CT angiography for brain death diagnosis.

BACKGROUND AND PURPOSE: Lack of cerebral circulation is an important confirmatory test for brain death (BD). Conventional angiography remains the standard imaging method, but CT angiography (CTA) is emerging as an alternative. France accepts BD diagnoses relying on a score based on lack of opacification of 7 intracerebral vessels in CTA images. The purpose of this study was to validate the efficiency of this score and to evaluate the sensitivity of a novel 4-point CTA score in confirming BD. MATERIALS AND METHODS: A prospective multicentric study was conducted during 12 months with 105 patients referred for CTA to confirm a clinical diagnosis of BD. Clinical data were recorded. CTA images were interpreted first by local radiologists at the referent center, resulting in a 7-point score based on lack of opacification of the pericallosal and cortical segments of the middle cerebral arteries (MCAs), internal cerebral veins (ICVs), and 1 great cerebral vein per patient and, second, by a consensus panel of 3 expert radiologists, blinded to the initial scores, resulting in novel 4-point scores based on the lack of opacification of the cortical segments of the MCAs and ICVs. RESULTS: Injection of contrast medium did not alter renal function. With the initial 7-point score, sensitivity was 62.8%. With the simplified 4-point score, sensitivity was 85.7% and specificity was 100%. Opacification of ICVs was absent in 98.1% of patients. CONCLUSIONS: Lack of opacification in the cortical segments of the MCAs and internal veins in CTA is efficient and reliable for confirming BD.

Hyperselective intra-arterial preoperative chemotherapy in patients with squamous cell carcinoma of the oral cavity: preliminary results.

OBJECTIVES: To investigate radiological response and findings after Intra Arterial Chemotherapy (IAC) for patients with Squamous Cell Carcinoma (SCC) of the oral cavity. MATERIALS AND METHODS: Patients received 1-2 cycles of IAC. Radiological assessment was performed on day 7 and day 21 after each cycle using CT scan and MRI. RESULTS: Six patients (median age: 52, ranging 46-60; male/female: 5/1) received 10 cycles (4 patients received 2 cycles). Primary tumors were floor of the mouth (4 patients) and oral tongue (2 patients). TNM classification was T2N0-2b in 3 patients and T4N0-1 in 3 patients. All patients had good locoregional/systemic tolerance and 3 showed clinical objective response (OR). Four patients were evaluable on both CT and MRI, 1 patient on MRI only and 1 patient did not tolerate imaging. Three patients showed OR both on CT and MRI, 1 patient showed stable disease (SD) on CT and OR on MRI and 1 patient showed SD on MRI. Contrast-enhancement of hemiperfused tongue was reported in all evaluable patients. Two patients presented intratumoral necrosis and 5 patients displayed local edema (MRI). One patient had modification of the sternocleidomastoid muscle after IAC. CONCLUSION: Radiological modifications were observed in the infused area and correlated well with clinical response. This study is ongoing.

[Stomach rupture after nasal oxygen administration]. / Rupture gastrique après oxygénothérapie par voie nasale.

We report a case of a spontaneous rupture of a normal stomach after therapeutic oxygen administration. In this case, early treatment precluded the need for a laparotomy. This rare complication highlights the importance of the right positioning of a nasal catheter and leads us to question its role compared to other means of oxygen delivery (nasal cannulae, Hudson mask, Venturi mask).

Hepatic venous pressure gradients measured by duplex ultrasound.

AIMS: The hepatic venous pressure gradient is a major prognostic factor in portal hypertension but its measurement is complex and requires invasive angiography. This study investigated the relationship between the hepatic venous pressure gradient and a number of Doppler measurements, including the arterial acceleration index. METHOD: We measured the hepatic venous pressure gradient in 50 fasting patients at hepatic venography. Immediately afterwards, a duplex sonographic examination of the liver was performed at which multiple measurements and indices of the venous and arterial hepatic vasculature were made. RESULTS: Hepatic arterial acceleration was correlated directly with the hepatic venous pressure gradient (r=0.83, P<0.0001) and with the Child-Pugh score (r=0.63, P<0.0001). An acceleration index cut-off value of 1m.s(-2) provided a positive predictive value of 95%, a sensitivity of 65% and a specificity of 95% for detecting patients with severe portal hypertension (hepatic venous pressure gradient>12 mmHg). A correlation between the hepatic venous pressure gradient and the congestion index of the portal vein velocity (r=0.45,P=0.01) and portal vein velocity (r=0.40,P=0.044), was also noted. CONCLUSION: Measuring the hepatic arterial acceleration index may help in the non-invasive evaluation of portal hypertension.

[Epithelioid hemangioendothelioma associated with nodular regenerative hyperplasia]. / Hémangioendothéliome épithélioïde associé à une hyperplasie nodulaire régénérative.

Epithelioid hemangioendothelioma of the liver is a rare neoplasm of vascular origin. We report a case of epithelioid hemangioendothelioma occurring in a patient with nodular regenerative hyperplasia. This association suggests that some hepatic vascular changes might promote the growth of epithelioid hemangioendothelioma.

Radiofrequency ablation of 100 hepatic metastases with a mean follow-up of more than 1 year.

OBJECTIVE: The objective of our study was to evaluate the efficacy and safety of radiofrequency ablation of hepatic metastases performed either percutaneously for treatment of hepatic metastases in patients deemed ineligible for surgery or intraoperatively during partial hepatectomy to destroy unresectable metastases. SUBJECTS AND METHODS: Sixty-eight patients with 121 hepatic metastases (<5 metastases per patient) that were mainly colorectal in origin underwent 76 sessions of radiofrequency ablation with cooled-needle electrodes under sonographic guidance. Twenty-one patients with 33 metastases of 5-20 mm in diameter (mean +/- SD,13 +/- 7 mm) underwent intraoperative radiofrequency ablation. Forty-seven patients with 88 metastases of 10 to 42 mm in diameter (mean +/- SD, 26 +/- 9 mm) were treated with percutaneous radiofrequency ablation. Procedure efficacy was evaluated with dynamic enhanced CT and MR imaging performed 2, 4, and 6 months after treatment and then every 3 months. RESULTS: Radiofrequency ablation allowed eradication of 91% of the 100 treated metastases that were followed up for 4-23 months (mean, 13.7 months). Tumor control was equivalent for percutaneous radiofrequency ablation (90%) and for intraoperative radiofrequency ablation (94%). Failure to achieve tumor control occurred mostly with the largest tumor nodules. One bilioperitoneum and two abscesses were the major complications encountered after treatment of 121 metastases with a follow-up of more than 2 months. CONCLUSION: Radiofrequency ablation appears to be a promising therapeutic modality capable of extending the possibilities of partial hepatectomy and of efficiently treating small metastases percutaneously.

Transcatheter ethanol renal ablation in 20 patients with persistent urine leaks: an alternative to surgical nephrectomy.

PURPOSE: We evaluate the efficacy of transcatheter ethanol renal ablation for destruction of a unilateral, poorly functioning kidney with persistent urinary leaks from fistulas or a nephrostomy tube. MATERIALS AND METHODS: From January 1992 to January 1999, 19 females and 1 male with a history of pelvic neoplasms, which were responsible for ureteral leaks through the nephrostomy tube in 13 cases or fistulas in 7, were treated with transcatheter ethanol renal ablation. Serum creatinine ranged from 60 to 140 micromol./l. (mean 90), and function of the involved kidney determined by diethylenetetraminepentaacetic acid scintigraphy in 16 patients or by morphological imaging in 4 was low. Drainage of the renal cavities and antibiotic therapy preceded renal ablation. After epidural anesthesia or intravenous sedation renal ablation was performed by catheterization of the renal artery and injection of 1. 5 to 12 ml. (mean 4.6) absolute ethanol, and completed by proximal occlusion with coils and absorbable gelatin sponge. RESULTS: Arterial flow was interrupted in all cases. Urinary flow ceased in 2 days in 18 of 20 patients, and drains were removed. Two patients had residual urine that was successfully treated with additional embolization. No complications occurred. CONCLUSIONS: Transcatheter ethanol renal ablation is safe and effective, and permits an in situ nephrectomy that can replace surgical nephrectomy for treatment of urinary leaks.

Hepatic intraarterial 131I iodized oil for treatment of hepatocellular carcinoma in patients with impeded portal venous flow.

PURPOSE: To evaluate the efficacy and safety of intraarterial hepatic iodine 131 iodized oil for treatment of hepatocellular carcinoma in patients with impeded portal venous flow. MATERIALS AND METHODS: Twenty-four patients (mean age, 61 years) with hepatocellular carcinoma underwent 38 courses of 131I iodized oil (one to three per patient), with a mean dose of 2,146 MBq injected into the proper hepatic artery. Hepatocellular carcinoma manifested as single nodules (n = 8; mean, 7.75 cm), multiple nodules (n = 13; mean, 5.46 cm), or a mass (n = 3) occupying more than two hepatic segments. Portal venous thrombosis was complete (n = 10), right (n = 9), left (n = 2), or multisegmental (n = 1). Two patients had hepatofugal portal flow. RESULTS: Among the 23 patients with evaluable results, response to treatment was partial in three, and disease was stable in 12 and progressive in eight. Estimated actuarial survival rates were 70%, 33%, 12%, and 6% at 3, 6, 9, and 12 months, respectively, with two patients alive at 9 and 11 months. The median survival time was 147 days. Adverse events were the early death of one patient owing to hepatic failure and transient symptomatic hepatic failure after 12 courses in nine patients. CONCLUSION: In this preliminary experience, intraarterial hepatic 131I iodized oil did not demonstrate high efficacy in the treatment of hepatocellular carcinoma in patients with portal venous thrombosis, as side effects were not rare.

Percutaneous gastrostomy with fluoroscopic guidance: single-center experience in 500 consecutive cancer patients.

PURPOSE: To evaluate the feasibility, complications, adequacy of feeding support, and tolerability of fluoroscopically guided gastrostomy in cancer patients. MATERIALS AND METHODS: Five hundred cancer patients were referred for fluoroscopically guided gastrostomy, among whom percutaneous endoscopic gastrostomy was contraindicated or had been unsuccessful in approximately one-fourth. Five hundred eight fluoroscopically guided gastrostomies with T-fastener gastropexy were performed in 496 patients. The procedure was unsuccessful in four patients, and 12 patients needed a second gastrostomy. RESULTS: Fluoroscopically guided gastrostomy was feasible in 99% of patients. During the first 30 postprocedure days, there were seven major complications (1.4%): cardiac failure (n = 1), hemorrhage (n = 1), and peritonitis (n = 5); one patient died of peritonitis. No major complications occurred after the 30th postprocedure day. There were 27 minor complications (5.4%) during the first 30 postprocedure days and 88 (17.6%) thereafter. Long-term minor complications mainly involved the disturbances and nearly always resolved once the tube was exchanged. Such exchanges were easily performed under fluoroscopic guidance except in two patients, who required repeat fluoroscopically guided gastrostomy. CONCLUSION: Fluoroscopically guided gastrostomy is highly feasible and safe and provides adequate feeding support, even when percutaneous endoscopic gastrostomy is impossible. Long-term complications, which are mainly tube disturbances, are easily treated.

[Treatment of malignant gastric or duodenal stenoses by the insertion of metallic prostheses under fluoroscopic control]. / Traitement des sténoses gastriques ou duodénales malignes par pose de prothèses métalliques sous contrôle fluoroscopique.

PURPOSE: To evaluate the efficacy of metallic stents for palliation of malignant gastro-duodenal stenosis. MATERIALS AND METHODS: Twenty-three patients aged from 36 to 88 years old presented with nausea, vomiting and weight loss due to duodenal (n = 16) or antro-pyloric (n = 7) malignant stenosis and underwent placement of 37 Wallstents (1 to 3 per patient) under fluoroscopic guidance. RESULTS: After initial stent placement 17 patients had normal food intake. One patient was able to eat fractionated meals. Five patients did not experience any improvement due to the presence of a jejunal stenosis downstream in 2, or insufficient stenosis coverage in 2 and stent migration in 1. Nine of the 18 patients with improvement died without symptoms within 101 +/- 56 days after stent placement and 6 were alive and symptom-free after a mean follow up of 176 +/- 83 days. Three asymptomatic patients were lost to follow up after 3 days, 1 and 2 months, respectively. CONCLUSIONS: Metallic stents appear to be a valuable option for the treatment of malignant gastro-duodenal stenoses.

Endovascular management of bleeding iliac artery pseudoaneurysms complicating radiation therapy for pelvic malignancies.

OBJECTIVE: We evaluated arteriographic findings and endovascular treatments of eight patients who had bleeding iliac artery pseudoaneurysms and who had undergone radiation therapy (3000-6500 rad [30-65 Gy]) and surgery for pelvic malignancies. CONCLUSION: Angiography revealed contrast media extravasation in 75% of patients who had bleeding iliac artery pseudoaneurysms and failed to show the source of bleeding in 25%. The patients who had positive findings at angiography were all successfully treated percutaneously, although two patients required additional bypass surgery. Among embolic materials, coils and balloons were safe and efficient, whereas cyanoacrylate was unsafe and led to complications in two of three patients. A covered stent, which was not available for most of our patients, was used in one patient and may be an effective means of treating pseudoaneurysms.

Self-expanding metallic stents as palliative treatment of malignant gastroduodenal stenosis.

OBJECTIVE: Our objective was to evaluate the efficacy of self-expanding metallic stents as palliative treatment in 10 patients with malignant stenosis of the stomach (n = 2) or the duodenum (n = 8). CONCLUSION: Metallic stents appeared valuable for the treatment of malignant gastroduodenal stenosis in this preliminary study because they provided durable relief of symptoms in eight of 10 patients for a mean of 93 days, until death. Particular attention should be paid to evaluating the digestive tract meticulously downstream because this zone was the cause of failure in two patients. Further studies are needed using a larger series.