CT appearance of gastric involvement in multifocal idiopathic fibrosclerosis.

Multifocal idiopathic fibrosclerosis (also called multifocal fibrosclerosis) is an uncommon disease in which there is a systemic overgrowth of fibrous tissues, with a spectrum of aggressiveness ranging from benign retroperitoneal fibrosis to pachymeningitis. We describe the first case of gastric involvement of multifocal fibrosclerosis and its appearance on CT.

Accuracy and significance of computed tomographic scan assessment of hepatic volume in patients undergoing liver transplantation.

BACKGROUND: A small liver volume is considered to be a poor prognostic factor in cirrhosis, often indicative of advanced liver disease. Radiologic assessment of liver volume before liver transplant is routinely performed in many transplant centers. We sought to assess the accuracy and significance of computed tomographic (CT) scanning in hepatic volumetric analysis by correlating CT-derived estimation of liver volume with that of corresponding liver explants. METHODS: A chart review of all patients aged 17 years or older undergoing liver transplant at Mount Sinai Medical Center between 1989 and 1995 was performed. Each patient underwent conventional CT scanning with measurement of liver volume (CTLV). Recipient liver volume (RLV) was defined as weight of liver explant after all attached ligaments, portal structures, and gallbladder were dissected free. Expected liver volume was calculated pretransplant based on age, gender, height, and weight. Patients were categorized into three groups based on etiology of liver disease: (1) hepatocellular (e.g., viral hepatitis, alcohol-related), (2) cholestatic (e.g., primary biliary cirrhosis), and (3) cryptogenic. The ratio of CTLV to RLV was used as a measure of the accuracy of CT volumetric analysis. RESULTS: A total of 579 patients was studied (group 1=376, group 2=139, group 3=64). All three groups were statistically similar with regard to age, prothrombin time and total bilirubin. Median CT liver volume was 1308 ml (range: 338-3847), 1651 ml (range: 641-3861), and 1210 ml (range: 348-2575) in groups 1-3, respectively; median ratio of CTLV to RLV was 1.02 (range: 0.50-2.31), 1.05 (range: 0.52-2.22), and 1.05 (range: 0.50-1.56) for groups 1-3, respectively. When RLV was small, it tended to be overestimated by CTLV. In contrast, when RLV was large, it was often underestimated. Clinical features such as history of esophageal variceal bleed, encephalopathy or ascites, and laboratory data did not influence accuracy of CT volumetric analysis. CONCLUSIONS: CT-derived estimation of liver volume appears to correlate closely with actual weight of liver explant regardless of the etiology of chronic liver disease. With extremes in CT volumetric analysis, actual liver volume tends to be under- or overestimated. For patients with end-stage liver disease, both CT-derived and actual liver volume are greater in cholestatic than in hepatocellular disorders.

Portal vein velocities measured by ultrasound: usefulness for evaluating shunt functioning following TIPS placement and TIPS revision.

BACKGROUND: To assess the usefulness of following portal vein velocities by Doppler ultrasound in evaluating shunt functioning after transhepatic intrajugular portosystemic shunt (TIPS) placement and revision. METHODS: We retrospectively analyzed 39 patients who underwent a TIPS procedure in the preceding 4 years. Portal vein (PV) velocities were measured by Doppler ultrasound before and after TIPS insertion and revision and were correlated with portosystemic gradients (PSG) measured at angiography. RESULTS: Mean PV velocities increased from 18 +/- 6 cm/s before TIPS placement to 50 +/- 21 cm/s (p < 0.001) after TIPS placement, with corresponding decrease of mean PSG from 20 +/- 6 to 8 +/- 3 mmHg (p < 0.001). Mean PV velocities significantly increased from 24 +/- 6 to 43 +/- 14 cm/s after TIPS revision (p < 0.02), with decrease of PSG from 17 +/- 6 to 9 +/- 5 mmHg (p < 0.05). A significant correlation was found between all PV velocities and their corresponding PSG (Spearman r < 0.61, p < 0.001). CONCLUSION: PV velocities significantly correlate with changes in PSG. Following portal vein velocities by ultrasound is useful for early evaluation of shunt functioning following TIPS.

Color Doppler applications in hepatic imaging.

Color Doppler sonography is an important modality in the non-invasive evaluation of the liver. It is commonly used to evaluate vascular changes which accompany cirrhosis. Doppler techniques are also used to evaluate patients who have undergone liver transplantation or transjugular intrahepatic portosystemic shunt (TIPS) placement. This review describes the various applications of color Doppler in hepatic imaging.

Liver transplant rejection: value of hepatic vein Doppler waveform analysis.

BACKGROUND: To determine whether abnormal hepatic vein Doppler tracings can be used to predict liver transplantation rejection. METHODS: A total of 158 hepatic vein Doppler tracings were obtained on 93 postliver transplant patients (63 patients without rejection and 30 patients with biopsy-proven rejection). Hepatic vein Doppler tracings were scored according to an established grading system (0 = normal triphasic waveform, 1 = dampened waveform, with loss of flow reversal, 2 = completely flat waveform). The hepatic vein Doppler tracings were then correlated with biopsy findings. RESULTS: In the group of 63 patients without rejection, 124 Doppler examinations were performed and graded as follows: 0 = 87 (70%), 1 = 31 (25%), and 2 = 6 (5%). In the group of 30 patients with biopsy-proven rejection, 34 Doppler examinations were performed and graded as follows: 0 = 16 (47%), 1 = 14 (41%), and 2 = 4 (12%). The sensitivity of abnormal hepatic vein Doppler tracings for detection of rejection was 53% and the specificity was 70%. The positive predictive value of an abnormal hepatic vein Doppler tracing was 33% and the negative predictive value of a normal Doppler tracing was 84%. CONCLUSIONS: Abnormal hepatic vein Doppler tracings are observed in patients with and without liver transplant rejection. Abnormal tracings cannot be used to predict liver transplant rejection.

Cryotherapy of metastatic carcinoid tumors.

BACKGROUND: To describe the use of hepatic cryotherapy to treat patients with symptomatic carcinoid metastates. METHODS: Hepatic cryotherapy was performed on five patients with carcinoid syndrome resulting from metastatic carcinoid tumors. Intraoperative ultrasound was used to guide the cryotherapy and to assess the adequacy of freezing. RESULTS: All five patients had relief of the carcinoid syndrome after treatment. In four of the five patients, the relief was prolonged (>3 months); in one patient, the relief of symptoms was transient (2 months). Four of five patients had a transient reduction in hormonal tumor markers (the fifth patient did not have hormonal-level follow-up). During a follow-up period of 2.5 years, four of the five patients died. The 6-month survival rate was 80%, the 1-year survival rate was 60%, the 2-year survival rate was 40%, and the 2.5-year survival was 20%. One patient is alive 30 months after treatment. CONCLUSION: Hepatic cryotherapy can provide symptomatic relief for patients with hepatic metastates producing the carcinoid syndrome.

MRI findings in adenosquamous carcinoma of the gallbladder.

In this report, we present the MRI findings of adenosquamous carcinoma of the gallbladder, a rare type of gallbladder malignancy. MRI examination not only helped established the diagnosis but also accurately depicted the extent of involvement of the adjacent liver. The ability to image in multiple planes was also useful in assessing the anatomic location of the tumor and in determining that the patient could be treated with surgical resection.

Avulsion fracture of the sublime tubercle of the ulna: a newly recognized injury in the throwing athlete.

OBJECTIVE: The purpose of this report is to describe the imaging features in three cases of avulsion injury of the sublime tubercle of the ulna that occurred in throwing athletes. CONCLUSION: Avulsion fracture of the sublime tubercle of the ulna is a potential cause of chronic medial elbow pain in the throwing athlete. This entity is best evaluated with a combination of plain radiographs and coronal MR images, particularly gradient-echo images that show the continuity of the avulsed fragment with the ulnar collateral ligament.

MRI of the liver. A pictorial essay.

Magnetic resonance imaging (MRI) is an extremely useful modality for evaluation of the complex pathophysiology of the liver. The high degree of soft tissue contrast afforded by MRI accurately detects and characterizes both focal and diffuse abnormalities of the liver. In this article we present a pictorial review of MRI of the liver.

Scintigraphic monitoring of reticuloendothelial system in patients with type 1 Gaucher disease on enzyme replacement therapy.

UNLABELLED: The purpose of this study was to define the scintigraphic pattern of marrow replacement and changes in reticuloendothelial activity after enzyme replacement therapy in patients with Gaucher disease. METHODS: Forty patients underwent baseline whole-body imaging with 99mTc-sulfur colloid and evaluation of liver and spleen volume with CT or magnetic resonance imaging. Thirty-seven of the 40 patients were treated with enzyme replacement. Therapeutic responses of central and peripheral bone marrow and the changes in pulmonary uptake of 99mTc-sulfur colloid were assessed visually at 1-4 yr after the start of therapy. Changes in liver and spleen volumes were analyzed quantitatively. The initial pattern of marrow involvement was correlated with disease severity (based on baseline blood counts and liver and spleen volumes). RESULTS: Baseline studies revealed that 38 of 40 (95%) and 28 of 40 (70%) of the patients in this study had abnormal peripheral and central marrow activity, respectively. Twenty of 24 evaluable patients (83.3%) on therapy showed regression of peripheral bone marrow activity to a more proximal location in the lower extremities, increased ratio of pelvic/proximal femoral activity to distal activity or both. Fourteen of 19 treated patients (73.7%) with abnormal initial central marrow activity showed detectable improvement in central bone marrow activity as a result of therapy. In patients with initial lung uptake of 99mTc-sulfur colloid, 91% showed complete resolution of the uptake after therapy. These changes in colloid uptake and distribution were associated with significant reductions in liver and spleen volumes and improvements in blood counts. CONCLUSION: Most patients with Gaucher disease demonstrate increased central bone marrow activity and regression of activity in peripheral bone marrow with enzyme replacement therapy. Additionally, the abnormal phagocytic pulmonary activity observed before therapy in many of the patients resolves.

Underassessment of lower extremity deep venous thrombosis using color flow Doppler compared to compression sonography.

The aim of this paper is to compare the accuracy of color Doppler to compression sonography in the diagnosis of lower extremity deep vein thrombosis. Longitudinal color flow imaging was performed in 60 lower extremities in patients with clinically suspected deep venous thrombosis (DVT). The study was then repeated by a blinded examiner using transverse compression sonography. The results were then correlated. Thirty-five examinations were negative by both color flow and compression methods. Twenty thrombi were diagnosed on compression sonography, while only 13 were diagnosed by the color flow method. Thirty-five percent of thrombi were missed using color flow imaging alone. We conclude that compression sonography should remain an integral part of the assessment of lower extremity DVT, as a significant number of thrombi might be overlooked using longitudinal color flow imaging alone. This is especially true in non-occlusive thrombi that are adherent to the vessel wall.

CT appearance of the Syed-Neblett device for interstitial brachytherapy of gynecologic malignancies.

Radiation therapy is an important adjuvant treatment for gynecological malignancies. However, the maximum amount of radiation treatment is limited by the side effects to the normal local tissue. We present a brief summary of the use and appearance of the Syed-Neblett intracavitary device. This device allows delivery of radioactive implants to a local tumor resulting in maximum dosage to tumor tissue, but limiting dosage to the surrounding normal tissue.

CT findings after laparoscopic pelvic lymph node dissection and transperineal radioactive seed implantation for prostatic carcinoma.

OBJECTIVE: The purpose of this paper is to describe the CT findings in patients undergoing transperineal sonographically guided radioactive seed implantation with and without laparoscopic lymph node dissection for treatment of carcinoma of the prostate gland. MATERIALS AND METHODS: Ninety-six CT scans of the pelvis were retrospectively reviewed in patients who had undergone radioactive seed implantation of the prostate gland. The CT readings were correlated with the type of procedure each patient had and the pathologic results of laparoscopic lymph node dissection. RESULTS: Of 73 patients who underwent laparoscopic lymph node dissection, 42 were found at CT to have low-attenuation masses along lymph node chains. These masses resembled necrotic nodes. Only one patient who did not undergo laparoscopic lymph node dissection had similar findings. Fourteen patients had fluid collections within the pelvis, 13 of whom had undergone laparoscopic lymph node dissection. Other imaging findings included ectopic seeds (10 patients) and subcutaneous and intrapelvic air (11 patients). All except two patients had negative pathology reports for the removed lymph nodes. CONCLUSION: A wide variety of imaging findings may be seen after radioactive seed implantation and laparoscopic lymph node dissection, including masses that resemble necrotic lymph nodes. Radiologists should be aware of these findings in asymptomatic patients.

The use of spiral computed tomography in the evaluation of vessel encasement for pancreatic cancer.

CONCLUSIONS: Spiral CT allows for a noninvasive evaluation of the mesenteric arterial and venous vessels. This test can be performed quicker, with less expense, and with a reduced radiation and contrast load than angiography. Comparison studies of angiography and spiral CT are needed in patients with pancreatic cancer to determine the best method of evaluating possible vessel involvement. BACKGROUND: Preoperative imaging of patients with pancreatic cancer is crucial in determining resectability and planning management. Computed tomography (CT) remains the diagnostic procedure of choice for the evaluation of the primary tumor and angiography is the gold standard to evaluate vessel encasement. This case evaluates the usefulness of spiral computed tomography in determining vessel encasement. METHODS: A 53-yr-old female presented with vague abdominal complaints and evaluation revealed a mass in the pancreas. CT suggested portal vein involvement and collateralization was noted in the upper abdomen. Spiral CT revealed normal arterial anatomy and near complete obstruction of the portal vein at the superior mesenteric vein (SMV) splenic vein (SV) confluence. RESULTS: Operative findings confirmed the involvement of the portal vein at the confluence of the SMV and SV. Pancreatico-duodenectomy with portal vein resection and primary anastomosis was performed. The patient's postoperative course was uneventful and she was discharged home on the 13th postoperative day.

Transient false-positive hepatobiliary scan associated with ceftriaxone therapy.

Drug related false-positive hepatobiliary imaging is uncommon. The authors present a case of a 54-year-old woman who was treated with intravenous ceftriaxone for bacterial meningitis. Symptoms of acute cholecystitis subsequently developed and a sonogram revealed a gallstone. A Tc-99m DISIDA hepatobiliary study was positive for cystic duct obstruction. After discontinuation of ceftriaxone, the patient's clinical condition improved and, 2 weeks later, a repeat hepatobiliary scan was normal. High doses of ceftriaxone and prolonged administration may lead to formation of pseudocholelithiasis and signs of acute cholecystitis. Although this condition is usually benign and reversible, discontinuation of the drug is warranted when symptoms of acute cholecystitis are accompanied by a positive hepatobiliary scan.

MRI features in de Quervain's tenosynovitis of the wrist.

De Quervain's stenosing tenosynovitis of the first dorsal extensor component is traditionally diagnosed clinically but may be encountered when performing MRI of the wrist. A retrospective review of wrist MR images was performed in cases where the diagnosis of de Quervain's synovitis was suggested (n = 5). Imaging findings were correlated with clinical findings in four cases and with wrist arthroscopy in one case. Increased thickness of the extensor pollicus brevis and abductor pollicis longus tendons was the most reliable finding on MRI, being present in all cases. Peritendinous edema was also a reliable finding. Surrounding subcutaneous edema and increased intratendinous signal were less reliable findings in confirmed cases of de Quervain's disease. De Quervain's tenosynovitis may be encountered when performing MRI of the wrist. Increased tendon thickness and peritendinous edema are the most reliable imaging findings.

Magnetic resonance appearance in a case of lipoblastomatosis.

Lipoblastoma-lipoblastomatosis represents a rare, benign tumorous proliferation of adipocytes and their mesenchymal precursor cells. Seen almost exclusively in early childhood, it should be considered in the differential diagnosis of any rapidly expanding soft-tissue mass. We present a case of lipoblastomatosis and its magnetic resonance appearance, which has not been previously described.

Transjugular intrahepatic portosystemic shunt: correlation of portal vein velocity measurements and portosystemic pressure gradients.

To assess the relationship between portal vein velocity measurements and portosystemic gradients, color Doppler sonography was performed on 12 patients before and after transjugular intrahepatic portosystemic shunt placement. An additional patient was examined before and after shunt modification. The average maximum portal vein velocity increased from 15.7 cm s-1 before shunt placement to 43.5 cm s-1 after shunt placement, while the average portosystemic gradient decreased from 22.0 mm Hg before shunt placement to 7.9 mm Hg after shunt placement. Flow was observed within the shunt in 11 of the 12 cases. Shunt velocity was measurable in nine patients, with an average value of 115.7 cm s-1. Reversal of intrahepatic portal vein flow was observed in 10 cases following shunt placement. Color Doppler sonography is a useful non-invasive tool in the evaluation of intrahepatic portosystemic shunts, and changes in portal vein velocity correlate well with changes in the portosystemic gradient.

MR appearance of intraocular silicone oil.

A 41-year-old man with AIDS and cytomegalovirus retinitis with retinal detachment was studied with CT and MR. Part of his treatment had been a vitrectomy with intravitreal injection of silicone oil as an attempt to stop further retinal detachment. This form of therapy is being used more frequently and radiologists should be familiar with the imaging appearance of such deposits of silicone oil. In this case the oil was hyperdense to muscle on CT and had a homogeneous intermediate signal intensity on all pulse sequences on MRI.