Endovascular management of pseudoaneurysms of the splenic artery: experience with six patients.

The purpose of this paper was to describe our experience with the endovascular management of splenic artery pseudoaneurysms (SAPA). Seven patients with documented SAPA on CT and/or angiography were considered for endovascular treatment. The pseudoaneurysms were located in the main splenic artery (n = 4) or its branches (n = 3). In one patient in whom the pseudoaneurysm was located in a hilar branch, selective catheterization of splenic artery failed. Metallic coils (n = 1), gelfoam and hydrogel particles (n = 1), metallic coils and gelfoam (n = 2), metallic coil, gelfoam and acrylic glue (n = 2) were used as embolization material in the remaining six patients. These patients were followed for a mean period of 11.3 months. Transcatheter embolization was successful in five patients with no procedure-related complications. In one patient, embolization was incomplete and the patient underwent surgery, but died on the 10th postoperative day because of irreversible shock. Another patient, after successful embolization, underwent surgery for management of an associated pseudocyst. Endovascular treatment is a safe and effective method of management of SAPA.

MRI features of tuberculosis of peripheral joints.

The aim of this article is to present the magnetic resonance imaging (MRI) features of peripheral tubercular arthritis. The clinical presentation of peripheral tubercular arthritis is variable and simulates other chronic inflammatory arthritic disorders. MRI is a highly sensitive technique which demonstrates fine anatomical details and identifies the early changes of arthritis, which are not visible on radiographs. The MRI features of tubercular arthritis include synovitis, effusion, central and peripheral erosions, active and chronic pannus, abscess, bone chips and hypo-intense synovium. These imaging features in an appropriate clinical setting may help in the diagnosis of tubercular arthritis. Early diagnosis and treatment can effectively eliminate the long-term morbidity of joints affected by tuberculosis.

Intra-arterial embolization of lumbar artery pseudoaneurysm following percutaneous nephrolithotomy.

The management of a patient with haematuria following percutaneous nephrolithotomy is described. The patient underwent renal angiography to assess the cause of bleeding. A pseudoaneurysm arising from first left lumbar artery was incidentally discovered, which was then successfully embolized using an indigenously fabricated metallic coil and gel foam particles in the same sitting.

A study of bone densitometry in patients with complex regional pain syndrome after stroke.

INTRODUCTION: This study was undertaken to evaluate the bone mineral density (BMD) in patients with complex regional pain syndrome type-I (CRPS-I) after stroke, and to correlate it with various clinical and neurophysiological parameters. PATIENTS AND METHODS: Twenty patients with CRPS-I after stroke were included and a detailed neurological evaluation was carried out. The severity of CRPS-I was graded on the basis of shoulder hand syndrome score. All the patients underwent bone mineral densitometry of paralysed and non-paralysed forearm by dual energy x ray absorptiometry. The BMD of paralysed forearm was also compared with that of age matched healthy controls. Neurophysiological tests included sympathetic skin response in both upper and lower limbs and median somatosensory evoked potentials. RESULTS: The mean age of patients was 57.2 (45-75) years and eight were females. Eight patients had severe weakness and 12 had moderate weakness of grade 2 on the hemiplegic side. There was significant reduction in BMD in the patients compared with controls (p<0.01). The bone density reduction correlated well with duration of illness (r = -0.673, p<0.01), shoulder hand syndrome score (r = -0.804, p<0.01), and Canadian neurological scale score (r = -0.738 p<0.01). Sympathetic skin response was not recordable bilaterally in all patients. Median somatosensory evoked potentials were not recordable in seven out of 20 patients who also had higher grade of CRPS-I. CONCLUSION: Our results show significant reduction of BMD in patients with CRPS-I after stroke. The reduction in BMD correlates with the severity of shoulder hand syndrome score, degree of weakness, duration of hemiplegia, and the severity of stroke.

Sonographic findings in renal parenchymal malacoplakia.

Malacoplakia of the kidney is a rare inflammatory disorder. We describe a case of bilateral renal malacoplakia in which the patient had diffuse involvement of the left kidney and a focal lesion in the right kidney. Sonography showed a diffusely echogenic, enlarged left kidney with loss of corticomedullary differentiation and a single anechoic lesion measuring 1.8 x 1.6 x 1.3 cm in the right kidney. A left nephrectomy was performed, and the right kidney was managed conservatively with sonographic monitoring.

Temporary balloon occlusion of internal carotid artery : a simple and reliable clinical test.

Balloon test occlusion of internal carotid artery has been frequently used in preoperative evaluation of patients with carotid aneurysms, fistulas and skull based neoplasms in whom arterial sacrifice is planned or considered as a possible part of therapy. We present our experience of the test in 28 patients. The test was positive in four and negative in twenty four patients. The results are compared with cross-compression angiography and the outcome following internal carotid artery sacrifice. There were no complications related to the test and the results accurately predicted the tolerance to occlusion of artery. We found the test safe, simple to perform and reliable to preoperatively detect patients at risk of ischaemic stroke following surgical ligation or endovascular occlusion of internal carotid artery.

MR demonstration of a giant cavernous carotid aneurysm with occlusion of the contralateral intracranial carotid artery: an unusual complication of cavernous sinus thrombosis.

We present an unusual combination of vascular complications of cavernous sinus thrombosis in a 7-year-old girl. MRI and MR angiography showed occlusion of the intracranial portion of the left internal carotid artery and a contralateral giant cavernous carotid aneurysm. This combination of vascular findings may influence the management in such cases.

Osteodysplastic primordial dwarfism type II with normal intellect but delayed central nervous system myelination.

We describe a 7-year-boy with severe prenatal and postnatal growth retardation, skeletal changes, normal intellect, and unusual facial appearance. The skeletal changes are suggestive of osteodysplastic primordial dwarfism type II (OPD II). He is the first patient of this kind from the Indian subcontinent and the 18th to be reported, based on a literature search (MEDLINE; 1982 to April 1997). He also represents the first case of OPD-II with normal intellect but delayed central nervous system myelination.

Traumatic carotid cavernous fistula: anatomical variations and their treatment by detachable balloons.

Endovascular balloon occlusion has become a standard mode of therapy in carotid cavernous fistulas. Many angioarchitectural variations are, however, encountered in individual cases, some of which influence the therapeutic mode and outcome. We report on three patients with carotid cavernous fistulas treated by endovascular techniques.

Staging of carcinoma of the gallbladder--an ultrasonographic evaluation.

BACKGROUND/AIMS: Preoperative staging of carcinoma of the gallbladder is important in choosing the most appropriate treatment modality. Ultrasonography is commonly used for the diagnosis of carcinoma of the gallbladder, but its role in staging of the disease has not been adequately evaluated. The aim of this study was to prospectively evaluate the role of ultrasonography performed by a single operator in the staging of carcinoma of the gallbladder. METHODOLOGY: Twenty-six patients with carcinoma of the gallbladder were evaluated in this study. Ultrasonographic staging was done by a single senior radiologist and compared with surgical staging using the AJCC TNM staging system. A retrospective evaluation was done of 122 operated patients with carcinoma of the gallbladder, and the findings were compared to the results of the prospective study. RESULTS: In the prospective study, the overall accuracy of ultrasonogaphy in correctly staging the disease was 38% (10/26). Only 1 patient was overstaged, while the majority of patients were understaged (15) due to missed distant metastasis (10) and missed advanced local infiltration (5). The sensitivity in detecting liver infiltration was 50%; lymph node metastasis, 50%; and liver metastasis, 8%. In the retrospective study, the similar detection rates were 27%, 25% and 10%, respectively. CONCLUSION: Real time ultrasonography has been found to have inherent limitations in staging carcinoma of the gallbladder. Its accuracy, though improved in a prospective study, is inadequate in staging the disease accurately. More accurate imaging modalities are therefore required to accurately stage the disease preoperatively, so as to avoid unnecessary laparotomies.

MRI in Japanese encephalitis.

We document the MRI features in seven patients with Japanese encephalitis. MRI was carried out on a 1.5 T system within 10-60 days of onset. In all the patients MRI revealed bilateral thalamic lesions, haemorrhagic in five. Signal changes were present in the cerebrum in four patients, the midbrain and cerebellum in three each, the pons in two and the basal ganglia in one. The lesions were haemorrhagic in three of the four patients with lesions in the cortex, two of the three with lesions in the midbrain and cerebellum, but the pontine lesions were haemorrhagic in both patients. Spinal cord involvement was seen in one of the three patients who underwent MRI. In two patients MRI was repeated 3 years after the onset, showing marked reduction in abnormal signal; and all the lesions gave low signal on both T1- and T2-weighted images. Bilateral thalamic involvement, especially haemorrhagic, may be considered characteristic of Japanese encephalitis, especially in endemic areas.

Iatrogenic renal vascular injuries and their radiological management.

Twenty-nine patients with significant haematuria after a renal invasive procedure (27 of whom had undergone a percutaneous renal procedure and 2 surgical pyelolithotomy) were investigated with angiography. Out of the 21 patients with evidence of arterial injury, 19 were treated by transarterial embolization with gelfoam with or with hydrogel particles; (n = 11), steel coils with gelfoam (n = 4), hydrogel particles (n = 1), surgicel (n = 2), silk with gelfoam (n = 1). The efficacy and technique of the therapeutic embolization procedure is emphasized.

Takayasu's arteritis: evaluation with three-dimensional time-of-flight MR angiography.

Three-dimensional time-of-flight MR angiography was performed in 16 patients with Takayasu's arteritis. Two regions were evaluated, the arch of aorta and its intrathoracic major branches, and the abdominal aorta with proximal portions of its major visceral and renal branches. Individual arteries and aortic segments, i. e. aortic arch and abdominal aorta, were evaluated for abnormalities such as stenosis, occlusion, dilatation and aneurysm formation. The results were compared with contrast angiography. Follow-up MR angiography was performed in three patients after 9-12 months. MR angiography demonstrated steno-occlusive lesions in all the patients and aneurysms in 2. In comparison with contrast angiography, good correlation was found in 129 of the 145 arteries and aortic segments. For the 12 false-positive results, incorrect slab placement and overestimation of stenosis were implicated. Interestingly, there were three false-negative results and one occlusion was underestimated as stenosis. A new lesion developed in 1 patient and one stenosis progressed in another patient upon follow-up. Three-dimensional time-of-flight MR angiography is a simple and fairly accurate method for documenting the lesions in Takayasu's arteritis and for its follow-up.

Tuberculosis in childhood nephrotic syndrome in India.

We studied the prevalence, clinical features, and impact of tuberculosis (TB) on children with nephrotic syndrome (NS). Of the 300 children with NS, 28 (9.3%) were diagnosed as having TB. This occurred following the initiation of immunosuppressive therapy in 27 children, and in 1 child it preceded the onset of NS. Pulmonary involvement was the commonest (22/28), followed by tubercular lymphadenitis (2/28), meningitis (2/28), and occult TB (2/28). Of the various diagnostic criteria, history of previous cough, fever, or exposure to a case of TB (23/28) and chest skiagram (21/28) were the most useful. The occurrence of TB did not induce a relapse or affect the subsequent response to steroid therapy (as is often seen with other infections) or have a deleterious effect on renal function. Patients who received higher doses of steroids (frequent relapsers, steroid dependent, initial non-responders, and subsequent non-responders) had a significantly higher prevalence of TB (19/148) than those who received lower doses (infrequent relapsers 8/151) (P = 0.04). We thus found TB to be an important complication of children with NS in our country. The conventional diagnostic tests, such as Mantoux and acid-fast bacilli isolation, are often unhelpful in these children, and a high index of suspicion is required, especially in children who require frequent courses of steroid therapy.

Arterial complications of pancreatitis and their radiological management.

Arterial haemorrhage from pseudoaneurysm in pancreatitis patients is a formidable complication with a high mortality rate. We encountered six patients in whom a pseudoaneurysm was demonstrated at angiography. Drainage of associated pseudocyst facilitated visualization in one patient. Four patients had pseudoaneurysms arising from the proximal part of the major peripancreatic vessels and were treated by steel coil embolization (n = 3) and surgically (n = 1). There was no episode of rebleeding in these patients during a follow-up period of 10-18 months. Of the two patients with distal small peripancreatic branch vessel involvement hydrogel particle and gelfoam embolization was successful only temporarily in one patient and unsuccessful in the other patient. The literature is reviewed and the efficacy of steel coil embolization is emphasized.

Magnetic resonance imaging features of an epidural spinal haemangioma.

Isolated spinal epidural haemangioma without vertebral involvement is rare. We report a case of an epidural capillary haemangioma in the thoracic region and present the magnetic resonance findings, including contrast-enhanced features.