[Radiographic diagnosis of cardiogenic pulmonary edema].

Development of pulmonary edema (increased extravascular lung water) is a common and sometimes life-threatening clinical problem in critical-care unit patients. There are three principal causes: cardiac failure, overhydration, and increased pulmonary capillary permeability. Among these, cardiogenic edema consists of left heart failure and overhydration. Determining the specific cause of any given case of pulmonary edema is important and leads to more rapid and definitive treatment. A plain chest film can often explicate the cause of edema with a high degree of accuracy if careful attention is given to certain radiographic features. The principal features useful for correctly determining the cause of edema in a high percentage of cases are the distribution of pulmonary blood flow, distribution of pulmonary edema, and vascular pedicle width. Ancillary features are pulmonary blood volume, bronchial cuffing, septal lines, pleural effusion, and air bronchograms. Cardiac size and shape as well as specific intracardiac calcifications could also help distinguish cardiogenic from noncardiogenic pulmonary edema.

Left midcardiac border of frontal chest radiographs of patients with annulo-aortic ectasia.

The utility of the frontal chest radiograph for the diagnosis of annulo-aortic ectasia (AAE) was evaluated in 12 patients with Marfan's syndrome and five patients with incomplete stigmata (forme fruste). Prominence of the left midcardiac border was seen in 11 patients: the upper midsegment in one, the lower midsegment in two, and the whole midsegment in eight patients. Either a linear or an arcuate contour was seen. The contours of the prominent left midcardiac border in three patients who had moderate to marked aortic regurgitation and a cardiothoracic ratio (CTR) over 59% were nonspecific. In the remaining eight patients (47%), the contour was considered to be characteristic of AAE, as suggested by the displacement of either all or part of the right ventricular outflow tract, main pulmonary artery and left atrial appendage. Six patients showed only left midcardiac border prominence. The contour of the left midcardiac border on the conventional frontal chest radiograph is characteristic and of paramount importance for the diagnosis of AAE in Marfan' s syndrome or its forme fruste, particularly in patients whose CTRs are within the normal range.

[Bilateral meningococcal pneumonia in a young Japanese woman].

A 22-year-old woman was admitted to the hospital with complaints of fever, loss of appetite, coughing, sputum production, and right-sided chest pain. The chest X-ray film and computed tomogram showed infiltrates in both lower lung fields. Meningococcal pneumonia was diagnosed when a sputum culture was found to be positive for Neisseria meningitidis. Infection with this organism is uncommon in Japan. The patient had never gone abroad, and the route of infection was unknown. N. meningitidis is a rare cause of respiratory infections. When this organism does cause respiratory disease, it is usually acute bronchitis rather than meningococcal pneumonia. The patient in this case was not immunodeficient. She was also not deficient in a terminal lytic component sequence (deficiency in that sequence promotes meningococcal infection). The patient was emaciated and malnourished, which was thought to have made her more susceptible to infection. Orally administered DU-6859a, one of a new generation of quinolones, was very effective and had no side effects.

[Percutaneous retrieval of intravascular foreign body from the pulmonary artery].

Percutaneous retrieval of intravascular iatrogenic foreign bodies is an important part of interventional radiology. Foreign body retrieval from the pulmonary artery is, however, not easy, and only a few cases reports have appeared in the literature. The authors have successfully removed dislodged CV catheter fragments from the pulmonary artery in 8 patients. Combined use of a long sheath and a balloon catheter is very helpful for this retrieval. The long sheath, originally designed for myocardial biopsy, is safely advanced to the pulmonary artery over the balloon catheter. Foreign bodies can be easily caught with a retrieval basket or snare, which is passed through the sheath. Another convenient device is a "balloon snare," which is a hand-made loop snare with an angiographic balloon catheter and a guide wire. For safe and easy retrieval of foreign bodies from the pulmonary artery, we recommend the combined use of a long sheath and a balloon catheter, or a "balloon snare."

[Perfusion patterns of 99mTc-MAA injected into subcutaneously implanted port--evaluation with SPECT].

Single photon emission computed tomography (SPECT) was performed in conjunction with 99mTc-macroaggregated albumin (Tc-MAA) hepatic arterial perfusion scintigraphy, and Tc-MAA activity was measured quantitatively. Three patients with colorectal liver metastasis were examined. In the first patient, the ratio of radioactivity in the area of the tumor was 3 times that in the surrounding liver. In the second patient, the right hepatic artery was ligated and Tc-MAA was injected into the left hepatic artery. Radioactivity in the right lobe was as much as in the left lobe. In the third patient, the left hepatic artery was ligated and Tc-MAA was injected into the right hepatic artery. Radioactivity was higher in the left lobe than in the right lobe. Previous reports suggested that Tc-MAA distribution accurately reflects the drug distribution injected into a regional blood supply. SPECT is useful in quantitative evaluation of Tc-MAA distribution.

[Transcatheter arterial embolization therapy of metastatic bony tumor in hepatocellular carcinoma--a case report].

Metastatic bony tumor was found in a patient with liver metastasis of hepatocellular carcinoma, 5 years and 2 months after hepatectomy. Transcatheter arterial embolization therapy via lumbar artery was performed two times, at first with 20 mg of doxorubicin. The response was Progressive Disease by CT and bone scintigraphy, but recovery of performance status 4 to 2 was achieved in five days. In conclusion, transcatheter arterial embolization therapy may be a choice of therapy for metastatic bony tumor of hepatocellular carcinoma.

[MR imaging of aortic arch anomalies--an analysis of MR visualization of ductus arteriosus].

MR imaging of 10 patients with aortic arch anomaly was performed on a 1.0 T system. Coronal and sagittal images with a 5 to 6-mm-thick slice were taken in each patient and the visibility of the ductus arteriosus (ductus ligament) was detected on the sagittal images including its anatomical connection between the pulmonary trunk and arch vessel. The result indicates that MR imaging is of great help for detection of the ductus in case of aortic arch anomaly.

Coronary angiographic abnormalities in mucocutaneous lymph node syndrome: acute findings and long-term follow-up.

Coronary arterial changes in mucocutaneous lymph node syndrome were evaluated by retrospectively analyzing 62 coronary angiograms of 42 patients with abnormal coronary arteries. A total of 108 aneurysms on the initial studies were classified as follows: eight diffuse, 18 saccular, and 50 fusiform aneurysms and 32 localized areas of dilatation. These were also classified as large, medium, or small aneurysms. Approximately one-third of the aneurysms were in the right coronary artery and two-thirds in the left. Seventy percent of the aneurysms were located in the proximal portion of the coronary artery, 16% in the middle portion, and 14% in the distal portion. Sixteen patients were followed up with angiography for periods ranging from 4 months to 8 years 11 months. At follow-up, 48% of the 62 aneurysms had regressed to normal, 37% were diminished in size, and 10% were unchanged. Small and medium-sized aneurysms frequently showed complete regression. In contrast, large aneurysms tended to persist, and stenotic lesions formed at or adjacent to the aneurysm in 41%. Aneurysms larger than 9 mm in diameter, especially those that were diffuse in shape, carried a high risk of subsequent total occlusion.

[Evaluation of left ventricular function by digital subtraction angiography: effect of dose and administration mode of contrast medium, and comparison with direct ventriculography].

Effects of contrast medium doses on left ventriculographic images using intravenous digital subtraction angiography (IVDSA-LVG) were assessed. The validity of IVDSA-LVG in evaluating ejection fraction (EF) and left ventricular regional wall motion was determined by comparison with conventional left ventriculography using direct injection (direct LVG). The advantages of left ventriculography using intraarterial subtraction angiography (IADSA-LVG) performed by injecting small doses of contrast media directly into the left ventricle were stressed. To assess the effects of doses of contrast media on IVDSA-LVG, 10, 20, and 30 ml Urografin-76 were injected into the superior vena cava in 16 patients, and the resulting images were compared in each patient. With only 10 ml contrast medium, left ventricular opacification was fairly good, and regional wall motion was evaluated in many cases, but 30 ml were needed to calculate ventricular volume and EF. To determine the validity of IVDSA-LVG in evaluating EF and regional wall motion, we compared IVDSA-LVG using 30 ml of contrast medium with direct LVG in 18 patients. There was a good correlation between the two methods in determining EF (r = 0.877), and 90% of the interpretations of regional wall motion were in agreement by the two methods. IVDSA-LVG was useful and accurate in evaluating EF and regional wall motion of the left ventricle. IADSA-LVG was performed for five patients, and good quality images were obtained in many cases, even with relatively small doses (10 ml) of contrast media. These results suggested that this method may be used in cases with impaired LV function, to avoid hemodynamic derangement induced by conventional direct LVG using large doses of contrast medium.

Nonsurgical retrieval of an accidentally dislodged vent catheter retention ring.

During open mitral commissurotomy in a patient with mitral stenosis, a vent catheter retention ring was accidentally slipped off into the left atrium and lodged near the orifice of the right renal artery. Nonsurgical retrieval of this intraarterial foreign body was performed successfully under fluoroscopic guidance in the operating room using a combined approach of angiographic catheters and guidewire, these being inserted via the arteriotomy site of the right femoral artery created for cardiopulmonary bypass.

Abdominal scanning with Tc-99m red blood cells. False-positive study due to ectopic kidney.

Abdominal scanning with Tc-99m red blood cells performed in a patient with gastrointestinal bleeding demonstrated a localized area of increased activity in the pelvic region that simulated either bleeding in a mass or encapsulated bleeding. Contrast angiography confirmed that the bleeding was due to a right ectopic kidney.

Evaluation of intracardiac thrombus with computed tomography.

Left atrial (LA) and left ventricular (LV) thrombus was evaluated by computed tomography in 56 patients. The patients were divided into 2 groups: Group I, 28 patients with mitral valve disease, and Group II, 28 patients with myocardial infarction. Computed tomography and 2-dimensional echocardiography were performed in all the patients studied. Cineangiocardiography was performed in all Group I and in 13 Group II patients. Open heart surgery or autopsy was performed in all Group I and 4 Group II patients. The sensitivity in detecting LA thrombus was 100% with computed tomography, 70% with angiocardiography, and 60% with 2-dimensional echocardiography. The specificity in detecting LA thrombus was 91% with computed tomography, 86% with 2-dimensional echocardiography, and 88% with angiocardiography. Thrombi located at the LA appendage were associated with great difficulties in detection by other methods, but were well delineated with computed tomography. LV thrombus was also visualized by computed tomography with similar or greater accuracy than other diagnostic methods, although the sensitivity and specificity were not ascertained because surgery or autopsy was performed in only a minority of Group II patients. Therefore, as far as the detection of intracardiac thrombus is concerned, computed tomography has the advantage of offering uniform slices of the heart in an attempt to detect thrombi in unknown areas of cardiac chambers, including the LA appendage or LV apex, without being disturbed by the surrounding cardiac and noncardiac structures. Thus, computed tomography has excellent accuracy in the detection of intracardiac thrombus.

Plain radiographic diagnosis of thrombosis of left atrial appendage in mitral valve disease.

Conventional posteroanterior chest radiographs of 42 patients with mitral valve disease who had had surgery were analyzed, and particular attention was directed to the presence or absence of the convexity of the left lower midcardiac border (left atrial segment). The flatness or concavity of this segment, despite other evidence of left atrial enlargement, was observed in six (60%) of 10 patients who had left atrial thrombosis, and in three (9%) of 32 patients who did not have thrombosis (false positive diagnosis). Four of the 10 patients who had left atrial thrombosis did not show this finding on the radiographs (false negative diagnosis). One of these four had a thrombus only against the posterior wall of the body of the left atrium. Therefore, the accuracy in the diagnosis of thrombosis of the left atrial appendage was 66.7% (six of nine) for patients who had thrombosis of the appendage. Standard chest radiographs are important in the evaluation of the patient with thrombosis of the left atrial appendage.