Right-to-Left Shunts Occur During Cardiopulmonary Resuscitation: Echocardiographic Observations.

OBJECTIVES: A significant proportion of the population has a patent foramen ovale (PFO). The intracardiac pressure during cardiopulmonary resuscitation (CPR) may differ from that of normal circulation, which may result in a right-to-left shunt in the presence of a PFO. In this study, transesophageal echocardiography (TEE) was conducted to evaluate whether CPR carried out in patients after cardiac arrest causes right-to-left shunt. DESIGN: A retrospective observational study. SETTING: One academic medical center from January 2017 to April 2020. PATIENTS: Patients older than 20 years who suffered from nontraumatic out-of-hospital cardiac arrest (OHCA) and underwent intra-arrest TEE. MEASUREMENT AND MAIN RESULTS: Patients who had microbubbles resulting from fluid injection in the right atrium, as indicated on TEE imaging, were included in the analysis. The presence of right-to-left shunt was defined as the appearance of microbubbles in the systemic circulation, including the left atrium, left ventricle, or aorta. A total of 97 patients were included in the final analysis. A right-to-left shunt was observed in 21 patients (21.6%), and no shunt was found in 76 patients (78.4%). The degree of the right-to-left shunt, determined by the number of microbubbles, was mild in 11 patients (52.4%), moderate in eight (38.0%), and severe in two (9.6%). Multivariate analysis showed that no factors were associated with the presence of right-to-left shunt during CPR. CONCLUSIONS: Right-to-left shunts can be appreciated during CPR in patients who experience OHCA. Further studies are needed to verify its clinical significance.

Management of post-gastrectomy anastomosis site obstruction with a self-expandable metallic stent.

Post-gastrectomy anastomosis site obstruction is a relatively rare complication after a subtotal gastrectomy. We present a case of a 75-year-old man who underwent a truncal vagotomy, omental patch, gastrojejunostomy, and Braun anastomosis for duodenal ulcer perforation and a gastric outlet obstruction. Following the 10(th) postoperative day, the patient complained of abdominal discomfort and vomiting. We diagnosed post-gastrectomy anastomosis site obstruction by an upper gastrointestinal series and an upper endoscopic examination. We inserted a self-expandable metallic stent (SEMS) at the anastomosis site. The stent was fully expanded after deployment. On the day following the stent insertion, the patient began to eat, and his abdominal discomfort was resolved. This paper describes the successful management of post-gastrectomy anastomosis site obstruction with temporary placement of a SEMS.

Can thymidine phosphorylase be a predictive marker for gemcitabine and doxifluridine combination chemotherapy in cholangiocarcinoma?: case series.

Unresectable cholangiocarcinoma is poorly responded to chemotherapy, especially for the case refractory to gemcitabine and cisplatin. Here, we tested whether high expression of thymidine phosphorylase (TP) can be a predictive biomarker for the indicator for gemcitabine and doxifluridine combination chemotherapy in the cholangiocarcinoma refractory to gemcitabine and cisplatin. Immunohistochemical staining for TP was performed with a biopsy specimen. We accepted the result as positive when more than 10% of cancer cells were stained with moderate intensity. Here, we report 2 cases of TP-positive cholangiocarcinoma well controlled with gemcitabine and doxifluridine combination chemotherapy, which had been refractory to the first line treatment with gemcitabine and cisplatin combination chemotherapy.

[A case of splenic hamartoma diagnosed by contrast-enhanced ultrasonography and magnetic resonance imaging].

Splenic hamartoma is a very rare benign tumor, which is usually found incidentally after splenectomy or autopsy. Although percutaneous needle biopsy can be performed, it carries a high risk of bleeding after the procedure. Therefore, diagnosis is usually made by surgical resection. Herein, we report a case of splenic hamartoma diagnosed by magnetic resonance imaging and contrast-enhanced ultrasonography, which enables visualization of the unique signals of microbubbles in the vessels in real time. Relevant literature is also reviewed.

Mass and fat infiltration of intercostal muscles measured by CT histogram analysis and their correlations with COPD severity.

RATIONALE AND OBJECTIVES: Chronic obstructive pulmonary disease (COPD) is characterized by progressive respiratory function impairment and respiratory muscle dysfunction. We hypothesized that the mass and fat infiltration of respiratory muscles correlates with COPD severity and emphysema extent. MATERIALS AND METHODS: Ninety-eight male patients with COPD underwent chest computed tomography (CT) and spirometry. The mass and fat infiltrations of intercostal and latissimus muscles were quantified as the cross-sectional area (CSA) and attenuation of these muscles using CT histogram analysis. Intercostal index and latissimus index were defined as intercostal CSAs and latissimus CSAs divided by body mass index. The emphysema extent was measured as the ratio of the emphysematous lung volume to the total lung volume using a density-mask technique. Pearson correlation analyses were performed to evaluate the relationships between these parameters. Multiple regression analysis was performed using forced expiratory volume in 1 second (FEV1) as the dependent parameter and the clinical and CT data as the independent parameters. RESULTS: FEV1 was significantly correlated with intercostal index (r = 0.57), latissimus index (r = 0.34), intercostal attenuation (r = 0.62), and latissimus attenuation (r = 0.38). Emphysema extent was significantly correlated with intercostal index (r = -0.36) and intercostal attenuation (r = -0.50). Multiple regression analysis showed that FEV1 was predicted by intercostal attenuation (B = 0.40), intercostal CSA (B = 0.23), emphysema extent (B = -0.23), and age (B = -0.21, R(2) = 0.64, P < .001). CONCLUSIONS: A decrease in intercostal mass and an increase in intercostal fat are associated with worsening of COPD severity.

Imaging findings of primary malignant gastrointestinal stromal tumor of the liver.

A primary gastrointestinal stromal tumor (GIST) arising in the liver is extremely rare. In our case of GIST, CT and MRI showed a well-defined, weakly enhancing mass with a cystic component in the left lateral segment of the liver that showed homogeneous and avid (18)F-fluorodeoxyglucose ((18)F-FDG) accumulation on positron emission tomography/computed tomography (PET/CT). We herein present a rare case of primary malignant GIST of the liver presenting with peritoneal seeding on CT, gadoxetic acid-enhanced MRI and (18)F-FDG PET/CT.

Fish bone foreign bodies in the pharynx and upper esophagus: evaluation with 64-slice MDCT.

BACKGROUND: Fish bone (FB) is one of the common causes of foreign body impaction in the pharynx and esophagus. PURPOSE: To investigate the efficacy of 64-slice multidetector computed tomography (MDCT) for the evaluation of pharynx and upper esophageal FB foreign bodies. MATERIAL AND METHODS: Sixty-six patients with suspected FB foreign body ingestion were examined by plain radiography (n = 40) and unenhanced MDCT (n = 66). We analyzed the presence, location, size, shape, and lying position of the foreign bodies. RESULTS: On MDCT, 46 foreign bodies were detected. Among them, 45 were confirmed by endoscopy. The sensitivity of MDCT for the detection of foreign bodies was 100%, which was superior to that of the plain radiography (51.7%). The location of the foreign bodies was most common in the upper esophagus (n = 22, 47.8%), followed by pharyngoesophageal junction (n = 10, 21.7%), transjunctional (n = 7, 15.2%), hypopharynx (n = 5, 10.9%), and oropharynx (n = 2, 4.3%). Their longest length was 5.3-40.1 mm (mean, 21.3 mm). Thirty-three FBs (71.7%) were linear and 13 (28.3%) were flat in shape. They showed transverse (n = 23, 50.0%), parallel (n = 13, 28.3%), and oblique positions (n = 10, 21.7%) to the long axis of the pharynx and esophagus, respectively. CONCLUSION: MDCT is useful for the evaluation of the pharynx and upper esophageal FB foreign bodies.

Acoustic radiation force impulse elastography for focal hepatic tumors: usefulness for differentiating hemangiomas from malignant tumors.

OBJECTIVE: The purpose of this study is to investigate whether acoustic radiation force impulse (ARFI) elastography with ARFI quantification and ARFI 2-dimensional (2D) imaging is useful for differentiating hepatic hemangiomas from malignant hepatic tumors. MATERIALS AND METHODS: One-hundred-and-one tumors in 74 patients were included in this study: 28 hemangiomas, 26 hepatocellular carcinomas (HCCs), three cholangiocarcinomas (CCCs), 20 colon cancer metastases and 24 other metastases. B-mode ultrasound, ARFI 2D imaging, and ARFI quantification were performed in all tumors. Shear wave velocities (SWVs) of the tumors and the adjacent liver and their SWV differences were compared among the tumor groups. The ARFI 2D images were compared with B-mode images regarding the stiffness, conspicuity and size of the tumors. RESULTS: THE MEAN SWV OF THE HEMANGIOMAS WAS SIGNIFICANTLY LOWER THAN THE MALIGNANT HEPATIC TUMOR GROUPS: hemangiomas, 1.80 ± 0.57 m/sec; HCCs, 2.66 ± 0.94 m/sec; CCCs, 3.27 ± 0.64 m/sec; colon cancer metastases, 3.70 ± 0.61 m/sec; and other metastases, 2.82 ± 0.96 m/sec (p < 0.05). The area under the receiver operating characteristics curve of SWV for differentiating hemangiomas from malignant tumors was 0.86, with a sensitivity of 96.4% and a specificity of 65.8% at a cut-off value of 2.73 m/sec (p < 0.05). In the ARFI 2D images, the malignant tumors except HCCs were stiffer and more conspicuous as compared with the hemangiomas (p < 0.05). CONCLUSION: ARFI elastography with ARFI quantification and ARFI 2D imaging may be useful for differentiating hepatic hemangiomas from malignant hepatic tumors.

Diffusion-weighted MR imaging of pyogenic intraventricular empyema.

INTRODUCTION: Pyogenic intraventricular empyema (PIE) is a potentially fatal CNS infection. However, it is sometimes difficult to diagnose PIE on the basis of clinical and conventional MRI findings. Diffusion-weighted imaging (DWI) has been accepted as a useful MR sequence for the diagnosis of various intracranial infections. The purpose of this study was to determine the DWI characteristics of PIE and the role of DWI in the diagnosis of PIE. METHODS: Eight patients with PIE underwent MRI including DWI. We assessed the presence and signal characteristics of PIE. In seven patients, the signal intensities of the PIE and cerebrospinal fluid (CSF) were measured and the contrast-to-noise ratio (CNR) percentage was calculated. ADC values of the PIE, CSF, and white matter were also determined. RESULTS: PIE was detected in all patients by DWI, in five (63%) by FLAIR imaging, and in two (25%) by T1- and T2-weighted imaging. The CNR percentages of the PIEs in relation to the CSF were highest for DWI, followed by FLAIR, T1-, and T2-weighted imaging. There were statistically significant differences between the images of each sequence. In all patients, PIE showed hyperintensities on DWI and hypointensities to the CSF and hypo- or isointensities to the white matter on ADC maps. The ADC values (mean+/-SD) of the PIE, CSF, and white matter were 0.60+/-0.27, 2.81+/-0.04, and 0.79+/-0.08 (x10(-3) mm(2)/s). There was a statistically significant difference between PIE and the CSF. CONCLUSION: PIE shows a bright intensity on DWI, and DWI is a sensitive MR sequence for the diagnosis of PIE.