). The "double lumen" feature was seen in 3 cases at the origin of the dissection. One patient died, surgical ligature of the internal carotid artery was performed in two cases, while the other patients received medical treatment with platelet inhibitors, except for the young patient affected by post-traumatic artery dissection. Complete recovery was observed in 82% of the patients. Follow-up angiograms demonstrated normal recanalization of the internal carotid artery in 4 out of 6 patients; one of them had two false aneurysms which following angiograms demonstrated to be completely resolved. Regression of stenosis was observed in 6 of the remaining patients by Doppler US. On the whole, the recanalization of the internal carotid artery was observed in 59% of cases. Angiographic findings seemed not to play a decisive role in the prognosis of carotid dissections, which largely depends on the overall patient's condition and on the presence/absence of ischemic cerebral damages.

[Preoperative embolization of angiomas of the face. Remote angiographic results]. / Embolizzazione prechirurgica di angiomi del viso. Risultati angiografici a distanza.

Preoperative embolization was performed on 27 patients with facial angiomas supplied by the external carotid branches. Sixteen were males and 11 females; 13 of these angiomas were high-flow arteriovenous (A-V), 14 were low-flow capillary malformations. Fourteen patients underwent surgical removal after preoperative embolization; in this group embolization was carried out with Spongel in 3 cases and with Lyodura in 11 cases. In 12 of these patients the last angiographic examination was performed 3-6 years later: angiography evidenced no recurrence in 8 cases (67%), while in 3 cases (25%) there was capillary residual angioma of negligible size. Treatment was unsuccessful in one patient only, due to the large recurrent A-V angioma. Thirteen patients underwent embolization only, which was carried out with Lyodura in 10 cases, and with Ivalon in 3 cases. On 12 of these patients the last angiographic study was performed 2-14 months later: there was recurrent A-V angioma in 5 patients (42%), who underwent a subsequent embolization; angiography evidenced no recurrence in the other 7 patients (58%). In both series, the best results were obtained in the patients with low-flow capillary angiomas. Embolization and subsequent surgical removal are the treatment of choice for facial angiomas; embolization alone is useful in the management of surgically inaccessible vascular malformations, and it can be the only treatment in patients with small low-flow angiomas when distal occlusion of the feeding vessels with Lyodura or Ivalon particles is performed.

[Tridimensional (3D) reconstruction in the osteoarticular area]. / Ricostruzione tridimensionale (3D) in ambito osteoarticolare.

Three-dimensional reconstruction techniques have been used since the development of computed tomography. In skeletal radiology they have been used to better visualize fractures and spatial relationships between fragments in maxillo-facial surgery. Aim of this paper is to illustrate the most important reconstruction techniques and their application in skeletal radiology. Images can be obtained by means of a Spiral CT scanner with the following parameters: collimation/pitch/reconstruction interval 2/1/1. Acquired images are sent to a workstation with a software running on a Window NT platform Vitrea 2.01 (Vital Images, USA) equipped with Volume Rendering algorithm. SSD as well as MPR and curved reformatted reconstruction algorithms is available at the CT console. Three-dimensional reconstruction have been shown to be useful for the diagnosis and for a preoperative planning. Other applications of three-dimensional reconstruction techniques are prosthesis engineering and biomechanic research. 3D images help the communication between radiologist and surgeons. Technical advances in acquisition methods and in reconstruction algorithms are needed to improve image quality and use in skeletal radiology.