US appearance of partial-thickness supraspinatus tendon tears: Application of the string theory. Pictorial essay.

The supraspinatus tendon is composed of 5 different layers consisting of intertwining bundles. On a front portion of the tendon, the layers become coated bundles which insert on the trochanter. At the insertion, the superficial or bursal surface of the tendon corresponding to the tendon fibers in contact with the subacromial bursa can be distinguished from the deep surface corresponding to the fibers in contact with the glenohumeral joint. A tendon tear may involve partial or total disruption of the tendon fibers and is called full-thickness tear if it affects the entire tendon, and partial-thickness tear if it involves only part of the tendon. Partial-thickness tears of the supraspinatus tendon include lesions of the superficial, deep and central surface or tendon delamination.A contrast enhanced examination requires injection of contrast agent into the joint (arthrography followed by computed tomography (CT) or magnetic resonance imaging (MRI)) to study the deep surface, and injection into the subacromial bursa (bursography followed by CT) to study the superficial surface. MRI and ultrasound (US) examination allow the study of these different tendon layers without the use of contrast agent (which is not possible at CT).

[Harmonic sonography of rotator cuff tendons: are cleavage tears visible at last?]. / Echographie des tendons de la coiffe en mode harmonique: les clivages sont-ils enfin visibles?

PURPOSE: For some, cleavage tears remain a pitfall of sonography (US). The purpose of this study is to demonstrate the visibility of intratendinous tears of the supraspinatus and infraspinatus tendons and describe their imaging features on tissue harmonic US. MATERIALS AND METHODS: Prospective study of 52 patients with suspected cuff pathology who underwent US prior to CT-arthrography, CT-bursography or MR arthrography. The US examinations were performed using 7-15 MHz transducers with tissue harmonic mode (pulse subtraction). An intratendinous tear was suggested by the presence of a hypoechoic intratendinous line, extending from a partial or full thickness tear. Results from US were correlated to contrast material enhanced CT or MR findings. RESULTS: Ten cases of cleavage tears were detected on US compared to 18 on arthrographic examinations. False negative results occurred in poor US candidates (n=4), excessively retracted tendons (n=2) or postsurgical cuffs (n=2). Sensitivity was 55% and specificity was 94%, with PPV of 83% and NPV of 80% for the detection of intratendinous tear. The accuracy of US was lower for intratendinous tear associated with full thickness tears (5/11) compared to intratendinous tears associated with partial thickness tears (5/6). CONCLUSION: We demonstrate that cleavage tears are now visible on US using high-frequency transducers and tissue harmonic mode. However, the sensitivity remains too low, especially in patients with full thickness tear, postsurgical patients and patients that are poor candidates to US.

[Hyperechoic rotator cuff tendon tear]. / Ruptures hyperéchogènes de la coiffe des rotateurs.

PURPOSE: To describe unusual rotator cuff tendon tears which are hyperechoic at ultrasonography (US). MATERIALS AND METHOD: We retrospectively reviewed the shoulder US examinations of 100 patients with rotator cuff tear demonstrated by CT arthrogram with bursography. We included in this study hyperechoic foci without surrounding hypoechoic zone. A second US examination was performed after bursal distension. RESULTS: Six (6%) hyperechoic foci were detected. The initial US diagnosis was tendinosis in five cases (n=5) and full thickness tear in one case (n=1). At repeat US examination, the hyperechoic area was completely or partially hypoechoic, probably because the tears were filled with the injected hypoechoic fluid. CONCLUSION: Some rotator cuff tears, filled with fibrinoid fragments, are probably underdiagnosed at US.

Ultrasound investigation of the rotator cuff after computed arthrotomography coupled to bursography.

OBJECTIVES: To evaluate the diagnostic performance of ultrasound rotator cuff imaging after injection of contrast medium into the glenohumeral joint and subacromial bursa. PATIENTS AND METHODS: Twenty-eight patients underwent ultrasonography before and after injection into the glenohumeral joint and subacromial bursa of a mixture of iodinated contrast medium and lidocaine solution. Findings were compared with those from computed tomography of the joint and bursa. RESULTS: Sixteen 16 (16/28, 57%) post-contrast ultrasound scans revealed or confirmed rotator cuff lesions. For supraspinatus and infraspinatus lesions, there were three false-negatives and no false-positives. Three false-negatives were recorded for subscapularis lesions. All false-negatives occurred both before and after the contrast medium injections. CONCLUSION: Injecting contrast medium into the glenohumeral joint and subacromial bursa improves the diagnostic yield of rotator cuff ultrasonography. We suggest that ultrasonography be performed after injections of drugs into the shoulder structures, particularly the subacromial bursa.

Rotator cuff imaging using bursography coupled to helical computed arthrotomography.

OBJECTIVE: To describe a rotator cuff imaging method with high sensitivity for the detection of partial tears of the superficial surface of the rotator cuff. PATIENTS AND METHODS: 33 patients with shoulder pain and no conventional arthrography evidence of a full-thickness rotator cuff tear were investigated by bursography coupled with helical computed arthrotomography. Nine subsequently underwent surgery or bursoscopy. RESULTS: Helical computed arthrotomography disclosed an abnormality of the superficial surface of the rotator cuff in 15 patients (45.5%). In the nine patients who had surgery or bursoscopy, findings from this investigation were consistent with those from bursography plus helical computed tomography. CONCLUSION: Bursography coupled with helical computed tomography may be of assistance for the diagnosis of lesions of the superficial cuff surface, which often escape detection by ultrasonography and magnetic resonance imaging.

[Aorto-arteriography of the lower limbs using carbon dioxide]. / Aorto-artériographie des membres inférieurs au gaz carbonique.

OBJECTIVES: Carbon dioxide is often used as a contrast medium for angiocardiography and has recently been proposed for peripheral arteriography. We therefore evaluated this method of opacification in comparison with iodine medium. METHODS: From December 1992 to February 1993, arteriographies using carbon dioxide contrast medium were performed in 13 patients (age range 57-83) with severe arteriopathies requiring revascularization: 2 aorta plus renal arteries, 2 aorta plus iliac and lower limb arteries, 9 lower limb arteries only. The intraarterial injections of carbon dioxide were delivered rapidly (< 20 sec) at a rate of 30 cm3/s (50 cm3/injection) for the aorta and 10-15 cm3/s (15-60 cm3/injection) for peripheral arteries. In 8 of the patients, control arteriographies were performed with iopamidol. RESULTS: The injections of carbon dioxide were well tolerated being painless in 12/13 patients. Digital subtraction images were satisfactory in 6, mediocre but conclusive in 5 and poor in 2. Images of distal arteries were the most difficult to interpret and images of the aorta were generally good. The low viscosity of carbon dioxide allowed the use of small 4F catheters. CONCLUSIONS: Carbon dioxide can be routinely used as a contrast medium, notably in diabetic patients, patients with renal impairment and those who are allergic to iodine based compounds.

[Treatment of diabetic arteriopathy. Importance of transluminal angioplasty]. / Le traitement des artériopathies diabétiques. Intérêt de l'angioplastie transluminale.

Results are reported of a retrospective analysis of transluminal angioplasty (TLA) interventions in 20 diabetic patients, 16 men and 4 women, mean age 56 years (range 32 to 82 years), with 24 dilated lesions, 16 patients having insulin-dependent diabetes. In 12 cases the lesions were at the intermittent claudication stage, trophic lesions being present in 8 cases. Stenotic lesions were iliac (12 cases), superficial femoral (2 cases), popliteal (6 cases) and tibial (4 cases). One patient developed an acute occlusion following popliteal-anterior tibial recanalization, the only direct complication of the angioplasty. Angiography showed immediate satisfactory results in 22 of the 24 dilated lesions. Functional and hemodynamic improvement was a constant finding in patients with intermittent claudication, trophic lesions being healed in 4 cases (50%) the other patient showing either no change or requiring an unavoidable amputation (2 cases). These overall findings suggest that at the intermittent claudication stage no differences exist in the results of TLA when compared with a non diabetic population; inversely, in the presence of trophic disorders, the local conditions (distal bed, infection, gangrene) interfere considerably in the course of the dilatation. Transluminal angioplasty should therefore be carried out as early as possible in diabetics; arteriography should be performed as soon as even minimal claudication appears and, a fortiori, even at the onset of a trophic lesion.

[Isolated dissecting aneurysm of the superior mesenteric artery. Dysplasia, a rare cause of mesenteric ischemia. Report of a case]. / Dissection isolée de l'artère mésentérique supérieure. La dysplasie, une cause rare d'ischémie mésentérique. Une observation.

We report a case of successful surgical revascularization of the superior mesenteric artery in a patient presenting with intestinal ischaemia due to fibrodysplasia. This is a rare pathology, with 5 cases operated in our institution and only 16 cases reported in the literature. Angiography may show other sites of arterial dysplasia. In such cases, success depends on early surgical revascularization.

[True and false popliteal artery entrapment in sportsmen]. / Vraie et fausse artére poplitée piégée chez les sportifs.

Popliteal artery entrapment and its various anatomical type I, II, III and IV has been perfectly described in previous studies. The only test that diagnoses true entrapment due to an anatomical abnormality in the course of the popliteal artery, where it is tied by an embryonic anomaly, is passive dorsiflexion of the foot on the extended leg the deviation then observed at ultrasonography and angiography and the disappearance of downstream signal at doppler examination are pathognomonic. Ultrasonography, computerized tomography (CT) and, more recently, nuclear magnetic resonance (NMR) provide detailed information on the abnormality: separation of the artery from the vein by a muscular bridge is the hallmark of true popliteal entrapment. On the other hand, there is a functional pathology due to dynamic compression of the popliteal artery by the medial gastrocnemius muscle, which raises difficult diagnostic and therapeutic problems, especially in high-level sportsmen for whom the leg muscle activity is very important. In these subjects with a developed muscular mass the medial gastrocnemius muscle crushes the popliteal artery against the femoral condyle without deviation of the artery, particularly in active dorsiflexion and activity hyperextension of the foot on the extended leg. In such case, the popliteal artery and vein remain close to each other, as demonstrated by ultrasounds, CT and NMR. True popliteal artery entrapment can be cured by surgery with subsequent resumption of sporting activities, but whether false entrapment must be operated is difficult to decide. Surgery has been performed with success in some cases of highly disabling false entrapment due to compression of the artery by the medical gastrocnemius muscle.(ABSTRACT TRUNCATED AT 250 WORDS)

[Study of the circle of Willis with digital angiography. Contribution to the detection of high-risk carotid clamping]. / Exploration du polygone de Willis par angiographie numérisée. Apport au dépistage des clampages carotidiens à risque.

Radiological studies of Willis' circle morphology are mainly performed in search of intracerebral aneurysms, and for this purpose digital imaging has not superseded conventional radiology. In contrast, conventional imaging does not seem to have given satisfactory results in the functional study of this substitute vascular network, and it is in this field that digital angiography is of particular value. Between January, 1985 and June, 1986, we performed 300 digital angiographies of the supra-aortic vessels in patients with carotid artery stenosis. Each exploration included a stage of investigation for intracranial substitute vessels by compression of the carotid artery on the side of the lesion. Substitute vessels were found to be adequate in 93 p. 100 of the cases. The test showed that there was no alternative blood flow in 3.7 p. 100 of the cases, which made it imperative to use brain protection measures during clamping of the carotid artery. The substitute network was found to be insufficient in 1 p. 100 of the cases, and the method failed in 2.4 p. 100.

[Preoperative assessment of clamping in carotid artery surgery and adaptation of the operative technic]. / Appréciation pré-opératoire du risque de clampage dans la chirurgie carotidienne et adaptation de la technique opératiore.

A retrospective study of 150 consecutive patients undergoing revascularization of internal carotid artery for atheromatous lesion of carotid bifurcation, included analysis of collaterals being compressed by common carotid artery simulating clamping. Two exploratory procedures had been applied routinely: global suprasigmoid digital subtraction angiography and Doppler velocimetry. Two groups of patients could be defined: clamping without risk (95.4%) and clamping at risk (4.6%). For the group of clamping at risk a surgical strategy is proposed allowing clamping without shunt by bypass between subclavian and internal carotid arteries of by bypass between common and internal carotid arteries because of the external carotid artery collaterals left untouched. A shunt is only necessary when the latter artery is occluded. Results of this series of patients explored in this way and operated upon confirmed these data: no clamping accident in the 1st group, one transient ischemic accident in the 2nd.

Long term follow-up of 43 pure dural arteriovenous fistulae (AVF) of the lateral sinus.

Forty-three patients with arterio-venous fistulae of the dura of the transverse sinus with a complaint of tinnitus are reviewed, with a follow-up of 12 months to 11 years. 34 patients were embolized, 2 treated surgically, and 7 were untreated. Embolization appears to have been beneficial. The frequently benign nature of this abnormality must be emphasized, and serious psychological study of the patient must be made before deciding on therapy.