Three-dimensional isotropic T2-weighted fast spin-echo (VISTA) ankle MRI versus two-dimensional fast spin-echo T2-weighted sequences for the evaluation of anterior talofibular ligament injury.

AIM: To compare the performance of axial images of the ankle joint on three-dimensional (3D) volume isotropic turbo spin echo acquisition (VISTA) with that of two-dimensional (2D) fast spin echo (FSE) T2-weighted images for the diagnosis of anterior talofibular ligament (ATFL) injury. MATERIALS AND METHODS: This retrospective study included 101 patients who underwent both 2D FSE T2-weighted and 3D VISTA magnetic resonance imaging (MRI) of the ankle. The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of both sequences were measured. The anatomical identification score and diagnostic performances of both sequences were evaluated by two radiologists. The diagnostic performances of 3D VISTA and 2D FSE images were analysed in terms of sensitivity, specificity, and accuracy for diagnosing ATFL injury. Surgically or clinically confirmed diagnoses were used as reference standards. RESULTS: The margin sharpness scores on 3D VISTA were significantly inferior to those of 2D FSE (p<0.001). Other scores (entire length, entire width) were not significantly different between the two imaging methods. The SNRs and CNRs of 3D VISTA were significantly higher than those of 2D FSE (p<0.001). When diagnoses were classified as normal and abnormal, the specificity of the 3D VISTA images for the diagnosis of ATFL injury was 95.7%, significantly superior to 2D FSE (84.3-85.7%). There were no significant differences between 3D VISTA and 2D FSE images in sensitivity or accuracy for diagnosis (p=0.227-1.000), with the exception of accuracy by reader 1 (p=0.039). CONCLUSION: 3D VISTA imaging has a diagnostic performance comparable to that of 2D FSE for the diagnosis of ATFL injury, although 3D VISTA is inferior to 2D FSE for the evaluation of margin sharpness. Replacing axial and coronal images with 3D VISTA can save imaging time without negatively impacting the diagnostic ability for ATFL injury.

Usefulness of the oblique coronal plane in ankle MRI of the calcaneofibular ligament.

AIM: To evaluate the usefulness and diagnostic accuracy of oblique coronal MRI of the calcaneofibular ligament (CFL) view for diagnosis of CFL injury. MATERIAL AND METHODS: This retrospective study included 91 patients who were suspected to have CFL injury who underwent CFL view imaging. Anatomical identification of the CFL on orthogonal MRI sequences and CFL views was evaluated. Two radiologists evaluated the CFL based on an entire length view, an entire width view, and margin sharpness using a four-point scale. Diagnostic accuracy using orthogonal and CFL views was evaluated by calculating sensitivity, specificity, and accuracy. Arthroscopic or clinical findings were used as the reference standard. RESULTS: Both readers found identification of lesions using the entire length, entire width, and sharp margin from CFL view images to be superior to that based on orthogonal images. The sensitivity and accuracy of diagnosing CFL injury were significantly higher when using the CFL view compared to the orthogonal view, although specificity was not significantly different between the CFL view and orthogonal view images. CONCLUSIONS: CFL view imaging enables better anatomical evaluation and improved sensitivity and accuracy of diagnosis of CFL injury. CFL view images should therefore be used to evaluate potential CFL injuries.

Evaluation of shoulder pathology: three-dimensional enhanced T1 high-resolution isotropic volume excitation MR vs two-dimensional fast spin echo T2 fat saturation MR.

OBJECTIVE: To evaluate the diagnostic accuracy of three-dimensional (3D) enhanced T1 high-resolution isotropic volume excitation (eTHRIVE) shoulder MR for the detection of rotator cuff tears, labral lesions and calcific tendonitis of the rotator cuff in comparison with two-dimensional (2D) fast spin echo T2 fat saturation (FS) MR. METHODS: This retrospective study included 73 patients who underwent shoulder MRI using the eTHRIVE technique. Shoulder MR images were interpreted separately by two radiologists. They evaluated anatomic identification and image quality of the shoulder joint on routine MRI sequences (axial and oblique coronal T2 FS images) and compared them with the reformatted eTHRIVE images. The images were scored on a four-point scale (0, poor; 1, questionable; 2, adequate; 3, excellent) according to the degree of homogeneous and sufficient fat saturation to penetrate bone and soft tissue, visualization of the glenoid labrum and distinction of the supraspinatus tendon (SST). The diagnostic accuracy of eTHRIVE images compared with routine MRI sequences was evaluated in the setting of rotator cuff tears, glenoid labral injuries and calcific tendonitis of the SST. RESULTS: Fat saturation scores for eTHRIVE were significantly higher than those of the T2 FS for both radiologists. The sensitivity and accuracy of the T2 FS in diagnosing rotor cuff tears were >90%, whereas sensitivity and accuracy of the eTHRIVE method were significantly lower. The sensitivity, specificity and accuracy of both images in diagnosing labral injuries and calcific tendonitis were similar and showed no significant differences. The specificity of both images for the diagnosis of labral injuries and calcific tendonitis was higher than the sensitivities. CONCLUSION: The accuracy of 3D eTHRIVE imaging was comparable to that of 2D FSE T2 FS for the diagnosis of glenoid labral injury and calcific tendonitis of SST. The 3D eTHRIVE technique was superior to 2D FSE T2 FS in terms of fat saturation. Overall, 3D eTHRIVE was inferior to T2 FS in the evaluation of rotator cuff tears because of poor contrast between joint fluid and tendons. ADVANCES IN KNOWLEDGE: The accuracy of 3D eTHRIVE imaging is comparable to that of 2D FSE T2 FS for the diagnosis of glenoid labral injury and calcific tendonitis of SST.

Usefulness of meniscal width to transverse diameter ratio on coronal MRI in the diagnosis of incomplete discoid lateral meniscus.

AIM: To evaluate the clinical utility of the meniscal width to transverse diameter ratio (L/M ratio) of the lateral meniscus in the diagnosis of incomplete discoid lateral meniscus (IDLM) as compared with the arthroscopic diagnosis, meniscal width to tibial diameter ratio (L/T ratio) and conventional lateral meniscus width criteria. MATERIALS AND METHODS: This retrospective study sample included 41 patients with IDLM who underwent knee magnetic resonance imaging (MRI) and arthroscopy, as well as 50 controls with normal lateral menisci. MRI examinations were interpreted independently by two radiologists, both of whom were blinded to clinical information and radiological reports. Assessment of meniscal width (L), maximal transverse diameter of the lateral meniscus (M), and transverse diameter of the tibia (T) was carried out on central coronal sections that were observed to pass through the medial collateral ligament. L/M and L/T ratios were calculated. These results were correlated with arthroscopic findings and analysed statistically using categorical regression analysis and non-parametric correlation analysis. Using arthroscopic findings as the standard of reference, sensitivity and specificity were calculated for: (1) 12, 13, 14, and 15 mm meniscal width thresholds; (2) 40%, 50%, 60%, and 70% L/M ratio thresholds; and (3) 15%, 18%, 20%, and 25% L/T ratio thresholds. RESULTS: The mean L/M ratio of the IDLM was approximately 67% and was statistically significantly higher than the control (44%). The best diagnostic discrimination was achieved using a threshold of 50%. The mean L/T ratio of the IDLM was approximately 23% and was statistically significant. The best diagnostic discrimination was achieved using a threshold of 18%. The threshold of 13 mm of meniscal width also showed high sensitivity and high specificity. CONCLUSION: The use of the L/M ratio or L/T ratio in combination with meniscal width criteria may be a useful method for evaluating IDLM.

Clinical correlation of a new practical MRI method for assessing central lumbar spinal stenosis.

OBJECTIVE: To evaluate interobserver agreement and determine whether a new MRI grading system agrees with symptoms and neurological signs. METHODS: We examined 160 patients (72 males and 88 females; mean age 57 years) who underwent MRI of the lumbar spine at our institution and were evaluated by two musculoskeletal radiologists. The presence and grade of central lumbar spinal stenosis (CLSS) at L3-4, L4-5 and L5-S1 were assessed according to a new grading system, the Lee system. The results were correlated with clinical manifestations and neurological examinations [positive neurological manifestation (PNM) and negative neurological manifestation (NNM)]. Statistical analyses were performed using kappa statistics and non-parametric correlation analysis (Spearman's correlation). RESULTS: Interobserver agreement in the grading of CLSS between the two readers was substantial (κ=0.780). Interobserver agreement of the L4-5 level and older age group was high (0.789, 0.814). The correlation coefficient (R) of Reader 1 between MRI Grades 0, 1, 2 or 3 and neurological manifestations (negative or positive) was 0.654; the R of Reader 2 was 0.591. In the younger age group (<57 years), the R of Reader 1 was 0.634 and the R of Reader 2 was 0.500. In the older age group (≥57 years), the R of Reader 1 was 0.650 and the R of Reader 2 was 0.645. Correlation coefficients were higher at the L3-4 level (0.612-0.678) than at other levels but did not show statistical significance (p>0.05). CONCLUSION: Interobserver agreement for the new CLSS grading system was substantial. Grade 0 was associated with NNMs and Grade 3 with PNMs in this cohort. Grade 2 demonstrates more cases of PNM than NNM but requires further evaluation. Correlations between MRI grades and clinical manifestations were moderate and slightly higher in older patients. ADVANCES IN KNOWLEDGE: The new practical MRI grading method can be useful in the categorisation of CLSS and shows strong clinical correlation.

A practical MRI grading system for cervical foraminal stenosis based on oblique sagittal images.

OBJECTIVE: To propose a new and practical MRI grading method for cervical neural foraminal stenosis and to evaluate its reproducibility. METHODS: We evaluated 50 patients (37 males and 13 females, mean age 49 years) who visited our institution and underwent oblique sagittal MRI of the cervical spine. A total of 300 foramina and corresponding nerve roots in 50 patients were qualitatively analysed from C4-5 to C6-7. We assessed the grade of cervical foraminal stenosis at the maximal narrowing point according to the new grading system based on T2 weighted oblique sagittal images. The incidence of each of the neural foraminal stenosis grades according to the cervical level was analysed by χ(2) tests. Intra- and interobserver agreements between two radiologists were analysed using kappa statistics. Kappa value interpretations were poor (κ<0.1), slight (0.1≤κ≤0.2), fair (0.2<κ≤0.4), moderate (0.4<κ≤0.6), substantial (0.6<κ≤0.8) and almost perfect (0.8<κ≤1.0). RESULTS: Significant stenoses (Grades 2 and 3) were rarely found at the C4-5 level. The incidence of Grade 3 at the C5-6 level was higher than that at other levels, a difference that was statistically significant. The overall intra-observer agreement according to the cervical level was almost perfect. The agreement at each level was almost perfect, except for only substantial agreement at the right C6-7 by Reader 2. No statistically significant differences were seen according to the cervical level. Overall kappa values of interobserver agreement according to the cervical level were almost perfect. In addition, the agreement of each level was almost perfect. Overall intra- and interobserver agreement for the presence of foraminal stenosis (Grade 0 vs Grades 1, 2 and 3) and for significant stenosis (Grades 0 and 1 vs Grades 2 and 3) showed similar results and were almost perfect. However, only substantial agreement was seen in the right C6-7. CONCLUSION: A new grading system for cervical foraminal stenosis based on oblique sagittal MRI provides reliable assessment and good reproducibility. This new grading system is a useful and easy method for the objective evaluation of cervical neural foraminal stenosis by radiologists and clinicians. ADVANCES IN KNOWLEDGE: The use of the new grading system for cervical foraminal stenosis based on oblique sagittal MRI can be a useful method for evaluating cervical neural foraminal stenosis.

Assessment of follow-up sonography and clinical improvement among infants with congenital muscular torticollis.

BACKGROUND AND PURPOSE: Infants grow rapidly, which causes the SCM to thicken physiologically. Therefore some cases of physiologically-thickened SCM can be confused with a poor response to physical therapy. There have been only a few quantitative ultrasonographic studies on the clinical outcome of rehabilitation for CMT. Our aim was to evaluate whether a new sonographic assessment method that uses the muscular thickness ratio of the SCM can help quantify the outcome of rehabilitation therapy for patients with CMT. MATERIALS AND METHODS: We evaluated 48 patients (male/female, 17:31; mean age, 3.9 months) who were diagnosed with CMT and who underwent initial and follow-up sonography. The ratio of the thickness of the involved SCM to the thickness of the intact SCM (SCM thickness ratio) was calculated. A scoring system based on the range of motion of the neck was used to assess clinical improvement. The correlations between clinical improvement and the thickness of the involved muscle, the difference in involved muscle thickness, the SCM thickness ratio, and the difference in the SCM thickness ratio were evaluated with Spearman rank correlations. RESULTS: Follow-up Cheng scores were higher than initial scores; this difference indicates clinical resolution (follow-up, 4.90; initial, 3.38). The SCM thickness ratio at follow-up was lower than that at the initial evaluation (follow-up, 1.29-1.34; initial, 1.65-1.77). Intra- and interobserver agreements were excellent. Most variables were moderately correlated with clinical improvement (correlation coefficients, 0.36-0.509). R1 showed the highest correlation with clinical improvement (0.481 and 0.509), followed by the initial maximal thickness of the SCM (0.434 and 0.488). ΔP (P1-P2) and ΔR showed similar correlation coefficients with clinical improvement. CONCLUSIONS: Measurement of the SCM thickness ratio appears to overcome the problem of a false-positive diagnosis of clinical aggravation of CMT resulting from physiologic growth. R1 and ΔR are accurate objective measurements, which can be used in the management of CMT.

Medial meniscal root tears and meniscal extrusion transverse length ratios on MRI.

OBJECTIVE: To evaluate the clinical utility of the meniscal extrusion transverse ratio of the medial meniscus in the diagnosis of meniscal root tear compared with the gold standard of arthroscopic diagnosis. METHODS: This retrospective study sample included 32 males and 35 females who underwent MRI at our institution. There were 24 meniscal root tear cases. The control groups were 18 cases of medial meniscal tears without root tears and 25 cases of negative meniscal findings on arthroscopy. Meniscal extrusion (L) and maximal transverse lengths (T) of the medial meniscus were measured, and L/T ratios were calculated. These results were correlated with arthroscopic findings and analysed statistically. With arthroscopic findings used as the standard of reference, the sensitivity and specificity of 10%, 11% and 12% extrusion thresholds, and 3 mm of medial meniscal extrusion (MME) as diagnostic thresholds, were calculated. RESULTS: The mean length of the meniscal extrusions of meniscal root tears was twice as long as the control group. The mean L/T ratio of the meniscal root tears was approximately 13%, while those of the control groups were 5%. The differences in the L and L/T between the meniscal root tears and normal and meniscal root tears and other meniscal tears were statistically significant (p<0.001), but those between normal and other meniscal tears were not. The best diagnostic discrimination was achieved using an extrusion ratio threshold of 10% (79% sensitivity, 86% specificity). The 3 mm of MME threshold demonstrated high specificity (98%), but not high sensitivity (54%). CONCLUSION: The mean L/T ratio of the meniscal root tears was approximately 13% and was statistically significant. The best diagnostic discrimination was achieved using an extrusion ratio threshold of 10%. Advances in knowledge The use of the L/T ratio in combination with MME can be a useful method for evaluating medial meniscal root tears.

Clinical and angiographic follow-up of stent-only therapy for acute intracranial vertebrobasilar dissecting aneurysms.

BACKGROUND AND PURPOSE: Little has been known about the clinical and angiographic follow-up results of stent-only therapy for intracranial vertebrobasilar dissecting aneurysms (VBDA). The purpose of this study was to evaluate the feasibility, safety, clinical, and angiographic follow-up of stent-only therapy for VBDA. MATERIALS AND METHODS: Twenty-seven patients with 29 VBDAs (11 ruptured, 18 unruptured), not suitable for deconstructive treatment, underwent stent-only therapy. Feasibility, safety, clinical, and angiographic follow-up were retrospectively evaluated. Angiographic outcomes were compared between single-stent and multiple-stent groups. RESULTS: All attempted stent placements were successfully accomplished without any treatment-related complication. Of the 11 ruptured VBDAs, 4 were treated by single stents, 6 by double overlapping stents, and 1 by triple overlapping stents. Of the 18 unruptured VBDAs, 6 were treated by stents, and 12 by double overlapping stents. One patient with a ruptured VBDA, treated by single stent, had rebleeding and died. None of the remaining patients had posttreatment bleeding during follow-up (mean, 28 months; range, 7-50 months). Eight patients with ruptured VBDA and all patients with unruptured VBDA had excellent outcomes (modified Rankin Scale, 0-1). The remaining 2 patients with ruptured VBDA were moderately disabled because of the initial damage. Angiographic follow-up was available in 27 VBDAs, 4 to 42 months (mean, 12 months) after treatment. Follow-up angiograms revealed complete obliteration of the dissecting aneurysm in 12, partial obliteration in 12, stable in 1, enlargement in 1, and in-stent occlusion in 1. Angiographic improvement (complete or partial obliteration) was more frequent in the multiple-stent group (17/17) than in the single-stent group (7/9; P < .05). CONCLUSIONS: In this small series, stent-only therapy was safe and effective in the treatment of VBDAs that were not deemed suitable for treatment with parent-artery occlusion.

Detailed MR imaging anatomy of the cisternal segments of the glossopharyngeal, vagus, and spinal accessory nerves in the posterior fossa: the use of 3D balanced fast-field echo MR imaging.

BACKGROUND AND PURPOSE: The cisternal segments of the lower cranial nerves (CNs) adjacent to the jugular foramen (JF) are difficult to identify reliably by routine MR imaging. We performed a 3D balanced fast-field echo imaging technique (3D-bFFE) to obtain detailed anatomy of the cisternal segments of CNs IX, X, and XI. MATERIALS AND METHODS: 3D-bFFE was used to image the cisternal segments of the lower CNs in 20 healthy volunteers. As an anatomic landmark, CSF recesses adjacent to the JF were divided into 3 parts: the recess for the cochlear aqueduct, the recess for CN IX, and the recess for the CN X/XI complex. MR images were evaluated to identify the cisternal segment of each cranial nerve in relation to these anatomic landmarks. RESULTS: The mean angles of the recess for the cochlear aqueduct for CN IX and CN X/XI to the posterior petrous bone were 41.6 +/- 2.5 degrees , 69.7 +/- 3.1 degrees , and 76.0 +/- 3.4 degrees , respectively (P < .01). The mean length of the recess for the cochlear aqueduct for CN IX and the CN X/XI complex was 5.91 +/- 0.19, 5.08 +/- 0.11, and 4.76 +/- 0.13 cm, respectively (P < .01). 3D-bFFE adequately depicted the cisternal segments of CN IX on 38 sides (95%) and the CN X/XI complex on 39 sides (97.5%). CONCLUSIONS: The cisternal segments of CN IX, CN X, and CN XI are well identified by using 3D-bFFE, especially by determining the angles of the CSF recesses adjacent to the JF.

Management and clinical outcome of acute basilar artery dissection.

BACKGROUND AND PURPOSE: There have been inconsistencies on the prognosis and controversies as to the proper management of acute basilar artery dissection. The aim of this study was to evaluate acute basilar artery dissection and its outcome after management. MATERIALS AND METHODS: A total of 21 patients (mean age, 53 years; range, 24-78 years) with acute basilar artery dissection were identified between January 2001 and October 2007. Clinical presentation, management, and outcomes were retrospectively evaluated. RESULTS: The patients presented with subarachnoid hemorrhage (n = 10), brain stem ischemia (n = 10), or stem compression sign (n = 1). Ruptured basilar artery dissections were treated by stent placement with coiling (n = 4), single stent placement (n = 3), or conservatively (n = 3). Of the patients treated with endovascular technique, 6 had favorable outcome (modified Rankin scale [mRS], 0-2) and the remaining patient, who was treated by single stent placement, died from rebleeding. All 3 conservatively managed patients experienced rebleeding, of whom 2 died and the other was moderately disabled. Unruptured basilar artery dissections were treated conservatively (n = 7) or by stent placement (n = 4). Of the patients with unruptured basilar artery dissection, 9 had favorable outcome and the remaining 2 patients, both of whom were conservatively managed, had poor outcome because of infarct progression. The group with the ruptured basilar artery dissection revealed a higher mortality rate than the group with the unruptured dissection (30% vs 0%). The group treated with endovascular means revealed more favorable outcome than the group that was treated with conservative measures (90.9% vs 50%). CONCLUSION: The ruptured basilar artery dissections were at high risk for rebleeding, resulting in a grave outcome. Stent placement with or without coiling may be considered to prevent rebleeding in ruptured basilar dissections and judiciously considered in unruptured dissections with signs of progressive brain stem ischemia.

Clinical outcome and ischemic complication after treatment of anterior choroidal artery aneurysm: comparison between surgical clipping and endovascular coiling.

BACKGROUND AND PURPOSE: Although coiling has been favorably comparable with clipping for treatment of most intracranial aneurysms, there is a controversy on which modality is safer for anterior choroidal artery (AchoA) aneurysm. We retrospectively evaluated the clinical outcomes and treatment-related complications after surgical clipping and endovascular coiling of AchoA aneurysms. MATERIALS AND METHODS: Seventy-three AchoA aneurysms were recruited from 1895 intracranial aneurysms, which were treated either by surgical clipping or by endovascular coiling in 4 institutions between May 1999 and December 2006. The AchoA aneurysms were dichotomized according to the modality of treatment, the coil group (37 patients; 38 aneurysms) and the clip group (35 patients; 35 aneurysms). Clinical outcomes and incidence of treatment-related complications between 2 groups and the factors influencing the clinical outcomes were evaluated. RESULTS: There was no rebleeding in both groups during follow-up, for 4-72 months (mean, 27 months) in the coil group and for 3-84 months (mean, 34 months) in the clip group. In the coil group, 31 patients (83.8%) had favorable outcome (modified Rankin Scale score [mRS], 0-3). In the clip group, 31 patients (88.6%) had favorable outcome. The complication of coiling was transient contralateral hemiparesis in 2 patients, who recovered completely. The complications of clipping were permanent contralateral hemiparesis due to AchoA infarction in 4 patients and third-nerve palsy in 1 patient. Hunt and Hess grade 4 or 5 and AchoA infarction were significantly correlated with poor outcome (mRS, < or =4). Clipping had significantly higher incidence of AchoA infarction than coiling (P < .05). CONCLUSION: Coiling of AchoA aneurysms appears comparable with clipping in clinical outcome and prevention of rebleeding, with significantly lower incidence of AchoA infarction than clipping.

White matter abnormalities in drug-naïve patients with obsessive-compulsive disorder: a diffusion tensor study before and after citalopram treatment.

OBJECTIVE: The aim was to investigate the white matter abnormalities of drug-naïve patients with obsessive-compulsive disorder (OCD) using diffusion tensor-imaging and the white matter changes in the patients after pharmacotherapy. METHOD: Thirteen drug-naïve OCD patients and 13 age- and sex-matched healthy comparison subjects were examined using diffusion tensor-imaging and structural magnetic resonance imaging. Measurements were made in OCD patients before and after 12 weeks of citalopram treatment. RESULTS: Compared with controls, the drug-naïve OCD patients showed significant increases in fractional anisotropy (FA) in the corpus callosum, the internal capsule and white matter in the area superolateral to the right caudate. The increases in FA were mostly no longer observed in patients after 12 weeks of treatment compared with controls. CONCLUSION: Our findings suggest that white matter alterations are associated with the pathophysiology of OCD, and the abnormalities may be partly reversible with pharmacotherapy.

Peripheral ossifying fibroma in the oral cavity: CT and MR findings.

We report a case of peripheral ossifying fibroma arising from the anterior oral cavity in a 12-year-old boy. CT and MR scans showed a large exophytic soft tissue mass overlying the anterior hard palate and maxillary alveolar ridge. The tumour revealed peripheral calcification without adjacent bone changes.

The most useful findings for diagnosing acute appendicitis on contrast-enhanced helical CT.

PURPOSE: To evaluate the most useful findings to look for in diagnosing acute appendicitis on contrast-enhanced helical CT. MATERIAL AND METHODS: Appendiceal helical CT scans with intravenous contrast administration (abdomen, 7-mm collimation; abdominopelvic junction, 5-mm collimation) of 71 patients with surgically proven acute appendicitis and 167 patients with alternative diagnoses were reviewed retrospectively. Three radiologists analyzed the following parameters: enlarged appendix (>6 mm in diameter), appendiceal wall thickening, appendiceal wall enhancement, no identification of the appendix, appendicolith(s), appendiceal intraluminal air, intramural air, extraluminal air, periappendiceal fat stranding, extraluminal fluid, phlegmon, abscess, lymphadenopathy, segmental terminal ileal wall thickening, focal cecal apical thickening, focal colonic wall thickening, and segmental colonic wall thickening. The features that best distinguished appendicitis from alternative diagnoses were selected with stepwise logistic regression analysis. RESULTS: Nine CT findings distinguished acute appendicitis from alternative diagnoses (P < 0.05): enlarged appendix (R = 0.739), appendiceal wall thickening (R = 0.525), periappendiceal fat stranding (R = 0.414), appendiceal wall enhancement (R = 0.404), focal cecal apical thickening (R = 0.171), appendicolith(s) (R = 0.157), extraluminal air (R = 0.050), intramural air (R = 0.043), and phlegmon (R = 0.030). Enlarged appendix (sensitivity, 93%; specificity, 92%), appendiceal wall thickening (sensitivity, 66%; specificity, 96%), periappendiceal fat stranding (sensitivity, 87%; specificity, 74%), and appendiceal wall enhancement (sensitivity, 75%; specificity, 85%) showed the statistically most significant association with acute appendicitis. CONCLUSION: On 5-mm-section contrast-enhanced helical CT examinations, enlarged appendix, appendiceal wall thickening, periappendiceal fat stranding, and appendiceal wall enhancement were the most useful findings for diagnosing acute appendicitis.

Proximal gastrectomy and jejunal pouch interposition: radiographic evaluation of postoperative findings.

BACKGROUND: We assessed the postoperative findings of proximal gastrectomy and jejunal pouch interposition with contrast radiography. METHODS: Eleven patients with proximal gastrectomy and jejunal pouch interposition for proximal gastric carcinoma underwent contrast radiography. We evaluated the radiographic findings of the remnant stomach and interposed jejunal pouch. RESULTS: The interposed jejunal pouch showed good expansion, and the motility of the remnant gastric antrum was normal in all patients. One patient had significant lumenal narrowing of the esophageal pouch anastomotic site. Leak at the anastomotic site was not found. Reflux into the esophagus from the pouch was observed in two patients. Gastric emptying time was considerably delayed in two patients. CONCLUSION: Follow-up upper gastrointestinal series of the proximal gastrectomy and jejunal pouch interposition showed different postoperative findings. Awareness of the normal and abnormal findings is essential in the accurate postoperative evaluation of these patients.

Preoperative embolization of cerebral arteriovenous malformations with silk sutures: analysis and clinical correlation of complications revealed on computerized tomography scanning.

OBJECT: The aim of this study was to determine the incidence and clinical significance of complications related to preoperative embolization of cerebral arteriovenous malformations (AVMs) with silk sutures as documented on postprocedure computerized tomography (CT) scans. METHODS: The CT scans were obtained within 12 to 24 hours after 221 (96%) of 230 consecutive embolizations in 70 patients. These CT scans were evaluated for the presence of ischemia, infarction, hemorrhage, or contrast agent extravasation. Adverse patient outcomes were determined after each embolization and were correlated with CT findings. New abnormalities demonstrated on CT scans were also correlated with the Spetzler-Martin AVM grade, degree of arteriovenous shunting, and location. New abnormalities, the majority of them infarcts, resulted from 29 (13%) of 221 embolization procedures. In 11 (38%) of 29 cases of new CT findings, patients were asymptomatic, including 10 with new infarcts on CT scans. New neurological deficits occurred in 20 (8.7%) of 230 total embolization procedures in 19 patients, including one death. Permanent deficits occurred in nine patients (3.9% per embolization procedure, 12.8% per patient). Of the patients with new neurological deficits, 18 (90%) of 20 embolization procedures resulted in new abnormalities on CT scans. Two patients with new transient neurological deficits had no new findings on CT scans. Spetzler-Martin grade, AVM location, degree of arteriovenous shunting, and higher numbers of procedures were not statistically associated with a higher incidence of abnormalities on CT scans or new permanent neurological deficits. CONCLUSIONS: Silk sutures are an effective and relatively safe embolic agent. After brain AVM embolization with silk sutures, new abnormalities were found on CT scans obtained in one of eight procedures. When a new CT finding occurred, the patient had roughly equal chances of having no new symptoms, having new transient neurological deficits, or having new permanent neurological deficits.

Successful removal of freckles in Asian skin with a Q-switched alexandrite laser.

BACKGROUND: : Although freckles are light-brown macules most frequently observed in individuals with red or blond hair and blue or gray eyes, freckles are common to Asian people, including Koreans. Treatment may be requested on cosmetic grounds. OBJECTIVE: : The objective of this study was to determine the effectiveness of the Q-switched alexandrite laser (wavelength 755 nm; pulse width 100 nsec) in treating the 197 cases of Asian skin with freckles and to observe any side effects such as pigmentary changes or scarring. METHODS: : One hundred ninety-seven patients with freckles were treated with the Q-switched alexandrite laser at 8-week intervals and clinically analyzed. RESULTS: : More than 76% removal of freckles required an average of 1.5 treatment sessions with 7.0 J/cm2. No scarring, long-standing pigmentary changes, or textural changes were seen in laser-irradiated skin. CONCLUSION: : The Q-switched alexandrite laser is a safe and highly effective modality for removing freckles without scarring or permanent pigmentary changes in Asian skin.

Colonic diverticulosis in Hong Kong: distribution pattern and clinical significance.

This is a retrospective study on the prevalence of diverticulosis in Hong Kong Chinese adults. Eight-hundred and fifty-eight consecutive barium enema examinations over a period of 18 months (January 1995-June 1996) were analysed. Results show that the prevalence of diverticulosis in our community is 25.1% with no significant difference between male and female adults. The prevalence is lower than Western countries but higher than in Asia. Moreover, the peak prevalence is at the 50-79 years age group with lower prevalence in the older age groups. This may be explained by the rapid rise in prevalence in the younger age groups so that the age-related increase in prevalence become obscured. We postulate that this may be due to Western cultural influence in our diet and lifestyle. There is no significant difference in the symptomatology of patients with and without diverticulosis, supporting the idea that diverticulosis alone is usually asymptomatic. There is predominance of right hemicolon involvement in our subjects, in contrast to the left hemicolon predominance in the Caucasian population. Of patients with diverticulosis, 55.3% have only right-sided involvement and 32.6% have bilateral involvement. Only 12.1% of patients with diverticulosis have exclusively left hemicolon involvement. Caecal and ascending colon diverticula are found in 6.4% and 17.6% of all the adults under study, respectively. Clinicians caring for patients from our community should take note of this high frequency of caecal and ascending colon diverticulosis as caecal and ascending colon diverticulitis is notoriously difficult to diagnose clinically.

Left renal vein entrapment syndrome in two girls with orthostatic proteinuria.

Left renal vein entrapment was documented by bilateral ureteral catheterization and imaging studies as a cause of orthostatic proteinuria in two girls. Renal ultrasonography showed compression of the left renal vein between the aorta and the superior mesenteric artery (Nutcracker phenomenon). Abnormal collateral veins and high pressure gradients between the left renal vein and the inferior vena cava were found on left renal venography and pressure tracing, respectively. The left kidney was documented as the source of postural proteinuria by bilateral ureteral catheterization. Our observations suggest renal congestion due to left renal vein entrapment was the cause of orthostatic proteinuria.