Use of magnetic resonance imaging in evaluation of placental invasion.

AIM: To review and describe the magnetic resonance imaging (MRI) features in patients with suspected placental invasion and correlate the findings with surgery and pathology findings. MATERIALS AND METHODS: A retrospective review was undertaken of the MRI images of seven consecutive patients with ultrasound findings suspicious for placental invasion. Two experienced MRI radiologists, blinded to the pathology and surgery findings, reviewed the MRI. The pathology or surgical findings were used as the reference standard to establish accuracy and concordance with the MRI findings. RESULTS: Three MRI features described in an earlier series were consistently present in the patients with placental invasion: lower uterine bulging, heterogeneous placenta, and dark intraplacental linear bands on T2-weighted images. CONCLUSION: MRI features, which were described in patients with placental invasion in an earlier series, were useful in establishing the presence and depth of placental invasion.

Gadolinium-enhanced magnetic resonance angiography in renal artery stenosis: comparison with digital subtraction angiography.

OBJECTIVES: To evaluate the accuracy of gadolinium-enhanced magnetic resonance angiography in assessing renal artery stenosis compared to catheter digital subtraction angiography. DESIGN: Retrospective study. SETTING: Singapore General Hospital. PATIENTS: Records of patients who underwent magnetic resonance angiography as well as digital subtraction angiography for assessment of renal artery stenosis from January 2003 to December 2005 were reviewed. RESULTS: There were 27 patients (14 male, 13 female) with a mean age of 62 (range, 44-77) years. There were 10 patients with renal transplants; their native renal arteries were not evaluated. Each of the two experienced interventional and body magnetic resonance radiologists, who were blinded to the results, reviewed the digital subtraction angiography and magnetic resonance angiography images respectively. Digital subtraction angiography was used as the standard of reference. A total of 39 renal arteries from these 27 patients were evaluated. One of the arteries was previously stented and could not be assessed with magnetic resonance angiography due to severe artefacts. Of the remaining 38 renal arteries, two were graded as normal, seven as having mild stenosis (<50%), eight as having moderate stenosis (> or =50% but <75%), and 21 as having severe stenosis (> or =75%). Magnetic resonance angiography and digital subtraction angiography were concordant in 89% of the arteries; magnetic resonance angiography overestimated the degree of stenosis in 8% and underestimated it in 3% of them. In the evaluation of clinically significant renal artery stenosis (> or =50%) with magnetic resonance angiography, the overall sensitivity, specificity, positive predictive value, and negative predictive value were 97%, 67%, 90%, and 86% respectively. The sensitivity and specificity of magnetic resonance angiography in transplant renal artery stenosis was 100%. CONCLUSION. Our experience suggested that gadolinium-enhanced magnetic resonance angiography is a sensitive non-invasive modality useful in the assessment of clinically significant renal artery stenosis.

Prevalence of significant extracoronary findings on multislice CT coronary angiography examinations and coronary artery calcium scoring examinations.

The purpose of the study was to review the prevalence of significant extracoronary findings in patients who underwent multislice CT coronary angiography examinations and coronary artery calcium scoring examinations. We reviewed the reports of 295 consecutive patients who underwent multislice CT coronary angiography examinations and 140 consecutive patients who had separate coronary calcium scoring examinations from September 2004 to March 2006 in our department's radiology information system. Additional investigations carried out as a result of these findings were also recorded. Fifty-six (19%) out of 295 patients had significant extracoronary findings on coronary CT angiography requiring clinical or radiological follow up. There were 60 significant extracoronary findings. These included 24 patients who had pulmonary abnormalities, 4 who had mediastinal abnormalities, 20 who had upper abdominal abnormalities and 5 who had non-coronary cardiac abnormalities. Three patients had both pulmonary and upper abdominal abnormalities. Eleven (8%) out of 140 patients had significant pulmonary, breast, mediastinal, upper abdominal and cardiac abnormalities on coronary artery calcium scoring examinations, yielding a total of 12 significant findings. In our experience, 19% of the patients who underwent multislice CT coronary angiography and 8% of the patients who underwent coronary artery calcium scoring examinations had significant extracoronary findings requiring follow up. It is therefore imperative for the reporting physician to review the entire examination after the coronary arteries have been assessed. The prevalence of extracoronary findings on these examinations may be of significance, resulting in additional 'hidden costs' if widespread 'screening' is adopted.

Enterolith formation in the roux limb hepaticojejunostomy.

Enterolith in the Roux limb of Roux-en-Y hepaticojejunostomy is rare. We report a case of a Roux loop enterolith presenting with recurrent cholangitis. Cholescintigraphy and magnetic resonance imaging aided in the preoperative diagnosis. Intraoperatively, a large enterolith was extracted distal to the biliodigestive anastomosis. A kink of the small bowel was also noted distal to the stone. The mechanism for enterolith formation in the Roux loop is discussed.

Endovascular stent graft treatment of leaking thoracic aortic tuberculous pseudoaneurysm.

Mycobacterium tuberculosis infection is one of the leading causes of death from communicable diseases worldwide. However, the incidence of leaking thoracic aortic tuberculous pseudoaneurysms is rare as a complication. Conventional treatment of a leaking tuberculous pseudoaneurysm involves surgery with graft interposition or patch repair. With the emergence of stent graft treatment as a viable option for leaking pseudoaneurysms, we report a 63-year-old man who had his leaking toracic aortic tuberculous pseudoaneurysm treated with endovascular stent grafting.

Coronary subclavian steal syndrome: a rare cause of acute myocardial infarction.

The coronary subclavian steal syndrome (CSSS) leading to an acute myocardial infarction (AMI) post-coronary bypass is a rare occurrence. We describe an 83-year-old Indian man who presented with AMI and was subsequently found to have CSSS. The patient had severe stenosis of his left subclavian artery ostium with retrograde flow up his left internal mammary artery graft. Angiographical steal from the left anterior descending artery was demonstrated during coronary angiogram and was thought to be the main contributing cause of his AMI. Percutaneous transfemoral angioplasty and stent implantation was performed to the left subclavian artery, with resolution of myocardial blood flow steal and anterior ischaemia.

Constrictive pericarditis--a rare but important cause of recurrent cardiac failure: a case report.

Constrictive pericarditis (CP) is an uncommon cardiac disease which is often difficult to diagnose because of its vague and myriad clinical presentations. We report a case of a middle-aged lady who had non-specific symptoms and signs for six years before she was eventually diagnosed to have idiopathic constrictive pericarditis. An awareness and understanding of this condition is important, as it is a progressive condition and the likelihood of cure depends very much on its early identification and treatment.

Primary intrathoracic malignant effusion: a descriptive study.

BACKGROUND: Patients who present with malignant pleural/malignant effusion without a definite primary site are not well described in the medical literature. In the course of our clinical practice, we have observed certain traits that are peculiar to patients with such a presentation. We have applied the term primary intrathoracic malignant effusion (PIME) to describe this condition. STUDY OBJECTIVES: Patients must fulfill the following criteria before a diagnosis of PIME can be made: clinical presentation dominated by pleural/pericardial effusion; histologic proof of malignancy obtained from the pleura and/or pericardium; no definite primary site in the lungs or elsewhere from CT scan of the chest, chest radiograph, or physical and endoscopic examination; no history of malignancy; and no history of asbestos exposure. Exposure to environmental tobacco smoke (ETS) among the nonsmokers was examined in a case-control setting. METHODS: We conducted a retrospective search of our database of patients who were referred to the Department of Medical Oncology with a diagnosis of pleural/pericardial effusion from January 1993 to January 2000. RESULTS: Seventy-one of 200 patients from our database met the criteria. A significant majority of the patients were women (65%) and nonsmokers (72%). All patients had adenocarcinoma shown on biopsy. The majority of patients (63%) had disease localized to the intrathoracic serosal surfaces; the rest had distant metastases involving the lung (50%), bone (27%), liver (19%), brain (8%), and skin (4%). Six patients had two or more sites of distant metastases. There was a significant association with ETS exposure when compared to a control group comprised of patients with colonic cancer, matched for sex and age. The median survival was 10 months for patients with disease localized to the pleura/pericardium and 7 months for those with distant metastases. Thirty-eight patients (54%) received chemotherapy. All had platinum-based chemotherapy, except for three patients. The median survival for patients treated or not treated with chemotherapy was 12 months and 5 months, respectively. This difference in survival was statistically significant (p = 0.003). CONCLUSIONS: PIME should be viewed as a distinct entity. Its etiology remains largely unknown, although exposure to environmental tobacco smoke may play a part. Platinum-based chemotherapy may have a positive biological effect on this disease. More studies are required to elucidate the epidemiology, possible etiologic factors, and treatment options for this group of patients.

Tension pneumocephalus and pneumorachis secondary to subarachnoid pleural fistula.

A case of tension pneumocephalus and pneumorachis secondary to a subarachnoid pleural fistula after thoracic spinal surgery is described. This rare complication was diagnosed on CT. The imaging findings, significance and management of this unusual condition are discussed.

Primitive neuroectodermal tumour of the chest wall--a report of two cases and review of literature.

INTRODUCTION: Primitive neuroectodermal tumours (PNETs) of the chest wall are rare entities and little is known regarding its biological activity and prognostic factors. Two cases are reported and the available literature reviewed to highlight the presentation and management of these tumours. CLINICAL FEATURES: We report 2 patients who were diagnosed with PNET of the chest wall in our centre. As there are no clinical features or basic diagnostic measures which are characteristic of these tumours, diagnosis is based on special tests. With the advent of newer immunohistochemical methods, it is now diagnosed more confidently. TREATMENT: Both patients received multidisciplinary modalities of treatment, comprising extensive surgical resection, chemotherapy and radiotherapy. OUTCOME: One patient succumbed to the disease one year after diagnosis and the other is currently disease-free, both clinically and radiologically at 24 months. CONCLUSION: Despite multidisciplinary modalities of treatment, the prognosis of PNET is still generally poor. Early diagnosis and treatment are important to improve the chances of survival.

Distribution patterns of inflammatory sinonasal diseases.

BACKGROUND/AIM OF STUDY: There has been an increase in the demand for coronal sinus CT scan since the introduction of functional endoscopic sinus surgery; as the information provided by the scans assist the surgeon in the pre-operative plannings. Babbel and colleagues had demonstrated five distinctive patterns of recurring inflammatory sinonasal disease on CT scan. The aim of this study was to evaluate the patterns in the local population and to see if there was a difference compared to the Caucasian population. METHODS AND MATERIALS: A retrospective review of 302 scans done between March 1993 and September 1995 was carried out. All scans were carried out using a 5 mm thickness to cover the posterior sinuses and a 3 mm thickness to cover the anterior sinuses. The scans were then grouped into the various patterns and an analysis was carried out comparing the differences in the patterns between the Chinese and the non-Chinese, and between the local population and the Caucasian population in Babbel's series. RESULTS: There was no significant difference between the Chinese and the non-Chinese in the distribution of the various disease patterns. When compared to the Caucasian population, the local population had more sinonasal polyposis and sphenoethmoidal recess obstruction. CONCLUSION: The smaller nasal passages of the Asians, particularly in the Chinese, could be the reason for the more prevalence of Type III and Type IV disease compared to the Caucasian population. The more constant and frequent exposure to allergens might also contribute to the increased prevalence of Type IV disease.

The reproducibility of bronchial circumference measurements using computed tomography.

Objective measurement of bronchial damage in patients with bronchiectasis is needed to identify progressive disease. This study evaluates the inter- and intraobserver variation in computed tomography (CT) measurements of bronchial wall circumference and examines the precision with which CT measurements of the bronchi can be repeated in patients with bronchiectasis. Twelve patients were scanned and the circumferences of 61 subsegmental bronchi were measured independently on two occasions, by three observers, using a tracing facility on the CT console. To determine the accuracy with which previously acquired sections could be repeated, five patients were scanned on two separate occasions. The mean bronchial circumference measured by the three observers was 16.1 +/- 8.3 mm. The standard deviations of differences between first and second measurements of bronchial circumference for the three observers (intraobserver variability) were: 0.60 mm, 0.67 mm and 0.40 mm. The standard deviation of readings for interobserver variability was 0.71 mm. The standard deviations of differences (and coefficients of variation) for measurements of bronchial circumference following rescanning were: 1.82 mm, 1.40 mm and 1.74 mm (9.9%, 7.6% and 9.3%, respectively). The reproducibility of measurements of wall circumference, between and within observers and between examinations, indicates that such measurements may be clinically useful in demonstrating the progression of bronchiectasis.

Computed tomography of diffuse pulmonary haemorrhage with pathological correlation.

The utility of computed tomography (CT) is well established in patients with chronic interstitial lung disease. There are currently no descriptions of the CT appearances of diffuse pulmonary haemorrhage. The CT findings of six patients with diffuse pulmonary haemorrhage are presented. Pathological correlation from open lung biopsies in two of these patients provided a pathological basis for the CT appearances. All six patients had diffuse nodular opacities with no zonal predominance. The nodules were of uniform size in any single patient but varied (1-3 mm diam.) between patients. Patchy areas of 'ground-glass' opacification of the lung parenchyma due to recent haemorrhage was associated with apparent prominence of the segmental bronchi and obscured the background nodularity. The CT findings were similar in all six patients and, although not pathognomonic, awareness of the CT features described should raise the possibility of the diagnosis.

Microbiology of cerebral abscess: a four-year study in Malaysia.

A prospective study was carried out to determine the aetiology of cerebral abscess in relation to the primary source of infections. Seventy-five patients with cerebral abscess were included in the study in the period January 1985 to December 1988. More than half of the patients studied had single lesions and the overall most common sites were in the frontal and parietal regions. Chronic suppurative otitis media, cyanotic congenital heart diseases and meningitis were among the important predisposing conditions in these patients. Approximately 25% of the patients with cerebral abscesses had no documented antecedent infections. Pure cultures were found to be predominant (66.7%) and sterile cultures were obtained from 10 (13.3%) patients. Streptococci were isolated from 23 (30.7%) patients, the commonest species being Streptococcus milleri. Proteus sp, Pseudomonas aeruginosa, Pseudomonas putrifaciens and Bacteroides sp were almost exclusively found in cerebral abscesses secondary to chronic suppurative otitis media; these organisms were found in mixed cultures. Streptococcus milleri, Bacteroides sp and Eikenella corrodens were found in pure cultures in patients with cyanotic congenital heart disease. In patients with ventriculoperitoneal shunts in-situ, Staphylococcus aureus, Staphylococcus epidermidis and diphtheroids were common. Anaerobes were found in 15 (20.0%) patients, the majority in mixed cultures. Culture, as well as gas-liquid chromatographic analysis of volatile fatty acids of cerebral pus, was carried out to enhance the detection of the anaerobes. Based on these findings, an antibiotic regimen consisting of penicillin, chloramphenicol and metronidazole is recommended as an initial therapy while awaiting culture and sensitivity results.

Use of gas liquid chromatography as an adjunct to conventional bacteriological methods in the diagnosis of anaerobic cerebral abscess.

Forty cases of cerebral abscesses were studied prospectively to establish the microbial agents implicated in these cases. Chronic otitis media (14 patients, 35%), congenital heart disease (five patients, 12.5%),a and meningitis (five patients, 12.5%) were among the important predisposing factors. Streptococcus (14 patients, 35%) was the most common causative pre-isolated, the predominant species being Streptococcus milleri (11 patients, 27.5%). Other organisms isolated included Proteus mirabilis in six patients (15%) and Staphylococcus aureus in five patients (12.5%). Anaerobes (12 patients, 30%), predominantly Bacteroides sp. (eight patients, 20%), played an important role in these cases, the majority of which were isolated in mixed cultures. Gas-liquid chromatographic analysis of pus detected the presence of anaerobes in another 11 cases of cerebral abscess, in which cultures of anaerobes were negative. Therefore, gas-liquid chromotography is useful as an adjunct to conventional bacteriological methods in providing a rapid and sensitive means of detecting anaerobes in pus obtained especially from patients who had received antibiotic therapy prior to hospitalization.

Case report: deep venous thrombosis diagnosed on indium-111 labelled white cell scanning.

We report a patient with pyrexia in whom deep venous thrombosis was diagnosed incidentally on Indium-111 labelled white cell scanning. The role that white cells play in thrombogenesis is discussed.