Magnetic resonance imaging versus bone scan for assessment of vascularization of the hydroxyapatite orbital implant.

We prospectively studied 10 patients who were status postenucleation and primary placement of the hydroxyapatite orbital implant. Both the technetium-99m bone scan and gadolinium-enhanced magnetic resonance images (MRI) were obtained on the same day at variable time points in the postoperative period in order to assess the degree of vascularization. Up to 78% of the bone scans were interpreted as being completely vascularized, while only 10% of the corresponding MRI scans were consistent with complete vascularization. Cost analysis showed that MRI was cost-effective imaging modality. We conclude that contrast-enhanced MRI provides a more accurate assessment of vascularization of the hydroxyapatite orbital implant when compared to bone scan.

Ethanol embolization of vascular malformations.

Absolute ethanol was used to treat 20 patients with symptomatic vascular malformations (SVMs) (ie, venous malformations, arteriovenous malformations, and congenital and posttraumatic arteriovenous fistulas) in whom previous surgery or standard embolotherapy had failed or who were not candidates for surgery. All large complex lesions required multiple embolizations as staged procedures. Immediate thrombosis was achieved in all patients; complications (13% of cases) were generally minor and were treated conservatively. Follow-up studies, performed in 19 of 20 patients, showed persistent occlusion of the SVM in all cases. Ethanol embolization of SVMs, performed according to strict techniques, has proved efficacious in SVM management and is emerging as a definitive form of therapy.

Blue digit syndrome: treatment with percutaneous transluminal angioplasty.

Ten patients with classical blue digit syndrome were treated with percutaneous transluminal angioplasty (PTA). None experienced embolization. Nine were clinically improved; in eight, microembolization did not recur during follow-up of 7-86 months (mean, 28 months). Three clinical and three angiographic features were common to these eight patients: (a) few clinical episodes of microembolization; (b) no episodes of macroembolization; (c) no livedo reticularis in the affected extremity, and no symptoms of systemic cholesterol embolization; (d) focal, high-grade (greater than 90%) stenoses that were hemodynamically significant; (e) no diffuse atheromas in the aorta; (f) patent tibial runoff arteries. Affected patients with these clinical and angiographic characteristics make up a subgroup, previously unrecognized, to the authors' knowledge, in whom PTA followed by antiplatelet therapy should be the initial treatment of choice. The blue digit syndrome in these patients was probably due to microemboli composed of fibrinoplatelet aggregates rather than cholesterol debris.

Chemical ablation of the canine kidney using sodium tetradecyl sulfate (Sotradecol). A histopathologic study.

We studied the histopathologic effect of intraarterial Sotradecol (Elkins-Sinn, Inc., Cherry Hill, NJ) on the kidney and examined the mechanism for destruction of renal parenchyma by Sotradecol. Sotradecol was injected into one renal artery distal to an occlusion balloon catheter in six dogs, and the kidneys were removed for histologic examination; four dogs within 20 minutes, and one each at 12 and 24 hours after embolization. The contralateral kidney of each dog underwent the same procedure but was injected with normal saline, and served as control. Histologic examination of the control kidneys was unremarkable. The embolized kidneys revealed extensive endothelial denudation and mural necrosis of the arteries and coagulation necrosis of the renal parenchyma. The changes were evident as early as 20 minutes after embolization, and necrosis became complete by 24 hours. The arteries were filled with red blood cell sludge. Sotradecol produces extensive tissue necrosis and complete renal parenchymal destruction through its direct cytotoxic action on the arterial wall, blood cell elements, and renal parenchyma.

Transcatheter embolization with sodium tetradecyl sulfate. Experimental and clinical results.

Sodium tetradecyl sulfate (Sotradecol), which has been employed for sclerotherapy of varicose veins, was evaluated in dogs and humans as an agent for selective arterial embolization. In dogs, intraarterial injection of Sotradecol 3% into the proximally occluded renal, hepatic, splenic, and deep femoral arteries produced arterial occlusion and tissue destruction. Transcatheter embolization with Sotradecol was performed in 11 patients and was successful in 10; in the remaining patient, failure was attributed to rapid dilution by unobstructed blood flow in arteriovenous malformations of the neck. The authors conclude that Sotradecol is a safe and efficient agent for selective arterial embolization.

Observations on CT differentiation of pleural and peritoneal fluid.

Distinguishing juxtadiaphragmatic pleural and peritoneal fluid by computed tomography (CT) is sometimes difficult. We evaluated the distribution of fluid in 50 consecutive patients with pleural effusion or ascites or both. Juxtadiaphragmatic pleural fluid was nearly always found posteromedially, whereas peritoneal fluid typically distributed lateral to the liver or spleen or both in the posterior upper abdomen. This difference in distribution is easily explained by pertinent upper abdominal peritoneal and extraperitoneal anatomy. On the basis of distribution alone, pleural and peritoneal fluid could be differentiated in 47 of 50 patients. Difficulty was encountered with loculated pleural fluid and with ascites having a large left subphrenic component; in those situations, previously reported CT signs may be helpful.

Urine sugar reagent tablet ingestion causing gastric and duodenal ulceration.

The accidental or intentional ingestion of urine sugar reagent (Clinitest) tablets, a potent caustic, has been reported to cause severe esophageal mucosal damage and stricture formation. Gastric mucosal damage was reported once before in a man who intentionally ingested 26 Clinitest tablets. We encountered a case of accidental Clinitest tablet ingestion causing gastric and duodenal ulceration without esophageal damage, a previously undescribed complication of inadvertent Clinitest tablet ingestion. Our case reemphasizes the role of early fiberoptic endoscopy in the evaluation of caustic ingestions.

Urinary incontinence in the elderly.

Transient urinary incontinence in an elderly person is often due to a potentially reversible factor that can be recognized and corrected by the primary care physician. The cause of established incontinence may also be found after office evaluation. Treatment may include bladder retraining, use of an anticholinergic or alpha-adrenergic drug, and/or surgery. Referral to a specialist may be indicated. In many elderly patients, no cause for incontinence is apparent even after careful examination of the patient. Management in this case is controversial: The patient may be referred for further evaluation or treated empirically for presumed uninhibited neurogenic bladder. In some situations, incontinence can be managed only by the use of a bedpan or special garments or, as a last resort, catheterization.