Implantable Central Venous Port: Comparison between Interventional Radiological Procedure and Surgical Procedure

PURPOSE: We evaluated the results and complications of implantable port placement between the interventional radiological procedure and the surgical procedure. METHODS: From April 2001 to December 2003, 151 implantable ports were placed in 135 patients by an interventional radiologist and 191 ports were placed in 185 patients by a surgeon. RESULTS: The implantable port was successfully placed in all cases. The duration of catheterization was 219.8 days for the interventional radiological procedure and 203.8 days for the surgical procedure. 139 patients underwent port placement via the internal. jugular vein using the peel-away sheath by the interventional radiologist and 163 patients had their ports placed via the external jugular vein cut-down method by the surgeon. Early complications that occurred were pulmonary air embolism (1 case) and hematoma (1 case) for the radiological procedure and catheter malposition (1 case) for the surgical procedure. Late complications that occurred were infection (24 cases), catheter migration or occlusion (6 cases), catheter-related fever (4 cases) for the radiological procedure and infection (7 cases), migration (3 cases), central vein thrombosis (1 case), catheter-related fever (2 cases) for the surgical procedure. CONCLUSION: The safety of the surgical central venous port placement was high and the complication rate was low. In comparison with the interventional radiological procedure, the surgical procedure may be considered as a potentially useful primary procedure for implantable central venous port placement.

A Case of Tuberous Sclerosis with Spontaneous Rupture of Renal Angiomyolipoma / 대한신장학회잡지

Tuberous sclerosis is an autosomal dominant disorder characterized by seizures, mental retardation and hamartomatous tumors in multiple organs, including subependymal giant cell astrocytomas, cortical tubers, cardiac rhabdomyoma, pulmonary lymphangiomyomatosis and renal angiomyolipomas. However, these clinical features are not always present. The following is a report concerning a 30-year-old woman with tuberous sclerosis who suffered a spontaneous hemorrhage into the angiomyolipoma of the kidney and underwent curative selective renal embolization. The patient had a medical history of focal seizures. Moreover, brain magnetic resonance imaging revealed typical signs of tuberous sclerosis, and a high resolution computerized tomography of the chest showed bilateral nodules with irregular margins and multiple thin-walled cystic lesions. There was no family history of renal disease or of tuberous sclerosis. As such, this case exhibited rare clinical manifestations of tuberous sclerosis involving multiple organs.

Implantable Central Venous Chemoport: Comparision of Results According to Approach Routes and Methods

PURPOSE: To evaluate the results and complications of placement of implantable port according to approach routes and methods. MATERIALS AND METHODS: Between April 2001 and October 2002, a total of 103 implantable chemoport was placed in 95 patients for chemotherapy using preconnected type (n=39) and attachable type (n=64). Puncture sites were left subclavian vein (n=35), right subclavian vein (n=5), left internal jugular vein (n=9), right internal jugular vein (n=54). We evaluated duration of catheterization days, complications according to approach routes and methods. RESULTS: Implantable chemoport was placed successfully in all cases. Duration of catheterization ranged from 8 to 554 days(mean 159, total 17,872 catheter days). Procedure related complications occurred transient pulmonary air embolism (n=1), small hematoma (n=1) and malposition in using preconnected type (n=2). Late complications occurred catheter migration (n=5), catheter malfunction (n=3), occlusion (n=1) and infection (n=11). Among them 15 chemoport was removed (14.5%). Catheter migration was occured via subclavian vein in all cases (13%, p=.008). Infection developed in 10.7% of patients(0.61 per 1000 catheter days). There were no catheter-related central vein thrombosis. CONCLUSION: Implantation of chemoport is a safe procedure. Choice of right internal jugular vein than subclavian vein for puncture site has less complications. And selection of attachable type of chemoport is convenient than preconnected type. Adequate care of chemoport is essential for long patency.

Traumatic Intracranial Aneurysms in Children

PURPOSE: To describe the imaging findings of traumatic intracranial aneurysms (TICA) in children. MATERIALS AND METHODS: Five boys aged 3-15 (mean, 7) years with surgically confirmed TICA were included in this study. All had a history of nonpenetrating head trauma, and they underwent precontrast CT imaging immediately after the injury and follow-up CT or MRI. In all cases, angiography revealed the presence of aneurysms, which at surgery were shown to be pseudoaneurysms with severe adhesions. RESULTS: Angiography demonstrated that all aneurysms were located in the anterior cerebral artery (ACA) or its branches. The precise locations were the A2 segment of the ACA, the site of origin of the callosomarginal artery or its first branch, or of the anterior internal frontal artery, or between the first and second branch of the pericallosal artery. In all patients, precontrast CT performed immediately after trauma depicted subarachnoid hemorrhage (SAH) in the anterior interhemispheric fissure (AIHF). Follow-up precontrast CT showed nodular high density around the anterior falx in three, recurrent SAH in the AIHF in two, and intracerebral hemorrhage (ICH) with intraventricular hemorrhage in two. In two patients with a nodular high-density lesion, nodular enhancement was demonstrated at postcontrast CT, and in one, follow-up MRI revealed a nodular signal void around the anterior falx; nodular enhancement was seen at postcontrast imaging, and MR angiogram depicted a saccular aneurysm. In one patient, MRI demonstrated infarction in the caudate nucleus and ACA territory. CONCLUSION: If, after head injury, an area of nodular high density is revealed by CT, or a signal void by MRI, or if SAH or ICH is present around the anterior falx, the possibility of TICA should be considered.

Radiologic Management of Hepatic Arterial Stenosis or Thrombosis Following Liver Transplantation

PURPOSE: To assess the results and usefulness of interventional procedures for hepatic arterial stenosis or thrombosis following liver transplantation. MATERIALS AND METHODS: During the past five years, eight patients aged 1-59 (mean, 39) years among 187 liver transplant recipients showed elevated of liver enzyme levels (AST/ALT) and decreased arterial flow at Doppler ultrasound. Hepatic arteriography revealed luminal stenosis or occlusion at the proper hepatic artery, and six patients, one of whom required thrombolysis before the procedure, underwent percutaneous transluminal angioplasty (PTA) using a balloon. In two with thronbosis, thrombolysis without PTA was performed. In order to increase hepatic arterial flow, four patients underwent additional coil embolization of the gastroduodenal or splenic artery. RESULTS: Hepatic arterial flow recovered in all six patients after PTA. Three required repeat PTA for restenosis and one of these needed stent placement after repeated PTA. At follow-up, 6-17 months later, the three had good hepatic function. Within four days, the other three expired due to graft failure, hepatorenal syndrome and sepsis. One of the patients who underwent thrombolysis without PTA expired and the other required retransplantation. In this case there were no procedure - related complications. CONCLUSION: Radiologic interventions are useful for treatment of hepatic arterial stensis or thrombosis in patients with liver transplantations.

Usefulness of MR Imaging for Diseases of the Small Intestine: Comparison with CT

OBJECTIVE: To evaluate the usefulness of MR imaging for diseases of the small intestine, emphasizing a comparison with CT. MATERIALS AND METHODS: Thirty-four patients who underwent both CT and MR imaging using FLASH 2D and HASTE sequences were analyzed. All patients had various small bowel diseases with variable association of peritoneal lesions. We compared the detectabilities of CT and MR imaging using different MR pulse sequences. The capability for analyzing the characteristics of small intestinal disease was also compared. RESULTS: MR imaging was nearly equal to CT for detecting intraluminal or peritoneal masses, lesions in the bowel and mesentery, and small bowel obstruction, but was definitely inferior for detecting omental lesions. The most successful MR imaging sequence was HASTE for demonstrating bowel wall thickening, coronal FLASH 2D for mesenteric lesions, and axial FLASH 2D for omental lesions. MR imaging yielded greater information than CT in six of 12 inflammatory bowel diseases, while it was equal to CT in six of seven neoplasms and inferior in five of seven mesenteric ischemia. In determining the primary causes of 15 intestinal obstructions, MR imaging was correct in 11 (73%) and CT in nine (60%) patients. CONCLUSION: MR imaging can serve as an alternative diagnostic tool for patients with suspected inflammatory bowel disease, small intestinal neoplasm or obstruction. is a high-speed, heavily T2-weighted sequence with a great sensitivity for fluid (11). This advance may make it possible to use breath-hold turbo spin-echo MR.

CT Staging of Renal Pelvis Tumor

PURPOSE: To assess the value of computed tomography (CT) in the preoperative staging of transitional cellcarcinoma (TCC) of the renal pelvis. MATERIALS AND METHODS: We retrospectively evaluated the CT TNM staging of 38patients with TCC of the renal pelvis who had undergone preoperative abdominal CT examination between January 1990and January 1998. In CT staging for differentiation between early-stage (TO-2) and advanced-stage disease (T3-T4),three criteria were used, namely the presence or obliteration of the renal sinus fat layer, the smoothness orirregularity of margin between the tumor and renal parenchyma, and the presence or absence of hydronephrosisproximal to the tumor. CT staging was performed by two genitourinary radiologists blinded to the pathologicresults, and was compared with pathologic staging. RESULTS: Pathologic results revealed 19 cases of early stagedisease (TO=8, T1=9, T2=2) and 19 of advanced stage (T3=12, T4=7). Overall CT staging accuracy was 82%(31/38);fourcases were overstaged and three were understaged. In early-stage disease, sensitivity and specificity were 79%,and 84%, and in advanced stage disease were 83% and 80%. Three of four overstaged cases showed hydronephrosisproximal to the tumor. In the second CT staging, using proximal hydronephrosis of the tumor as a criterion forearly-stage disease, the sensitivity and specificity of early-stage disease were 95% and 75%, respectively, andthe specificity of advanced-stage disease was 95%. CONCLUSION: When hydronephrosis proximal to a tumor wasconsidered to be a sign of early stage disease, the CT staging of renal pelvic TCC was highly accurate.

MR Findings of Atypical Meningioma: Comparison with Benign Meningioma

PURPOSE: Atypical meningioma is an intermediate type, between benign and malignant meningiomas, and has ahigher recurrence rate and poorer prognosis than the benign type. The purpose of this study was to evaluate thedifferential imaging findings between atypical and benign meningiomas. MATERIALS AND METHODS: Over a five-yearperiod, 11 acses of atypical meningioma (in ten patients) were pathologically proven, and 30 benign meningiomaswere collected consecutively over 6 months. In retrospective analysis, the MR findings of atypical and benignmeningiomas were compared with respect to tumor respect to tumor margin, lobulation, intra-/peritumoralhemorrhage, cystic change, heterogeneity peritumoral edema, enhacement of adjacent meninges, invasion of adjacentvenous sinus and adjacent bony change. RESULTS: Significant differential MR findings between the two groups wereill-defined tumor margin(atypical-27%;benign-0%), lobulation(82%;43%), heterogeneity(73%;30%), and peritumoraledema(100%;47%). With regard to moderate edema, there was no significant difference between the twogroups(36%;23%), and with regard to intra-/peritumoral hemorrhage, cystic change, enhancement of adjacentmeninges, invasion of adjacent venous sinus, and adjacent bony change, MR findings between the two groups were notsignificantly different. CONCLUSION: The MR findings of atypical meningioma are significantly different inseveral ways from those of benign meningioma, and these differences may help differentiate the two types.

The CT of Bowel Obstruction following Abdominal Cancer Operation

PURPOSE: To evaluate the usefulness of CT for determining the causes of intestinal obstruction followingsurgery for abdominal cancer. MATERIALS AND METHODS: CT scans were performed in 54 patients with benign (n = 25)or malignant (n = 29) bowel obstruction after surgery for abdominal malignancies ; the causes of obstruction wereconfirmed pathologically (n = 34) or clinically (n = 20). Three radiologists interpreted the CT scans andevaluated their accuracy, sensitivity, and specificity. Through analysis of CT findings, malignant and benignobstruction was compared with regard to the presence of mass or lymphadenopathy, bowel change, mesenteric change,ascites, and other ancillary findings. RESULTS: In distinguishing malignant from benign obstruction, thediagnostic accuracy achieved by three radiologists was 67%, 74%, and 78%. When there was a mass at the obstructedor prior surgical site, lymphadenopathy, an abrupt transitional zone, or irregular wall thickening at anobstructed site, malignant obstruction was suspected (P < .05) ; in the absence of a mass, CT findings ofmesenteric vascular engorgement, extensive ascites, a smooth transition zone and normal or smooth wall thickeningat the obstructed site suggested benign obstruction (P < .05). The presence of omental infiltration, mesentericinfiltration and metastatic lesions at other sites did not always indicate malignant obstruction. In addition,bowel wall thckness, luminal diameter and the interval between surgery and bowel obstruction were notstatistically significant. CONCLUSION: CT is useful for determining the causes of obstruction following surgeryfor abdominal cancer, though particularly when definite peritoneal mass is not demonstrated this usefulness inlimited.

A Comparative Study of Single and Multiple Hand Tasks Using

PURPOSE: To assess, using functional MRI and by comparing activated motor sensory areas, the independence ofbrain activation during single and alternative multiple hand tasks. MATERIALS AND METHODS: The subjects were sixhealthy volunteers. Using at 1.5T Siemens system and single shot FID-EPI sequencing(T2* weighted image;TR/TE0.96msec/61msec, flip angle 90 degrees, matrix size 96X128, slice thickness/gap 5mm/0/8mm, FOV 200mm) and T1-weightedanatomic images, functional MRI was performed. The paradigm of motor tasks consisted of appositional fingermovements; the first involved the separate use of the right, left, and both hands, while an alternative taskinvolved the use of the right, left, and both hands in sequence. Using cross-correlation method(threshold:0.6) andfMRI analysis software (Stimulate 5.0), functional images were obtained. The activated area of brain cortex, thenumber of pixel, the aberage percentage change in signal intensity, and correlation of the time-signal intensitycurve in the activated motor area were analysed and compared between the two task groups. Statistical analysisinvolved the use of Wilcoxon signed-rank test. RESULTS: It was seen on fMRI that durina both single andalternative motor tasks, the same areas were consistently activated; in four volunteers, most activation occurredin the contralateral primary motor area. Between the two task methods, the average change in the number ofactivated pixels was 12.3+/-5%, but the difference was not statistically significant(P>0.1). Increased signalintensity in the alternative task group(7.48+/-1.22%) was more statistically significant than in the single taskgroup(5.77+/-0.9%)(p<.001). With regard to the time-intensity curve, there was significant correlation between thetwo groups(0.87+/-0.07). CONCLUSION: Brain activation did not differ according to whether the motor task wassingle or alternative. We therefore suggest that during multiple stimuli, the relevant functional areas andneuronal column are activated independently.

Evaluation of Preoperative Embolization of Meningioma

PURPOSE: To evaluate the efficacy and safety of preoperative embolization of intrancranial meningioma. MATERIALS AND METHODS: We retrospectively reviewed intrancranial meningioma patients (n=37) who underwentpreoperative embolization. They were categorized into two groups, skull base lesions (n=22) and non-skull baselesions (n=15), according to tumor location. In addition, embolization results were classified by comparisonbetween pre- and post-embolization angiography as complete (residual tumor staining or= 10 or 30%). In each group, estimated blood loss (EBL) was estimated by amount ofintraoperative transfusion with pre- and post-operative hemoglobin level. Tumor resectability was evaluated byfollow-up computed tomography. New symptoms occurring within 24 hours of embolization were considered to be thoseassociated with embolization ; symptoms improved by conservative treatment were regarded as mild, while thoseresulting in new deficits were considered severe. RESULT: In the group with skull base lesions (n=22), completeembolization with the criteria of residual tumor staining of less than 30% was performed in 14 patients(EBL=1770ml;complete surgical removal in nine patients and incomplete removal four). Incomplete embolization wasperformed in eight patients (EBL=3210ml; complete and incomplete removal each in four patients). In the group withnon-skull base lesions, complete embolization with the criteria of residual tumor staining of less than 10% wasperformed in five patients (EBL=970ml) and incomplete embolization in ten (EBL=2260ml). Complete tumor removal waspossible in this group regardless of the completeness of preoperative tumor embolization. In a case ofintraventricular meningioma (3%), intratumoral hemorrage occurred on the day following embolization. Other mildpost-embolization complications occurred in three cases (8%). CONCLUSION: Preoperative embolization can be aneffective and safe procedure for meningioma and may reduce intraoperative blood loss. Its effectiveness may dependon tumor location and the degree of embolization, though the procedure seems to be helpful for lseions at theskull base.