Computed tomographic evaluation to exclude traumatic aortic disruption.

Traumatic aortic disruption from blunt trauma remains a lethal injury. The role of computed tomographic (CT) scanning in the diagnosis of traumatic aortic disruption (TAD) has been debated and varying results have been reported. We reviewed our experience with 133 consecutive cases of blunt trauma with abnormal findings on chest x-ray films of sufficient concern to require further evaluation for TAD. Of the 105 patients who underwent CT scanning as the initial evaluation, 11 (10%) required aortography (Ao) for diagnosis; seven had TAD. Twenty-eight patients with highly suggestive signs of TAD underwent Ao as the initial diagnostic test; five had TAD. Ten of the 12 patients (83%) undergoing surgical repair had good results; one died of exsanguination at surgery and the other suffered a profound neurologic injury. Follow-up by phone or chart review at 6 months to more than 5 years after injury revealed no late mortalities from unrecognized TAD. We conclude that high quality CT evaluation of patients with worrisome chest x-ray films following blunt trauma can be used to exclude TAD in the majority of cases. Aortography is reserved for cases in which there is a high clinical suspicion of TAD and for those patients in whom TAD cannot be confidently excluded by CT scanning.

CT of intra-abdominal fluid collections.

A wide variety of fluids including ascites, blood, pus, urine, bile, lymph, chyle, mucin, and cerebrospinal fluid can accumulate within the peritoneal and pelvic cavities. The location, appearance, and distribution of this fluid is governed by a number of anatomic and gravitational factors that when carefully analyzed, can help to reveal their source and etiology. Computed tomography is ideally suited to document the presence of abdominal and pelvic fluid collections; display their location and full extent; characterize the fluid and often suggest its source; and provide guidance for percutaneous diagnostic and therapeutic procedures when required.

Multimodality approach to pericardial imaging.

In this chapter, three modalities--computed tomography, nuclear magnetic resonance imaging, and echocardiography--have been discussed. Each of these techniques offers unique advantages in the diagnosis of pericardial disease. Although echocardiography is the least expensive, most sensitive, and least invasive technique for the identification of pericardial effusion, false-positive and negative studies may be encountered. These are often resolved with the use of computed tomography and may be resolved with magnetic resonance imaging. Plain film radiography still has the advantage of identifying pericardial calcifications and will suggest the diagnosis of large pleural effusions at low cost and radiation dose. Exquisite portrayal of cross section anatomy using CT will aid in the diagnosis of multiple small tumor deposits and will clearly identify pericardial thickening. The value of magnetic resonance imaging awaits carefully controlled blinded studies, but its role in characterization of the content of pericardial effusions appears especially promising.

CT diagnosis of idiopathic aneurysms of the thoracic systemic veins.

Three patients with idiopathic aneurysms of the superior vena cava, left innominate vein, and inferior vena cava are presented. The advantages of CT over other diagnostic modalities are discussed.

Evaluation of superior vena cava syndrome by axial CT and CT phlebography.

Transverse axial computed tomography (CT) has been combined with CT digital phlebography to study nine patients with superior vena cava syndrome. Six were due to malignancy, two were secondary to benign disease, and one was a paraneoplastic manifestation. This combined CT approach successfully identified the abnormal morphology of the superior vena cava, demonstrating external compression, encasement, or intraluminal thrombus in all patients and the collateral venous channels in eight. The efficacy and advantages of this technique are discussed. This technique is a rapid, informative, and cost-effective method for the workup of superior vena cava syndrome. The CT digital phlebogram, however, is not successful in regularly and optimally opacifying the normal superior vena cava because of the limited amount of contrast material, dilution effect of the nonopacified incoming flow from the jugular and azygos veins, and the lack of image enhancement from the CT digital scanograms.

Computed tomographic demonstration of anomalous inferior vena cava with azygos continuation.

A case of anomalous inferior vena cava with azygos continuation first diagnosed by computed tomography (CT) and later confirmed by venography is presented. In addition to identifying the dilated azygos vein in the chest, CT can determine the direction of flow in the vein by means of a bolus contrast medium injection. Once this is established, a search for the etiology of the dilated vein can be directed to the appropriate anatomic area.

Computed tomography in the evaluation of liver disease in cystic fibrosis patients.

The results of a study of cystic fibrosis patients with liver disease using computed tomography are reported. The findings are described, and a discussion of their significance and place in patient investigation is offered.

Pancreatic pseudotumors: computed tomography.

Although pancreatic disease is suspected initially by historical or biochemical findings, the nature of the pathologic process in the past was frequently established only through invasive procedures. Inferences can be drawn from routine roentgenologic examinations, but visualization of the pancreas has only recently been achieved. Of the currently available noninvasive imaging procedures, computed tomography, in our opinion, is the screening procedure of choice. Care in the interpretation of pancreatic masses must be exercised since some of the findings can be attributed to anatomic variants, normal adjacent structures, or other neighboring pathologic processes.

Diagnosis of sellar and parasellar lesions by computed tomography and other diagnostic modalities.

A review of 5,000 computed tomographic (CT) brain scans revealed 76 patients with proved pathology involving the sellar and parasellar areas. The overall diagnostic accuracy of CT scanning was 93.4%, whereas the accuracy of isotope scanning, angiography, and pneumoencephalography was 55.4, 81 and 100% respectively. The criteria used in making the diagnosis with CT scanning are listed. The results indicate that CT scanning is the initial diagnostic procedure of choice, but that other modalities, particularly angiography, are still required for more accurate evaluation in the majority of cases.

Ultrasonically guided percutaneous biopsy of peripheral pulmonary masses.

Ultrasonically guided percutaneous biopsy and aspiration of solid and cystic structures in the abdomen, neck, and pericardial space are common practice. The technique may be utilized for biopsy of peripheral pulmonary masses in contact with the chest wall, in order to assure accurate placement of the needle in the center of the mass, reduce the risk of pneumothorax, and eliminate the exposure to radiation that occurs with fluoroscopic guidance. Four patients had successful biopsies in this manner, without complications. Histologic studies revelaed malignant neoplasms in three and lipoid pneumonia in one.