A case report of a normal aorta misdiagnosed as type A dissection by modern multidetector computed tomography.

Computed tomography (CT) is generally considered the investigation of choice to exclude acute aortic syndrome. We report an important potentially disastrous misdiagnosis using a modern 32 slice multidetector CT system.

The role of computerized tomography in the evaluation of gastrointestinal bleeding following negative or failed endoscopy: a review of current status.

Gastrointestinal bleeding remains an important cause for emergency hospital admission with a significant related morbidity and mortality. Bleeding may relate to the upper or lower gastrointestinal tracts and clinical history and examination may guide investigations to the more likely source of bleeding. The now widespread availability of endoscopic equipment has made a huge impact on the rapid identification of the bleeding source. However, there remains a large group of patients with negative or failed endoscopy, in whom additional techniques are required to identify the source of bleeding. In the past, catheter angiography and radionuclide red cell labeling techniques were the preferred 'next step' modalities used to aid in identifying a bleeding source within the gastrointestinal tract. However, these techniques are time-consuming and of limited sensitivity and specificity. In addition, catheter angiography is a relatively invasive procedure. In recent years, computerized tomography (CT) has undergone major technological advances in its speed, resolution, multiplanar techniques and angiographic abilities. It has allowed excellent visualization of the both the small and large bowel allowing precise anatomical visualization of many causes of gastrointestinal tract (GIT) bleeding. In addition, recent advances in multiphasic imaging now allow direct visualization of bleeding into the bowel. In many centers CT has therefore become the 'next step' technique in identifying a bleeding source within the GIT following negative or failed endoscopy in the acute setting. In this review article, we review the current literature and discuss the current status of CT as a modality in investigating the patient with GIT bleeding.

Case report. Renal cell carcinoma vertebral body metastasis extending into the azygos venous system causing superior vena cava obstruction.

We describe a case of superior vena cava (SVC) obstruction caused by extension of tumour thrombus from a vertebral body metastasis through the azygos system to the SVC. The primary tumour was a renal cell carcinoma.

Embolization of iatrogenic venous pseudoaneurysm.

A case is described where a patient on long-term anticoagulation developed a venous pseudoaneurysm in the antecubital fossa following venepuncture. This venous pseudoaneurysm was successfully treated with coil embolization.

A prospective controlled study of high-resolution thyroid ultrasound in patients with globus pharyngeus.

The sensation of a lump in the throat may be the presenting symptom of thyroid enlargement, but the majority of thyroid abnormalities are undetectable by clinical examination. The thyroids of 43 patients with globus pharyngeus and 33 controls were prospectively examined by high-resolution ultrasound, to test the hypothesis that a higher incidence of impalpable thyroid abnormalities exists in patients with globus pharyngeus than in the normal population. Abnormalities were present in 31/43 (72%) patients with globus and in 11/33 (33%) controls (P < 0.001). Of the patients with globus, 17 had solitary nodules or cysts, 10 had multiple abnormalities and diffuse abnormality was present in four patients. Solitary nodules ranged from 4 to 29 mm. Impalpable, ultrasound-detectable abnormalities are significantly more common in patients with globus pharyngeus than in controls. Abnormalities of the thyroid gland may be responsible for globus symptoms.

Long-term venous access service based in the barium room.

27 totally implantable venous access devices (ports), 12 long term dual-lumen venous access catheters and one tunnelled long line were placed over 13 months in a standard district general hospital (DGH) screening room. No significant early complications occurred. Two patients referred from outside hospitals were lost to follow-up. Of the 38 lines with comprehensive follow-up, three required removal because of suspected infection and one because of thrombosis giving a major complication rate of 4 per 6800 access days, i.e. 0.59 per 1000 access days. The minor complications comprised five treatable infections and one resolving subclavian thrombosis in 6800 access days. These rates compare favourably with previous radiological series in which procedures were performed in "clean" vascular suites, and with previous surgical series. Radiological insertion of these devices with rapid scheduling and local anaesthesia methods is feasible in a DGH without the use of a specialized vascular suite.

Superior mesenteric artery blood flow in man measured with intra-arterial Doppler catheters: effect of octreotide.

Changes in splanchnic blood flow are important in the pathogenesis of portal hypertension, but research in this area is hampered by the difficulty in measuring splanchnic arterial blood flow in man. We therefore investigated the use of intra-arterial Doppler catheters in measuring superior mesenteric artery blood flow in man and assessed the effect of intravenous octreotide on superior mesenteric artery blood flow in a placebo-controlled double-blind study. Nine experiments were performed in a flow model using vessels with internal diameters of 6.5, 4.5 and 3.0 mm, with flow rates ranging from 50 to 700 ml/min. In this model the catheters gave instantaneous, reproducible measurements of blood flow in vessels of 6.5 mm internal diameter with a mean error ranging from +5.3% to +36.4%, compared to electromagnetic flowmetry, but were less accurate in smaller vessels. When used in patients, the catheters provided stable, reproducible measurements of superior mesenteric blood flow, in 16 out of 20 patients studied. In a double-blind placebo-controlled study, including 12 subjects, superior mesenteric artery blood flow was significantly reduced in patients receiving octreotide. We suggest that measurement of splanchnic arterial blood flow using intra-arterial Doppler catheters may be a useful additional investigation in the assessment of splanchnic vascular pathophysiology and pharmacology in man.

The influence of needle size on post-myelography headache: a controlled trial.

This study aimed to test the hypothesis that the use of fine rather than larger calibre needles for myelography reduces the incidence of post-procedural headache. 160 patients were randomized in a prospective controlled trial of 22 gauge versus 26 gauge needles. The incidence and overall severity of headache as measured at 1, 4 and 21 days after myelography was not significantly different in the two groups.

Thrombolysis in high risk patients.

The advent of intra-arterially administered thrombolytic agents of minimal antigenicity, together with small gauge good torque control catheters, enables thrombolysis to be used in patients that may previously have been deemed unsuitable for thrombolytic therapy. Thrombolysis may be used even in the presence of factors formerly and empirically considered to be contra-indications. The continued use of thrombolytic agent may also be warranted despite iatrogenic complications such as vessel wall perforation, particularly if the alternative is major amputation. We report on a series of eight patients in whom intra-arterial tissue plasminogen activator was used despite either recent vascular surgery, or iatrogenic vessel perforation. Suggestions for the use of thrombolysis in high risk patients and following iatrogenic complications are discussed.

Computed tomography of cranial metastatic malignant melanoma: features, early detection and unusual cases.

The cranial computed tomographic (CT) scans reported as showing metastatic disease in patients with malignant melanoma (MM) seen at the Westminster Hospital over a 5 year period were reviewed. Ninety-eight patients with intracranial metastatic MM were identified. Twelve had an initial scan which was reported as normal and particular attention was given to these to see if, in retrospect, any early features of metastatic disease were discernible. Fifty-eight cases showed the "typical" features of intracranial MM; the remainder were unusual in appearance, behavior, or site. Radiological regression was shown in only seven cases on follow-up scans; all but one of these patients had one or two large metastases. No significant lesion was thought to have been missed on a scan after the administration of intravenous contrast medium, but the lesions of three patients were difficult to discern on plain scans. Thus when MM metastasis is suspected, the use of the contrast-only scan is advocated.