A case report and literature review of sigmoid volvulus in children.

RATIONALE: Sigmoid volvulus (SV) is an exceptionally rare but potentially life-threatening condition in children. CHIEF COMPLAINT: Abdominal distention for 1 week. DIAGNOSES: Sigmoid volvulus. PATIENT CONCERNS: We present a case of a 12-year-old boy with mechanical ileus who was finally confirmed to have SV with the combination of abdominal plain film, sonography, and computed tomography (CT) with the finding of mesenteric artery rotation. INTERVENTIONS: Because bowel obstruction was suspected, abdominal plain film, sonography, and CT were performed. The abdominal CT demonstrated whirlpool sign with torsion of the sigmoid vessels. In addition, lower gastrointestinal filling study showed that the contrast medium could only reach the upper descending colon. Therefore, he received laparotomy with mesosigmoidoplasty for detorsion of the sigmoid. OUTCOMES: The postoperative recovery was smooth under empirical antibiotic treatment with cefazolin. A follow-up lower gastrointestinal series on the seventh day of admission showed no obstruction compared with the previous series. He was finally discharged in a stable condition 8 days after admission. LESSONS: SV is a congenital anomaly and an uncommon diagnosis in children. Nevertheless, case series and case reports of SV are becoming more prevalent in the literature. Failure to recognize SV may result in life-threatening complications such as sigmoid gangrene/perforation, peritonitis, sepsis, and death. Thus, if the children have persistent and recurrent abdominal distention, abdominal pain, and vomiting, physicians should consider SV as a "do not miss diagnosis" in the differential diagnosis.

A survey of the current status of coronary CT angiography using 64-slice multidetector CT in Taiwan.

BACKGROUND/PURPOSE: The 64-slice multidetector CT (64-MDCT) has bolstered the sensitivity and specificity of coronary CT angiography (CCTA) for detecting coronary artery disease. We performed this study to understand the current status of CCTA using 64-MDCT, so as to determine further promotion and optimal regulation schemes of CCTA in Taiwan. METHODS: Information about CCTA from 68 domestic hospitals with 64-MDCT was collected by means of a questionnaire from July 2009 to January 2010. The studied details included: (1) the implementation background of CCTA; (2) the interdisciplinary cooperation and report processing of CCTA; and (3) the promotion strategy of CCTA. RESULTS: The majority of CCTA sites (89.7%) were administered by diagnostic radiologists. Most cardiologists and cardiac surgeons have confirmed its clinical value by referring patients to undergo CCTA. Of the CCTA reports by radiologists, 41.2% had their report supplemented by referring cardiologists. Such cooperation amongst specialists promoted the development of CCTA. Of CCTA studies, 89.7% included coronary calcium scoring. Most (60.3%) respondents asserted the cost of a study to be 15,000 to 20,000 new Taiwan dollars. Nearly two-fifths (41.2%) of the respondents supported the restriction of subjects for CCTA to those who were high risk group for coronary artery disease or those > 40 years of age. CONCLUSION: Diagnostic radiologists are primarily in charge of managing CCTA sites in Taiwan. The interdisciplinary cooperation amongst radiologists and cardiologists in reporting CCTA may expedite the development of CCTA. The domestic radiologists are expected to standardize the process, which includes interpreting and reporting CCTA findings.

Spontaneous dissection of the celiac artery: a case report and literature review.

Epigastralgia is a common chief compliant in the emergency department. Most of them are not fetal events, but some are life threatening such as aortic dissection or abdominal aneurysm rupture. Spontaneous visceral artery dissection is an uncommon occurrence with an unpredictable natural history and is rarely considered in the diagnosis of acute abdominal pain; however, it is as critical as aortic dissection and even easier to be ignored because of its rarity. We present a case of a 48-year-old man who presented to our emergency department with the chief concern of epigastric pain and diagnosed as having isolated spontaneous celiac artery dissection involving the hepatic artery, gastroduodenal artery, and splenic artery. Most cases required surgical intervention in previous reports; there are some, as in this case, managed well nonoperatively.

Effects of propranolol on the left ventricular volume of normal subjects during CT coronary angiography.

OBJECTIVE: The purpose of this study is to determine the effects of propranolol on the left ventricular (LV) volume during CT coronary angiography. MATERIALS AND METHODS: The LV volume of 252 normal Chinese subjects (126 subjects with propranolol medication and 126 age- and gender-matched Chinese subjects without medication) was estimated using 64 slices multi-detector CT (MDCT). The heart rate difference was analyzed by the logistic linear regression model with variables that included gender, age, body height, body weight, systolic blood pressure (SBP), diastolic blood pressure (DBP) and the dosage of propranolol. The following global LV functional parameters were calculated: the real-end diastolic volume (EDV), the real-end systolic volume (ESV) and the real-ejection fraction (EF). RESULTS: The female subjects had a greater decrease of heart rate after taking propranolol. The difference of heart rate was negatively correlated with the dosage of propranolol. The real-EDV, the real-ESV and the real-EF ranged from 48.1 to 109 mL/m², 6.1 to 57.1 mL/m² and 41% to 88%, respectively. There was no significant difference in the SBP and DBP between the groups without and with propranolol medication (123 ± 17 and 80 ± 10 mmHg; 120 ± 14 and 80 ± 11 mmHg, respectively). The real-EDV showed no significant difference between these two groups, but the real-ESV and real-EF showed significant differences between these two groups (69.4 ± 9.3 and 70.6 ± 8.9 mL/m²; 23.5 ± 5.7 and 25.6 ± 3.7 mL/m², 66.5 ± 5.1% and 63.5 ± 4.6%, respectively). CONCLUSION: The difference of heart rate is significantly influenced by gender and the dosage of propranolol. Propranolol will also increase the ESV, which contributes to a decreased EF, while the SBP, DBP and EDV are not statistically changed.

Yoga and disc degenerative disease in cervical and lumbar spine: an MR imaging-based case control study.

The objective of the current study was to find out whether yoga practice was beneficial to the spine by comparing degenerative disc disease in the spines of long-time yoga practitioners and non-yoga practicing controls, using an objective measurement tool, magnetic resonance imaging. This matched case-control study comprised 18 yoga instructors with teaching experience of more than 10 years and 18 non-yoga practicing asymptomatic individuals randomly selected from a health checkup database. A validated grading scale was used to grade the condition of cervical and lumbar discs seen in magnetic resonance imaging of the spine, and the resulting data analyzed statistically. The mean number of years of yoga practice for the yoga group was 12.9 ± 7.5. The overall (cervical + lumbar) disc scores of the yoga group were significantly lower (indicating less degenerative disc disease) than those of the control group (P < 0.001). The scores for the cervical vertebral discs of the yoga group were also significantly lower than those of the control group (P < 0.001), while the lower scores for the yoga group in the lumbar group approached, but did not reach, statistical significance (P = 0.055). The scores for individual discs of yoga practitioners showed significantly less degenerative disease at three disc levels, C3/C4, L2/L3 and L3/L4 (P < 0.05). Magnetic resonance imaging showed that the group of long-term practitioners of yoga studied had significantly less degenerative disc disease than a matched control group.

Idiopathic spinal epidural lipomatosis - two cases report and review of literature.

Spinal epidural lipomatosis (SEL), an abnormal localized or tumor-like accumulation of fat in the epidural space, is an infrequent complication of chronic steroid usage and an uncommon cause of spinal cord compression. During the period of 1990 to 2006, we have two cases of medically heath SEL patients without history of steroid administration. Their initial clinical manifestations were low back pain, progressive lower extremities weakness, numbness, followed by rapid deterioration of neurogenic intermittent claudication. They were misdiagnosed and treated as degenerative spinal disease for a long time. Due to prominent neurological deficit, lumbar magnetic resonance image (MRI) was obtained and showed SEL. These 2 patients all underwent laminectomy and removal of epidural fat. Postoperatively, they both showed improvement. We reviewed the literature and discussed the current concept in the management of SEL.

Combination of tissue harmonic sonography, real-time spatial compound sonography and adaptive image processing technique for the detection of carotid plaques and intima-medial thickness.

BACKGROUND AND PURPOSE: Conventional sonography (CS) had many unwanted artifacts, which obscured the carotid artery lesions. We try to explore whether the combination of tissue harmonic imaging (THI), real-time spatial compound sonography (SCS), and adaptive image processing (AIP) techniques (CTX) could be a better way to reduce the artifacts in the carotid artery and enhance the visualization of its plaques and intima-medial thickness (IMT) than CS. METHODS: Eighty-three patients who harbored IMT (73) and carotid plaques (19) with variable degrees of stenosis underwent scanning for which five different ultrasound techniques were performed for overall image quality, lesion conspicuity, and elimination of artifacts. Two observers, who were blinded to the imaging techniques, graded the different images. A Friedman test was used for multiple statistical comparisons between the five techniques. To make paired comparisons between different imaging modes, Wilcoxon's signed-rank test was used. RESULTS: The mean Kappa score for the two independent observers was 0.812 (standard error, 0.021), and reflected moderate-to-high interobserver agreement. Combining SCS+THI+AIP (CTX) provided the best for overall image quality, lesion conspicuity, and elimination of undesired artifacts of carotid plaques whereas CS produced the worst quality (p<0.001). There were significant differences among the five techniques (p<0.001); however, there were no differences between SCS and THI on either image quality (p=0.417), lesion conspicuity (p=0.594), or elimination of artifact (p=0.064). CONCLUSIONS: The combined technique of SCS, THI, and AIP may represent the optimal ultrasonic technique for the evaluation of the IMT and carotid plaque echomorphology.

Dynamic effects of axial loading on the lumbar spine during magnetic resonance imaging in patients with suspected spinal stenosis.

BACKGROUND: Previous studies have shown that axial compression in extension (ACE) of the spine during magnetic resonance imaging (MRI) has revealed unexpected pathological features compared with the conventional psoas-relaxed position (PRP) used in imaging. The purpose of this study was to evaluate the dynamic effect of axial loading on lumbar spinal stenosis using MRI in patients with spinal stenosis. METHODS: A total of 14 women and 11 men with lumbar spinal stenosis were examined in both PRP and ACE positions. We calculated the dural-sac cross-sectional area (DCSA) to evaluate severity of spinal canal stenosis. DCSA, as well as the dural-sac anteroposterior diameter (DAPD) and dural-sac transverse diameter (DTD) in both positions were measured using a digital image view station. A paired t test determined the differences in DCSA, DAPD and DTD between the two positions at each intervertebral disc level. RESULTS: Axial loading increased severity of lumbar spinal stenosis during MRI, as demonstrated by a decrease in DCSA from 20.5% to 6.3% (mean, 11.40 +/- 3.66%) between the PRP and ACE positions (p less than 0.01). Significant differences were also noted in DAPD and DTD between the PRP and ACE positions (p less than 0.01). A significant correlation was found between the decrease in mean DCSA and that in DAPD and DTD. The decrease in mean DCSA, DAPD and DTD following axial compression was greatest at the L4/5 and L5/S1 levels. CONCLUSION: Axial loading increases severity of lumbar canal stenosis and the effect of axial loading on MRI examination is greatest at the L4/5 and L5/S1 levels.

The benefits of comparing conventional sonography, real-time spatial compound sonography, tissue harmonic sonography, and tissue harmonic compound sonography of hepatic lesions.

This study aimed to compare conventional sonography, tissue harmonic imaging (THI), spatial compound sonography (SONOCT), and SONOCT+THI for overall image quality, lesion conspicuity, and elimination of artifacts of hepatic lesions. Forty-five patients were randomly selected, and 51 different hepatic lesions were scanned using each of the four techniques. The combined images of SONOCT+THI exhibited the best image quality for solid and cystic lesions, while conventional images were the worst for most hepatic lesions (P<.001). SONOCT was the best for fatty liver.

Malignant fibrous histiocytoma presenting as hemoperitoneum mimicking hepatocellular carcinoma rupture.

Malignant fibrous histiocytoma (MFH) is a pleomorphic mesenchynal sarcoma. It is uncommonly arises primarily from the intra-peritoneal cavity. Primary peritoneal MFH with tumor bleeding and rupture is rare. We describe the imaging features of a 70-year-old patient presenting with ruptured hemorrhagic peritoneal MFH at subhepatic area, accompanied by massive hemoperitoneum, mimicking a ruptured pedunculated hepatocellular carcinoma. Computed tomography (CT) revealed a large heterogeneous enhanced subhepatic mass with adjacent liver, gallbladder and colon invasion. Tumor hemorrhage and rupture complicated with peritoneal seeding and massive bloody ascites were also detected. Angiography showed a hypervascular tumor fed by enlarged right hepatic arteries, cystic artery and omental branches of gastroepiploic artery. The patient underwent laparotomy for tumor resection, but the tumor recurred one month after operation. To our knowledge, the CT appearance of ruptured intraperitoneal MFH complicated by hemoperitoneum has not been previously described.

Computed tomography findings of gossypiboma.

Gossypiboma is composed of non-absorbable surgical material with a cotton matrix. Gossypiboma is usually under-reported and is a severe medicolegal issue. Thus, we describe the computed tomography (CT) findings of gossypiboma in our institution. From January 2003 to June 2006, gossypibomas diagnosed in our institution and their data regarding sex, age, previous operation, location, the interval between the operation and the diagnosis of gossypiboma, clinical presentation, indication of CT, CT findings and further management were collected. There were 6 cases of gossypiboma, 4 men and 2 women. Three of our cases had previous chest surgery and the other 3 cases had previous abdominal surgery. The locations of 3 (50%) cases were in the left anterior subphrenic space. The mean interval between original operation and diagnosis was 24.6 +/- 33.4 months (range, 17 days to 8 years). With regard to CT findings, 3 (50%) cases had an isodense mass and 3 (50%) had a typical mass containing curvilinear opaque structures. The mean size of the gossypibomas was 62 x 62 x 67 mm. Because gossypiboma is due solely to human factors and is a severe medicolegal issue, continuous education should be considered.

Primary pancreatic Burkitt's lymphoma mimicking carcinoma with obstructive jaundice and very high CA19-9.

Primary pancreatic lymphoma is a rare neoplasm. We report the case of a 49-year-old man who presented with biliary obstruction due to a neoplasm involving the pancreatic head. Initial computed tomography revealed a suspicious periampullary mass. Consequently, magnetic resonance imaging was performed 16 days later, showing a relatively clearly defined and homogeneous signal mass in the pancreatic head with biliary dilatation on enhanced study. In combination with high tumour marker associated antigen CA19-9 levels (1872 and 2110 U/ml), these findings were highly suggestive of a pancreatic carcinoma. He underwent Whipple's procedure. Examination of the surgical specimen revealed a Burkitt's lymphoma. This case demonstrates that lymphoma can present with features mimicking pancreatic head carcinoma on imaging, clinical and laboratory studies. Neither clinical nor imaging nor laboratory methods indicate correct diagnosis, but a relatively clearly defined and homogeneous mass should prompt the physician to include lymphoma in a differential diagnosis of a pancreatic mass.

Hepatic arterial infusion chemotherapy for hepatocellular carcinoma with portal vein tumor thrombosis.

AIM: Hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is associated with poor prognosis. The aim of this prospective study was to evaluate the efficacy of hepatic arterial infusion chemotherapy (HAIC) for patients with this disease. METHODS: Eighteen HCC patients with PVTT were treated with HAIC via a subcutaneously implanted injection port. A course of chemotherapy consisted of daily cisplatin (10 mg for one hour) followed by 5-fluorouracil (250 mg for five hours) for five continuous days within a given week. The patients were scheduled to receive four consecutive courses of HAIC. Responders were defined in whom either a complete or partial response was achieved, while non-responders were defined based on stable or progressive disease status. The prognostic factors associated with survival after treatment were analyzed. RESULTS: Six patients exhibited partial response to this form of HAIC (response rate=33%). The 3, 6, 9, 12 and 18-month cumulative survival rates for the 18 patients were 83%, 72%, 50%, 28%, and 7%, respectively. Median survival times for the six responders and 12 non-responders were 15.0 (range, 11-18) and 7.5 (range, 1-13) months, respectively. It was demonstrated by both univariate and multivariate analyses that the therapeutic response and hepatic reserve function were significant prognostic factors. CONCLUSION: HAIC using low-dose cisplatin and 5-fluorouracil may be a useful alternative for the treatment of patients with advanced HCC complicated with PVTT. There may also be survival-related benefits associated with HAIC.

Surgical management of hemangioblastomas of the spinal cord.

BACKGROUND AND PURPOSE: Intramedullary hemangioblastomas are relatively rare intraspinal tumors. Total removal of these tumors without causing significant neurological deficit remains a great challenge. This study analyzed the preoperative characteristics, management, and outcome in patients with successful total removal of spinal intramedullary hemangioblastomas. METHODS: Data from the medical records of patients with intraspinal hemangioblastomas treated from 1993 to 2003 were reviewed. The neurological function of these patients was graded and the preoperative data were recorded and correlated with clinical outcome. RESULTS: Ten patients with spinal intramedullary hemangioblastomas underwent microsurgical resection by the same neurosurgeon during the 10-year study period. They included 3 men and 7 women with age ranging from 20 to 49 years, with a mean age of 33 years. Five of the patients met the diagnostic criteria for von Hippel-Lindau disease. Preoperative neurological function was grade I in 6 patients, grade II in 3 patients and grade III in 1 patient. Immediate postoperative neurological function was worse in 3 cases, but all of these patients recovered their preoperative function within 3 weeks. At 3 months' follow-up, 9 patients had achieved functional grade I, and 1 patient with preoperative grade III function had improved to grade II. CONCLUSIONS: Detailed preoperative evaluation and skillful microsurgery are mandatory in successful total removal of intramedullary hemangioblastomas. The management of spinal hemangioblastomas associated with von Hippel-Lindau disease requires a cautious observation of clinical course and timely surgical intervention of symptomatic lesions to avoid possible neurological deficit.

Spiral biphasic contrast-enhanced computerized tomography in the diagnosis of hepatocellular carcinoma.

Advances in spiral computerized tomography (CT) have made rapid biphasic contrast-enhanced CT possible. This study evaluated the capability of biphasic contrast-enhanced spiral CT to detect hepatocellular carcinoma (HCC). A total of 125 patients (68 men and 57 women) with proven HCC underwent preliminary noncontrast (NC) scanning, followed by hepatic arterial phase (HAP) and portal venous phase (PVP) imaging. Contrast medium (80 mL, 300 mgI/mL) was administered routinely at a rate of 2 mL/second using an automated contrast injector under guidance software monitoring. Study of NC and PVP images without concurrent study of HAP images detected 131/171 (76.6%) cases of HCC. In contrast, combined study of NC, PVP, and HAP images detected 153/171 (89.5%) cases of HCC. Thus, combined study of NC and biphasic images was able to detect an additional 12.9% of HCC cases in comparison with conventional study of NC and PVP images only. All HCCs that were detectable only on HAP imaging were enhanced homogeneously with contrast medium during the arterial phase.