Pedicle involvement on MR imaging is common in osteoporotic compression fractures.

BACKGROUND AND PURPOSE: Pedicle involvement on MR imaging has been considered specific for malignancy. However, we also noted the findings in many patients with osteoporosis and hypothesized that it is not specific for malignant lesions. The aim of this study was to evaluate the prevalence of pedicle involvement in painful osteoporotic compression fractures and to determine whether the sign is specific for malignancy. MATERIALS AND METHODS: We retrospectively reviewed MR images and CT scans of 152 patients who underwent PV for painful compression fractures. There were 140 patients (225 vertebrae) with osteoporotic fractures and 12 patients (19 vertebrae) with malignant fractures. Three radiologists evaluated the degree and extent of signal-intensity changes of the pedicle on MR imaging by consensus. The CT findings were also evaluated. The chi(2) test was used for statistical analyses. RESULTS: Of the 225 vertebrae of osteoporotic fractures and 19 vertebrae of malignant fractures, pedicle involvement on MR imaging was seen in 144 (64%) and 16 (84.2%) vertebrae, respectively, and there was no statistically significant difference (P = .065). Positive pedicle involvement in osteoporotic fractures was seen in 84 (77%) of 109 vertebrae with early-phase fractures (< or =3 months) and 60 (51.7%) of 116 vertebrae with chronic-phase fractures (>3 months), and this was statistically significant (P < .001). Among 144 osteoporotic vertebrae that showed positive pedicle involvement on MR imaging, 45 (31%) showed pedicle fractures and 55 (38.2%) showed sclerotic change on CT. CONCLUSIONS: Pedicle involvement was seen frequently in patients with osteoporotic compression fractures and was not specific for malignancy in our study group.

MR imaging of clear cell carcinoma of the ovary.

Magnetic resonance imaging findings are reported for 12 pathologically proven lesions of clear cell carcinoma (CCC) of the ovary in 11 women (mean age 50 years). T1- and T2-weighted MR images were obtained in all patients, and gadolinium-enhanced MR images were obtained in 9. The mean diameter of the tumors was 13 cm. Seven patients presented with stage-I tumors. All 12 lesions consisted of cystic masses with solid protrusions occurring in 10 and solid masses in 2. The cysts were unilocular in 9 lesions and multilocular in 1. In four lesions, the cysts displayed with high intensity on T1-weighted images. Round solid protrusions were identified in 8 lesions. In 5 lesions, the number of protrusions was only a few. The solid portions of 5 masses had slightly high-intensity regions on T1-weighted images. The number of patients with ascites was three. Magnetic resonance imaging of CCC usually shows a unilocular large cyst with solid protrusions, which are often round and few in number. Such MR imaging findings suggest malignant tumor but are not specific.

Effect of portal hypertension caused by chronic high venous pressure on small-intestinal sugar absorption.

The effect of portal hypertension and chronic high venous pressure on the absorption of the small intestine was examined by constricting the suprahepatic and subdiaphragmatic inferior vena cava in rats. A group of rats with the constricted suprahepatic and subdiaphragmatic inferior vena cava comprised group 1 (n = 9) and another group of rats with only laparotomy comprised group 2 (n = 9). Two months after the operation, sugar absorption and other parameters were measured. The blood pressures of the infrahepatic inferior vena cava and the portal vein 8 wk after the operation in group 1 were significantly higher than those in group 2. The results of D-xylose absorption tests showed that the amount of excreted D-xylose in urine in group 1 was significantly lower than that of group 2, but the D-xylose everted sac test showed no significant differences between the two groups. The glucose everted sac test showed that the amount of glucose absorption in group 1 was significantly lower than that in group 2. These findings suggest that chronic high venous pressure caused by constriction of suprahepatic inferior vena cava may lead to sugar malabsorption. We conclude that portal hypertension with high venous pressure below the diaphragm can lead to sugar malabsorption in the intestine.

[1H-NMR spectroscopy of a patient with pachygyria].

1H-NMR spectroscopy was performed on a 6-month-old boy with pachygyria. A MRI study demonstrated an abnormally thick cortex localized in the right occipital lobe. 1H-NMR spectrums were collected from the lesion and the contralateral cortex that appeared normal on MRI. The N-acetylaspartate (NAA)/Cre (creatine) ratio was markedly lower in the abnormal cortex than in the contralateral cortex and the occipital cortex. NAA localizes to neurons, axons, dendrites and synaptic connections and increases with maturation of neurons. Its decrease is considered to represent the decrease in the number of these structures and/or disturbance of neuronal maturation. We conclude that NAA/Cre can be an important index that reflects the pathogenesis of pachygyria.

[Surgical outcome of aortic arch aneurysm in the institutes registered with Tokai Cardiovascular Surgeons Conference].

In aortic arch replacement, cerebral protection has been achieved by means of deep hypothermia associated with complete circulatory arrest, selective cerebral perfusion (SCP), or retrograde cerebral perfusion (RCP). We describe our results of the investigation with questionnaire to the institutes registered with the Tokai Cardiovascular Surgeons Conference in 1994. In 23 institute, surgical procedures of aortic arch were performed for 333 cases from 1989 to 1994, which were consisted of 126 cases of true atherosclerotic aneurysm and 206 cases of dissecting aneurysm. Cerebral disorders occurred in 11% (37/333). The incidence of cerebral disorders was significantly higher in patients with RCP methods (16%, 18/111), than SCP method (7%, 15/204, p < 0.05). In patients who had dissecting aneurysm, the incidence of cerebral disorders was 6% with SCP method (7/126) and 21% with RCP methods (14.66), respectively (p < 0.05). The cerebral disorders with RCP methods were most frequently caused by the malperfusion. In atherosclerotic cases, the causes of the cerebral disorders were mainly the embolic disorders.

Detection of myocardial ischemic injury during simple cold storage by measurement of myocardial electrical impedance.

The purpose of this study was to determine if graft viability during simple cold storage can be monitored from alteration of myocardial electrical impedance. Six anesthetized dogs underwent rapid cardiac extirpation and were placed in simple cold storage in saline for 12 hours. Myocardial electrical impedance was measured serially by use of a LCR meter and the changes of myocardial resistivity analyzed. Myocardial specimens were taken for myocardial ATP analysis and electron microscopic study during preservation. We investigated the correlation between myocardial resistivity and myocardial ATP content. Moreover in order to predict cardiac function after simple cold storage in saline, heterotopic cardiac transplantation in the neck was performed in mongrel dogs and left ventricular Emax (LV Emax) was measured with a micromanometer and conductance catheter method. It was then investigated whether or not it is feasible to predict cardiac function of the graft afer reperfusion from the changes in myocardial resistivity. Myocardial ATP remained above 50% of preischemic value 4 hours after preservation. Ultrastructural alterations of ischemia were observed in hearts preserved for 8 and 12 hours. In heterotopic cardiac transplantation, LV Emax at 120 minutes after reperfusion recovered to 94 +/- 13% of preischemic function in 4 hour-preserved heart, 72 +/- 10% in 8 hour-preserved heart. Percent recovery of LV Emax in the former was significantly higher than that in the latter (p<0.05). Turning points from reversible conditions to irreversible ones were between 4 and 8 hours based on myocardial ATP content, cardiac function after transplantation and morphological changes. With the time of preservation, resistivity began to increase in every dog and peaked during preservation. The time required to reach the peak point of resistivity ranged from 4 to 5.5 hours. Resistivity increase rate (RIR) decreased gradually during preservation and it was over 0.1 omega cm/min until a half-life of ATP. These results suggested that measurement of myocardial electrical impedance in the preserved heart should be feasible as an indicator of graft viability during preservation in heart transplantation.

[A surgically treated case of ruptured true aortic arch aneurysm in association with Stanford type A chronic dissection].

A 72-year-old woman was admitted to our hospital because of hemosputum. Enhanced CT showed ruptured true aortic arch aneurysm. True aortic arch aneurysm ruptured at distal portion of aneurysm. The aorta was chronically dissected from an entry proximal to ruptured portion, to ascending aorta. Ascending aorta to aortic arch was replaced with 20 mm gelatin sealed graft under selective cerebral perfusion with hypothermia. Post-operatively tracheostomy was done because of respiratory failure, and there was some leak from distal anastomosis portion which was 42 mm in diameter at the operation. So replacement of descending thoracic aorta was performed using elephant trunk of the previously replaced graft. Post-reoperative course has been uneventful. She weaned from respiratory support. True aortic arch aneurysm combined with Stanford type A dissection is very rare. We presented ruptured true aortic arch aneurysm in association with Stanford type A chronic dissection which had an entry in true aneurysm.

[Coronary artery bypass grafting in cases with the atherosclerotic ascending aorta].

Among 172 cases of coronary artery bypass grafting, 9 cases (5%) revealed severely atherosclerotic ascending aorta. In 3 of the 9 cases, total aortic cross-clamping in the distal anastomoses of saphenous vein graft (SVG) and partial aortic clamp in the proximal anastomoses of SVG were performed. In 1 case with this technique, cerebral infarction was occurred. In 4 cases, total aortic cross-clamping in the distal and proximal anastomoses of SVG was performed. In 2 of these cases with this technique, cerebral infarctions were occurred. Hypothermic circulatory arrest was performed in 2 of the rest. In one case that was predicted to have atherosclerosis of ascending aorta prior to operation, the left internal thoracic artery was anastomosed to the left anterior descending, and SVG to the right coronary artery with hypothermia and ventricular fibrillation. And during the proximal anastomoses of SVG, hypothermic circulatory arrest without aortic clamping was initiated. In another case, atherosclerosis of ascending aorta was noted after aortic cross-clamping. Then the aorta was declamped, hypothermic circulatory arrest was established, the aorta was opened, the diseased segment was resected, and proximal anastomoses of SVG was performed to Dacron patch which was implanted for aortic wall. There were no cerebral infarction in last two patients.

[Treatment of patients with chronic dissecting aortic aneurysm (DeBakey type IIIb) presenting with compromised renal perfusion].

We reviewed our experience for 6 patients of chronic dissecting aortic aneurysm (DeBakey type IIIb) with the false lumen extending into the abdominal aorta and the renal arteries being perfused from the false lumen. In three cases, whose abdominal aorta presenting with large aneurysmal lesions, we performed graft replacement of the thoracic descending aorta and abdominal aorta simultaneously. In other three cases, whose abdominal aorta presenting without aneurysmal lesions, and moreover age advanced or perioperative conditions poor, we performed graft replacement of thoracic descending aorta, using double barreled distal anastomosis technique to ensure of enough blood flow into both true and false lumens. All patients survived and there were no early postoperative complications. In 3 cases of thoracic aortic replacement alone, the mean follow-up term was 38 months, postoperative computed tomography showed neither apparent expansion of the false lumen nor compression of the true lumen of the abdominal aorta, and postoperative renal function were maintained. In conclusion, in treatment of chronic dissecting aortic aneurysm (DeBakey type IIIb) presenting with compromised renal perfusion, we considered that replacement of the thoracic descending aorta and abdominal aorta brings patient the most radical improvements. But in the patients, who are elder or in poor perioperative conditions, the replacement of thoracic descending aorta using double barreled distal anastomosis technique is one easier applicable and safer procedure to preserve the renal perfusion.

[Noninvasive detection of the limitation of simple cold storage of the heart by myocardial electrical impedance].

The purpose of this study was to determine if graft viability during simple cold storage can be monitored from alteration of myocardial electrical impedance. Twelve anesthetized dogs were underwent rapid cardiac extripation and were placed in simple cold storage. They were divided into two groups according to preserved solution. Group S was preserved in 12 hours in saline. Group U was preserved in 24 hours in the University of Wisconsin (UW) solution. Myocardial electrical impedance was measured serially by use of a LCR meter and analyzed the changes of myocardial resistivity during preservation. Myocardial specimens were taken for myocardial ATP measurement with high-performance liquid chromatography and for water content in two groups. Moreover in order to predict the cardiac function after transplantation in two groups, heterotopic cardiac transplantation in the neck was performed in mongrel dogs and left ventricular (LV) Emax was measured. Myocardial resistivity increased significantly until 5.5 hours in group S, 13 hours in group U. ATP remained above 50% at 5.5 hours in Group S, 13.7 hours in Group U. Resistivity increase rate was over 0.1 omega cm/min in the period ATP remained above 50%. Myocardial water content increased during preservation in group S, but did not in group U. There was no relationship between the increase of resistivity and myocardial water content. LVEmax at 120 min after reperfusion was over 90% of preischemic value in 4 hour preserved heart in saline and 12 hour preserved heart in UW. Measurement of myocardial resistivity during simple cold storage may be feasivle as a monitor of graft viability.

[A trial of antegrade perfusion to the lower half of the body with selective cerebral perfusion for repair of aortic arch aneurysm combined with atherosclerosis obliterance].

A 73-year-old man with aortic arch aneurysm combined with atherosclerosis obliterance underwent aortic arch replacement. As he had bilateral femoral artery obstruction, we instituted ECC with arterial perfusion through the ascending aorta. Then, the left ventricle started dilating due to mild degree of aortic regurgitation. So with selective cerebral perfusion, we perfused the lower half of the body through a Foley balloon catheter which was inserted from the aortic arch antegradely. We could perfuse with the catheter for 20 minutes for core cooling and then during repair until the catheter disturbed the operation. The Foley catheter had given us some difficulties for handling during the procedure. Based on this experience, we have made a catheter which had both a balloon for aortic occlusion and a tube for perfusion and which we could keep away from operative fields, similar to the way we used antegradely insertable aortic occlusion balloon catheter.

Screening of patients with ischemic heart disease by transesophageal atrial pacing and the selection of surgical therapy: in patients with arteriosclerosis obliterans and aortic aneurysm.

This study evaluated (1) a screening method for ischemic heart disease (IHD) using transesophageal atrial pacing (TEP), and (2) the appropriate surgical therapy for patients with concomitant IHD which was evaluated on the basis of the coronary score (CS) by Leaman. Thirty-nine patients with arteriosclerosis obliterans of the lower extremities (ASO) and 35 with aortic aneurysm underwent TEP and coronary angiography (CAG). Coexistent IHD was diagnosed in 25 patients (64%) with ASO and in 14 (40%) with aortic aneurysm. Screening for IHD by TEP was 96% sensitive, 71% specific, and 87% accurate in patients with ASO, and 79% sensitive, 90% specific, and 86% accurate in patients with aortic aneurysm. Coronary artery bypass grafting (CABG) and peripheral arterial revascularization (PAR) were performed by one stage surgery in 3 patients with a CS of 16 or more. In 18 patients with a CS of 5.5 or less, only PAR was performed. One stage surgery was performed in 6 patients with aortic aneurysm. Four patients had a CS of 9.5 or more, and 2 patients with coexistent stenosis of the left anterior descending branch (LAD) had CS of 3.5 and 8, respectively. Repair of the aneurysm was undertaken in 5 patients with a CS of 8 or less without LAD disease. In patients with ASO showing a CS of 5.5 or less and in those with aortic aneurysm showing a CS of 8 or less (and without LAD disease), the only surgical procedure performed was either PAR or repair of the aneurysm. There were no complications attributable to IHD observed in these patients during the perioperative period.

[A case of invasive thymoma with myasthenia gravis and pure red cell aplasia].

The patient was a 42-year-old man whose main complaints were ptosis, diplopia and muscle weakness. Chest X-ray film revealed a right hilar mass and chest CT showed a solid mass at right anterior superior mediastinum. Laboratory studies revealed myasthenia gravis (MG) on EMG and pure red cell aplasia (PRCA) on hematology. An extended thymectomy, including the thymoma, was performed. Thrombocytopenia appeared postoperatively, but it improved when a platelet transfusion was given. Steroid was administered for postoperative adjuvant therapy, and the MG and PRCA were alleviated. This rare case of simultaneous MG and PRCA as complications of a thymoma is reported.

[Surgical removal of right atrial myxoma in the elderly].

We have experienced a surgical treatment of right atrial myxoma in a 76-year-old woman. The patient was admitted with complaints of palpitation and low grade fever. Echocardiography revealed the atrial tumor, which prolapsed into the right ventricle in diastole. The tumor was removed under cardiopulmonary bypass including the atrial septum where it was attached. The tumor weighed 68 g and showed typical pathological findings of myxoma. The patient is doing well 6 years after surgery.

[Coronary revascularization using profound hypothermia with elective ventricular fibrillation and total circulatory arrest].

Profound hypothermia with elective ventricular fibrillation and total circulatory arrest was used in a patient undergoing coronary artery bypass grafting (CABG) with severe calcification of the ascending aorta. A 76-year-old woman with unstable angina was referred for coronary revascularization. Ascending aorta was severely calcified with the exception of limited region of proximal ascending aorta, and the coronary arteriography showed high-grade obstruction of the left anterior descending (LAD) and dominant right coronary artery (RCA). The left internal thoracic artery was anastomosed to the LAD, and the saphenous vein graft to the RCA under systemic moderate hypothermia and elective ventricular fibrillation. During the proximal anastomosis of the saphenous vein graft to the non-calcified ascending aorta, profound hypothermia and circulatory arrest was instituted for 11 minutes. The wean from extracorporeal circulation was successful, and the postoperative course was uneventful.

[Extraction of embolised catheter fragments using percutaneous technique: report of 3 cases].

Three cases are presented in which a basket catheter was used to retrieve broken central venous catheters successfully from the right side of the heart. Case 1: A 71-year-old female, in whom an IVH catheter was accidentally cut, and a fragment of which migrated into the pulmonary artery, was presented. Case 2: A 63-year-old male, fell into a restless state and pulled out the IVH catheter by himself, leaving a broken piece of catheter. Then, the catheter tip wandered into the right atrium. Case 3: In a 64-year-old male, it was found that the infusion port was detached from the catheter line for some unknown cause, and a chest X-ray film revealed migration of the catheter tip into the right atrium. We succeeded in removing the fragmented catheters by using basket catheters. They were inserted into the right heart transvenously, through a Fr. 8 sheath introducer (98cm long) under fluoroscopic control. We discussed the method and problems involved in removing intracardiac foreign bodies.

[A case of left atrial myxoma in the elderly (77-year-old)].

We reported a case of a 77-year-old female, whose left atrial myxoma with a cyst, which had been identified by 2D echocardiography, was successfully resected. Apart from echocardiogram-revealed tumor hemorrhages in atrial myxomas, reports of echo-lucency within cardiac tumors are considerably rare. She was successfully operated on, and the section through the tumor specimen showed a cyst with a diameter of 10 mm, that corresponded to the echo-lucencies noted on the 2D echocardiogram. Even in an elderly patient, surgical treatment of left atrial myxoma offers excellent results with low morbidity and low mortality.

[A surgical case of left coronary artery-left ventricular fistula].

Left ventricular fistulas arising from the left coronary artery are rare, and only 3 cases have been reported Japan. Surgical closure of a left coronary artery-left ventricular fistula in a 14-year old male was reported. The fistula was identified by coronary arteriography after the patient had been admitted to hospital complaining of recurrent chest pain. Ligation of the fistula involving the left anterior descending coronary artery was performed with cardiopulmonary bypass, chemical arrest and hypothermia. The blood flow through the LAD decreased from 370 ml/min to 100 ml/min after the fistula was ligated, and there was uneventful postoperative recovery. Furthermore chest pain of the patient was shown to diminish and movement of the left ventricular septum was improved, compared with the preoperative cineangiography. However, trivial residual flow fo the circumflex coronary artery to the left ventricle remained on postoperative coronary arteriography. The principal aim of the procedure for surgical correction should be effective closure of the fistula without compromising the distal blood supply of the coronary artery involved, cardiopulmonary bypass is considered necessary to appropriate closure of the fistula.

[A case of right intermediate bronchial stenosis due to an injury eighteen years before].

A 20 year-old man was admitted to our hospital suffering from fever and cough due to bronchiectasis. He had been injured in automobile accident 18 years before. The subsequent bronchography revealed a marked stricture of the right intermediate bronchus with post-stenotic bronchiectasis. Right middle and lower lobectomy was performed. Postoperatively, pneumonia improved, and pulmonary function was preserved. There is no agreement on criteria indicating the need for bronchial reconstruction in cases like this, because evaluation is difficult whether inflammatory changes in the lobes intending to the reimplant may be reversible. In our case, we considered that recurrent pneumonia and bronchiectatic changes of the right lower lobe were contra-indications to bronchial reconstruction.