Mycotic aneurysms in the abdominal aorta and iliac arteries: CT-based grading and correlation with surgical outcomes.

BACKGROUND: Computed tomography (CT) is the modality of choice in the diagnosis of mycotic aneurysms. The present study aimed to classify the CT findings of mycotic aneurysms, and to assess their predictive value based on the correlation of a CT-based grading system with prognostic factors and outcomes. METHODS: Over the past 21 years, 40 consecutive patients underwent open surgery for mycotic aneurysms of the abdominal aorta and iliac arteries in our hospital. The CT appearances of mycotic aneurysms were categorized into four grades: grade 1, periarterial changes without destruction of the arterial wall; grade 2, presence of saccular outpouching; grade 3, extensive retroperitoneal infection; and grade 4, massive perianeurysmal hemorrhage. Clinical data were recorded for analysis. RESULTS: The surgical mortality and overall aneurysm-related mortality rates were 17.5 and 25%, respectively. The poor prognostic predictors were shock, rupture, and concomitant gastrointestinal procedures. The increasing proportions of shock and rupture status corresponded to mycotic aneurysms of higher grades in the CT-based grading. In addition, one patient in grades 1 and 2, versus five in grades 3 and 4 (P = 0.02), required concomitant gastrointestinal procedures. The CT-based grading exhibited a strong association with surgical mortality (Cramer's V coefficient = 0.65; P = 0.002) and a relatively strong association with overall aneurysm-related mortality (Cramer's V coefficient = 0.53; P = 0.01). CONCLUSIONS: For patients surgically treated for abdominal mycotic aneurysms, the CT-based grading is correlated with clinical severity, surgical complexity, and outcomes, and thus it may serve as a simple scale for risk classification.

Intracranial Rosai-Dorfman disease with unusual transcranial extension.

A 48-year-old woman presented with a growing palpable mass at the left frontal area. The imaging studies and histopathological examination of the mass was consistent with dural-based Rosai-Dorfman disease with unusual transcranial extension. We reported this case not only because of its rarity, but also because of the infiltrative pattern. The infiltrative nature presented in this case may be taken into consideration for surgical treatment of intracranial Rosai-Dorfman disease.

Spontaneous hemorrhage within the neck of a neurofibromatosis type 1 patient.

BACKGROUND: Spontaneous arterial bleeding in patients with type 1 neurofibromatosis is uncommon. It can be fatal if not recognized and treated in a timely manner. OBJECTIVES: Diagnose and treat an uncommon complication in type 1 neurofibromatosis. CASE REPORT: We report a patient with type 1 neurofibromatosis who bled spontaneously from a pseudoaneurysm arising from a branch of the left thyrocervical artery. The patient was successfully treated with endovascular therapy. CONCLUSION: Due to the high fragility of involved vessels in patients with type 1 neurofibromatosis, emergent angiography and endovascular therapy should be undertaken without delay, regardless of the presence or absence of contrast extravasation on computed tomography scan.

Intramural blood pools accompanying aortic intramural hematoma: CT appearance and natural course.

PURPOSE: To evaluate multidetector computed tomographic (CT) images to investigate the prevalence, morphology, natural course, and prognostic effect of intramural blood pools (IBPs) in patients with acute intramural hematoma (IMH). MATERIALS AND METHODS: Institutional review board approval and written informed consent were obtained. Sixty-five patients (41 men; mean age, 65.9 years ± 11.3 [standard deviation]) with acute IMH undergoing three or more multidetector CT examinations during follow-up for 12 months or longer (median = 18 months), except for those undergoing surgery (n = 16), were enrolled. Associated factors of developing and resorption of IBP in IMH were analyzed by using logistic regression. RESULTS: There were 40 IBPs in 10 patients at initial multidetector CT, and 15 new IBPs developed in 11 patients during follow-up. IBPs occurred most in the descending thoracic (55% [31 of 56]) and abdominal (41% [23 of 56]) aorta in 28% (18 of 65) of patients. During 33.8 months (range, 2.8-50 months) of follow-up in these 18 patients, 57% (32 of 56) of IBPs showed complete resorption in 15 patients, 29% (16 of 56) of IBPs showed incomplete resorption in eight patients, and 14% (eight of 56) of IBPs had interrupted follow-up because of surgery or death in three patients. Logistic regression showed that age younger than 70 years (odds ratio [OR], 8.74; 95% confidence interval [CI]: 1.03, 76.9) and IMH wall thickness greater than 10 mm (OR, 4.93; 95% CI: 1.04, 23.0) were associated with developing IBP at initial multidetector CT, while IBP with larger transmural diameter (OR, 1.16; 95% CI: 1.02, 1.31) and multidetector CT-demonstrated connection with intercostal or lumbar artery (63% [35 of 56]) (OR, 5.44; 95% CI: 1.43, 20.9) were associated with incomplete resorption. CONCLUSION: IBPs are frequently observed at multidetector CT in patients with IMH. They may resolve over time or appear during follow-up. These findings are not associated with a poor prognosis, and IBPs should be distinguished from ulcerlike projections.

Congenital left ventricular diverticulum in a patient with coronary artery disease.

Congenital ventricular diverticulum is rare. We present the case of a 76-year-old man who underwent cardiac multidetector computed tomography (MDCT) for recent intermittent chest pain. Obstructive single-vessel coronary artery disease was diagnosed. A left ventricular diverticulum of about 10 x 9 mm was found incidentally. Conventional angiography confirmed both diagnoses. Ventricular diverticulum may be more frequently found in the era of cardiac MDCT and should be differentiated from postinfarct (pseudo)-aneurysm.

Fluoroscopic guidance of retrograde exchange of ureteral stents in women.

OBJECTIVE: The purpose of this study was to review our experience with fluoroscopically guided retrograde exchange of ureteral stents in women. MATERIALS AND METHODS: During a 48-month period, 28 women (age range, 38-76 years) were referred to our department for retrograde exchange of a ureteral stent. The causes of urinary obstruction were tumor compression in 26 patients and benign fibrotic stricture in two patients. A large-diameter snare catheter (25-mm single loop or 18- to 35-mm triple loop) or a foreign body retrieval forceps (opening width, 11.3 mm) was used to grasp the bladder end of the stent under fluoroscopic guidance. The technique entailed replacement of a patent or occluded ureteral stent with a 0.035- or 0.018-inch guidewire with or without the aid of advancement of an angiographic sheath. RESULTS: A total of 54 ureteral stents were exchanged with a snare catheter in 42 cases or a forceps in 12 cases. One stent misplaced too far up the ureter was replaced successfully through antegrade percutaneous nephrostomy. Ten occluded stents, including one single-J stent, were managed with a 0.018-inch guidewire in three cases, advancement of an angiographic sheath over the occluded stent into the ureter in five cases, and recannulation of the ureteral orifice with a guidewire in two cases. No complications of massive hemorrhage, ureter perforation, or infection were encountered. CONCLUSION: With proper selection of a snare or forceps catheter, retrograde exchange of ureteral stents in women can be easily performed under fluoroscopic guidance with high technical success and a low complication rate.

Coronary arterial calcification on low-dose ungated MDCT for lung cancer screening: concordance study with dedicated cardiac CT.

OBJECTIVE: Coronary artery calcification (CAC) is frequently detected on low-dose ungated MDCT performed for lung cancer screening. We aimed to determine the concordance of CAC scores on low-dose ungated and regular-dose ECG-gated MDCT. SUBJECTS AND METHODS: The subjects were 513 patients consecutively registered for health screening and undergoing both low-dose ungated (120 kVp, 20 mAs) and regular-dose ECG-gated MDCT (120 kVp, 150 mAs, retrospective ECG gating). The first 30 cases were used for protocol optimization and a training session. Agatston score on regular-dose ECG-gated and low-dose ungated MDCT in the other 483 cases (320 men; mean age, 62.2 +/- 13.2 [SD] years) was calculated by two observers in a blinded manner. Interobserver and intertechnique scoring variability and concordance were calculated. RESULTS: The mean of interobserver scoring variability for regular-dose ECG-gated MDCT was 3.6% and for low-dose ungated MDCT was 9.6%. Regular-dose ECG-gated MDCT depicted CAC in 221 (46%) of the subjects. With low-dose ungated MDCT, observers 1 and 2, respectively, had five and seven false-positive and five and four false-negative predictions. All the miscategorized scores were 12 or less. The negative predictive values of CAC on low-dose ungated MDCT were 98% and 99% for observers 1 and 2, respectively. For patients with CAC, the mean intertechnique scoring variability was 40-43%. For all 483 subjects, the intertechnique concordance of the four major score ranks (0, 1-100, 101-400, > 400) was high (kappa = 0.89 for the two observers). CONCLUSION: Low-dose ungated MDCT with an optimized protocol is reliable for prediction of the presence of CAC and categorization of the four major Agatston score ranks. This technique may be useful for coronary artery disease risk stratification of persons undergoing low-dose ungated MDCT for lung cancer screening.