Cavernous haemangiomas (angiomas) of the brain: clinically significant lesions.

A review of 2000 consecutive magnetic resonance imaging (MRI) brain studies identified 18 (0.9%) patients with lesions that satisfied MRI criteria for cavernous haemangiomas. The clinical, computed tomography (CT) and MRI findings in 23 patients with probable cavernous haemangiomas were compared. Thirty-three lesions were identified with multiple lesions in five (22%) patients. In 19 (82%) patients the neurological presentation corresponded to a cavernous haemangioma. The presenting symptoms were: seizures in 11 patients (48%); progressive neurological symptoms and signs in four (17%); and acute symptoms and signs due to haemorrhage in four (17%). T2 weighted images suggested the diagnosis in all cases, with 24 (73%) lesions showing the typical appearance of an area of mixed signal intensity with a rim of low signal intensity. In the absence of acute haemorrhage, CT demonstrated well circumscribed, round or oval hyperdense lesions without significant mass effect and with normal surrounding brain tissue in the majority of cases. Although not diagnostic, these CT features are strongly suggestive of cavernous haemangiomas.

Radiology and the breast.

Mammography should be able to: Detect a high proportion of breast cancers well in advance of any other alternative currently available, and with good positive and negative predictive values. Provide access to impalpable lesions. Offer valuable information in many cases about the tumour, and useful correlation with clinical and pathological findings. Mammography can not: Find all breast cancers. Up to three per cent of even advanced cancers may be missed, especially those of the invasive lobular type. Offer close pathological correlation where the mammographic appearances are indeterminate or non specific. The role of mammography in benign breast disease or the role of radiological modalities other than mammography in the staging and follow up of diagnosed breast cancer has not been discussed. There is nevertheless a mounting excitement within the radiology community that in the absence of useful preventive measures to control the devastating effects of breast cancer, early and accurate diagnosis is the best we can do. The films must be of excellent quality and must be interpreted by experienced people with common sense, an openness to continuing education and a committed desire to do the best for every woman.

The perivertebral collar--a new sign in lymphoproliferative malignancies.

Nine patients with lymphoproliferative malignancies, one of whom had not been previously diagnosed, were found on CT examination for back pain to have partial or complete soft tissue perivertebral collars. The thoracic and or lumbar regions were involved in all. Only 3 had gross bony changes at the time, and in others the changes appeared so innocuous that in combination with the vague clinical symptoms their significance was underestimated. Five patients ultimately had episodes of cord compression, and in all nine the appearance of this spinal lesion appeared to be of grave prognostic significance. All 9 were dead within 1 year of the presentation of their spinal lesions. The observation of a perivertebral collar in the context of a known or suspected lymphoproliferative malignancy should therefore raise the strong suspicion of spinal involvement. The vertebrae should be examined on bone windows and the contents of the spinal canal on narrow windows to assess bony and epidural spread.

Sonographic appearance of plasmacytoma of the testis.

A case of solitary extramedullary plasmacytoma of the testis is presented demonstrating the appearances on ultrasound. The clinical implications of this diagnosis are discussed.

The post therapy breast.

Both systemic and local therapy, for conditions of the breast and unrelated to it, may produce mammographic changes. Some of these are characteristic, such as the pattern of scarring seen in reduction mammoplasty. In many other instances, however, the changes produced overlap features commonly seen in malignancy. A knowledge of the timing, natural history and spectrum of these changes will aid mammographic interpretation.

Reporting: the neglected aspect of the new imaging modalities.

Introduction of the new imaging modalities has led to reports with a high potential information content and the promise of improved pathological correlation. These reports require planning and structure. Key considerations are discussed and a broad outline suggested.

Mammographically indeterminate microcalcifications--can we do any better?

In the first round of the mammographic screening program of the South Australian Breast X-ray Service, 80 (0.73%) of the first 10,848 women screened over 18 months were referred after primary and second-stage assessment for definitive histology because of microcalcifications. Obvious mass lesions associated with calcification were excluded from this study, as were women whose calcification was regarded as sufficiently benign to warrant routine rescreening in two years. After classic patterns of malignant microcalcification were excluded, a large group (75%) remained, whose calcifications fell into the indeterminate grades of radiological suspicion. Of these, only 15% proved to have cancer, and in one third of these the cancer was mammographically occult. A high rate of discordant readings was noted in lesions which ultimately proved benign. Neither family history, distribution of calcification nor the presence of a faint soft tissue density proved to be unfailingly reliable predictors of benign or malignant histology in this group. Vigorous pursuit of histopathological correlation and performance statistics are urged to monitor and minimise the proportion of women who remain in this indeterminate group and to follow their natural history. Current mammographic techniques are still inadequate for the provision of definitive information on microcalcification in all cases, but a sustained commitment will reduce the number proceeding to histology for benign disease.

A review of imaging practice in bone and soft tissue lesions.

Thirty six consecutive bone and soft tissue lesions which were referred to the Bone Transplantation Service between January 1987 and June 1989 were reviewed with respect to the information provided by pre-operative CT, MR and plain X-ray and the final histopathologic diagnosis. The ability of CT and MR to demonstrate cortical destruction, periosteal reaction, a soft tissue mass and soft tissue calcification was scored on a scale of one (low suspicion of abnormality) to four (definite abnormality) in each case. Of the thirty six cases reviewed there were twenty-two histologically confirmed tumours with all of the above three imaging modalities available for comparison. In each of these tumours MR was found to provide an equal or more accurate assessment of soft tissue extent. On a scale of 1 to 4 the average point scores were 3.6 and 2.6 for MR and CT respectively. Little difference was shown between CT and MR with respect to medullary involvement (4.0 points vs. 3.9) and cortical destruction (2.5 points vs. 2.7). CT (3.7 points) was more sensitive than MR (1.2 points) in detecting fine soft tissue calcification. In only five cases did the radiology report correctly nominate the histologic diagnosis and thus the role of imaging was more valuable in staging than diagnosis. For this reason a management oriented report should include comment regarding cortical destruction, the intramedullary extent of tumour and the extent of soft tissue involvement. MR is recommended in the investigation of all suspected malignant soft tissue or bone tumours.

Mammographically detected microcalcifications due to pseudoxanthoma elasticum.

Mammographic detection and analysis of microcalcification is a key component in the detection of early breast cancer. A casting configuration or granular morphology has a strong association with malignancy. These are relatively easily recognised, but with the proliferation of mammographic screening, other varieties of calcification are being encountered which may pose diagnostic dilemmas. This case report describes the findings in a patient with Pseudoxanthoma Elasticum (PXE) who presented in this way. To our knowledge, this has not previously been documented. Such calcification is not usually visible on conventional radiographs.

Fukuyama congenital muscular dystrophy in two Australian female siblings.

The clinical course of two female siblings with congenital muscular dystrophy is briefly described, and includes congenital cerebral malformations consisting of pachygyria, polymicrogyria and white matter abnormalities. The first sibling died in infancy; the second is now 18 years of age. The changes found at autopsy in the first sibling are identical to MRI changes in the surviving sibling.

Magnetic resonance imaging in herpes simplex encephalitis.

Four patients with clinical and serologically proven Herpes Simplex Encephalitis (HSE) were examined by Magnetic Resonance Imaging (MRI) following Computed Tomographic (CT) scans. MRI proved more sensitive at detecting the temporal lobe abnormalities than CT and invariably showed the lesions to be more extensive than suspected. The findings were consistent with an acute inflammatory process. Haemorrhage was present in only one patient. The sharp transition to normal at the lentiform nucleus previously described on CT was present in only one of the four patients, but was observed in a different patient with cerebral lymphoma and no evidence of HSE and is thus concluded to be less specific than previously thought. A repeat MRI scan at seven months on one of the patients showed persisting increased signal on T2 weighted images after resolution of the mass effect. The pathology and suspected mechanisms for the MRI appearances are discussed. MRI is concluded to be a valuable tool in the early diagnosis of HSE and in the longer term for further evaluation of residual disabilities.

Turtleback liver on CT and ultrasound: Schistosoma japonica revisited.

Schistosomiasis in its many forms still presents a major public health challenge. Its tendency to cause dystrophic calcification makes it ideal for radiologic study. With population movement the disease may be encountered in unexpected countries especially with the sensitivity of CT to the presence of calcium. S. japonica produces pathognomonic "turtleback" calcification in the liver, in association with hepatic fibrosis but not necessarily cirrhosis. This paper illustrates a classic case and reviews the literature.

'Dialysis related arthropathy': a survey of 95 patients receiving chronic haemodialysis with special reference to beta 2 microglobulin related amyloidosis.

Ninety five patients receiving chronic haemodialysis (CHD) were surveyed to determine the prevalence of rheumatic disease and, where possible, its aetiology. At least three distinct rheumatic syndromes were identified--a group of patients with a syndrome consisting of large and medium joint synovial swelling, restricted hips and shoulders, tenosynovitis, carpal tunnel syndrome, and bone cysts due to deposition of beta 2 microglobulin related amyloid (AM beta 2m); a second group with erosive azotaemic osteoarthropathy; and a third group with age related degenerative disease of small, large, and axial joints. The data presented suggest that in patients receiving CHD (a) the prevalence of AM beta 2m deposition and the associated syndrome increases with duration of dialysis, but in patients who have been dialysed for more than 10 years the risk of developing AM beta 2m is related to age; (b) AM beta 2m deposition in subchondral cysts, but not synovium, causes joint destruction; also, AM beta 2m may be more prone to deposition in synovium of joints already damaged by other processes; (c) in the absence of synovial iron deposition synovial AM beta 2m is not associated with an inflammatory infiltrate; (d) hyperparathyroidism and perhaps other factors such as synovial iron deposition are probably more important than AM beta 2m as causes of peripheral joint degeneration and destructive spondyloarthropathy in patients receiving CHD.

Mammographic hook wire localization--a step by step guide.

A practical approach to hook wire localization of impalpable mammographic lesions is described, together with hints and potential pitfalls. A standard set of five radiographic projections is outlined. This consists of: 1. The "Right Angle" View 2. The "Needle Placement" View 3. The "Depth Adjustment" View 4. & 5. The "Hook Check" Views Modifications of the technique for more experienced operators are also described. The technique is simple and accurate in many circumstances.

Rationales for the use of intravenous contrast medium in computed tomography.

There are currently many computed tomographic units with differing performance capabilities, resulting in confusion over protocols for contrast medium usage. Additionally, the development of the safer but more expensive low osmolar contrast agents has increased interest in evolving clearer indications for contrast medium usage in C.T. scanning. Rationales for the use of intravenous agents in C.T. scanning are proposed. These include the labelling of normal structures for anatomic clarification, the assessment of perfusion, the characterisation of a specific lesion, CT Angiography, demonstration of defects in the blood brain barrier and the phenomenon of neovascularity. The logical use of contrast agents should involve the deliberate invocation of one or more of these mechanisms coupled with the appropriate technique of administration.

Acute portal vein thrombosis.

The findings in acute portal vein thrombosis in a patient with chronic calcific pancreatitis and two episodes of pancreatic surgery are described. The diagnosis was made by ultrasound, which showed a dilated portal vein filled with low-level echoes, surrounding hepatic oedema, hypertrophy of the hepatic artery, splenomegaly, collateral vessels and ascites. This was confirmed by computed tomography. The ultrasonic differences in appearance between acute and chronic portal vein thrombosis are discussed, in the context of portal hypertension. The diagnosis of acute portal vein thrombosis should be considered in patients in the appropriate situation who suffer a sudden clinical deterioration with right upper quadrant or abdominal pain. Ultrasound is recommended as the imaging modality of first choice because of the flexibility of its scanning plane and its real time and Doppler capabilities. Computed tomography is valuable in patients with an ileus or heavy pancreatic calcification and for its ability to demonstrate patent vessels on intravenous injection of contrast medium.