Successful management of tracheo-innominate artery fistula with endovascular stent graft repair.

Tracheo-innominate artery fistula is a highly lethal complication after tracheostomy. A 37-year-old man who had undergone a tracheostomy 14 years earlier because of dysphagia after brain surgery had a tracheo-innominate artery fistula with exsanguinating hemorrhage from his tracheostomy site. After temporary control of the bleeding, a stent graft was implanted in the innominate artery through the brachial artery. The patient recovered uneventfully and remained well 14 months after the procedure, with no sign of infection. Endovascular stent grafting may be the treatment of choice for patients with tracheo-innominate artery fistula.

Sjögren's syndrome: comparison of assessments with quantitative salivary gland scintigraphy and contrast sialography.

UNLABELLED: This study compared the quantitative parameters of salivary gland scintigraphy and the sialographic stages in patients with Sjögren's syndrome. METHODS: One hundred sixteen patients suspected of having Sjögren's syndrome were examined with salivary gland scintigraphy and contrast sialography. When contrast sialography was used as the gold standard, Sjögren's syndrome was diagnosed in 50 of these 116 patients; Sjögren's syndrome was not seen in the other 66 patients. After injection of 370 MBq 99mTc-sodium pertechnetate, dynamic salivary gland scintigraphy with lemon juice stimulation was performed for 50 min. Functional parameters for the parotid and submandibular glands were calculated, and scintigraphic and sialographic results were compared. RESULTS: With the progression of sialographic stages from 0 to 4, the quantity of tracer accumulation decreased in the submandibular gland (P < 0.0001), and the quantity of tracer secretion decreased in the parotid gland (P < 0.0001). The sialographic stage in patients with Sjögren's syndrome was correlated with these scintigraphic parameters (P < 0.0001): sialographic stage = 3.243 - 0.337 x (submandibular gland uptake ratio) - 0.026 x (parotid gland maximum secretion). CONCLUSION: The decreased accumulation in the submandibular gland and the decreased secretion in the parotid gland were highly sensitive indicators of salivary gland disease in Sjögren's syndrome. The sialographic stage was correlated with these scintigraphic parameters.

Perfusion and blood pool scintigraphy for diagnosing soft-tissue arteriovenous malformations.

PURPOSE: Six arteriovenous malformations were assessed to determine the effectiveness of perfusion and blood pool scintigraphy to diagnose arteriovenous malformations of soft tissue. METHODS: After injection of Tc-99m RBC or Tc-99m DTPA-HSA, dynamic perfusion and early and delayed blood pool images were analyzed. RESULTS: Four of six arteriovenous malformations showed increased activity on perfusion images and slightly increased activity on blood pool images; the remaining two arteriovenous malformations showed increased activity on perfusion and normal activity on blood pool studies. CONCLUSIONS: This expansion of the authors' previous studies of hemangiomas shows that perfusion and blood pool scintigraphy are useful methods to differentiate arteriovenous malformations from various types of hemangiomas.

67Ga whole-body scintigraphy in the evaluation of head and neck squamous cell carcinoma.

The diagnostic accuracy of 67Ga-citrate whole-body scintigraphy for the evaluation of primary tumours, local recurrences, cervical node metastases and distant metastases was investigated in patients with head and neck squamous cell carcinoma (SCC). Altogether, 102 67Ga-citrate whole-body scans were performed on 83 patients with head and neck SCC using a dual-headed gamma camera. The results were compared with those of computed tomography (CT) and final diagnosis. 67Ga scintigraphy correctly diagnosed 28 of 29 primary lesions, a sensitivity of 97% (CT = 97%). For tumour recurrence, 67Ga scintigraphy correctly diagnosed 13 of 15 recurrences and 53 of 58 instances of no recurrence, giving a sensitivity of 87% and a specificity of 91% (CT = 80 and 62%, respectively). Scintigraphy correctly diagnosed 23 of 31 metastatic sides of the neck and all 173 negative sides of the neck, giving a sensitivity of 74% and a specificity of 100% (CT = 90 and 84%, respectively). Finally, scintigraphy correctly diagnosed all 12 distant metastases as well as 86 of 90 cases of no metastasis, resulting in a sensitivity of 100% and a specificity of 96%. Furthermore, in five patients, distant metastases were initially detected on 67Ga scintigraphy. In conclusion, 67Ga whole-body scintigraphy with a dual-headed camera resulted in a high sensitivity and specificity for the detection of primary lesions, recurrences and distant metastases of head and neck SCC. Although the sensitivity for detecting neck node metastases was relatively low, the specificity was high. Thus, 67Ga scintigraphy is an effective technique for the evaluation of head and neck SCC, especially tumour recurrence and distant metastases.

Quantitative evaluation of salivary gland scintigraphy in Sjörgen's syndrome.

UNLABELLED: This study compared the quantitative characteristics of salivary gland scintigraphy in patients with Sjogren's syndrome with the histopathologic grading of labial biopsy. METHODS: Thirty-nine patients with Sjögren's syndrome were studied by salivary gland scintigraphy and labial biopsy. Twelve normal volunteers were also studied as a control group for scintigraphic parameters. After injection of 370 MBq 99mTc sodium pertechnetate, dynamic salivary scintigraphy with lemon juice stimulation was performed for 50 min. Functional parameters for the parotid and submandibular glands were calculated, and scintigraphic and histopathologic results were compared. RESULTS: With the progression of histopathologic grades 1-4, the velocity of tracer secretion decreased in the parotid gland (P < 0.05), and the quantity of tracer accumulation decreased in the submandibular gland (P < 0.05). The histopathologic grade in patients with Sjögren's syndrome was correlated with these scintigraphic parameters (P < 0.05): Histopathologic grade = 2.304 - 0.014 x (submandibular gland maximum accumulation) + 0.196 x (parotid gland time interval of tracer secretion). CONCLUSION: Decreased secretion velocity in the parotid gland and decreased accumulation in the submandibular gland were sensitive indicators of salivary gland disease in Sjögren's syndrome. The histopathologic grade was correlated with these scintigraphic parameters.

Tl-201 myocardial SPECT in patients with systemic arterial diseases.

We compared the results of Tl-201 myocardial SPECT of patients with arteriosclerosis obliterans (ASO), abdominal aortic aneurysm (AAA), and Takayasu arteritis (TA), so that coronary artery disease could be evaluated in them. Twenty-three patients (ASO, 9; AAA, 8; TA, 6) had Tl-201 myocardial SPECT with stress testing, and SPECT data was assessed qualitatively and quantitatively. Qualitative analysis showed that myocardial perfusion was decreased most in patients with ASO, followed by patients with AAA, and was minimally decreased in patients with TA. Quantitative analysis indicated that segmental uptake was significantly less in four segments in ASO compared with TA, less in two segments in AAA compared with TA, and less in two segments in ASO compared with AAA. Thus patients with ASO and AAA were found to have a marked abnormality in Tl-201 myocardial SPECT, indicating that this procedure should be performed in these patients. In patients with TA, however, because of minimal abnormality in myocardial perfusion, the role of SPECT is limited.

Diagnostic accuracy of technetium-99m-pertechnetate scintigraphy with lemon juice stimulation to evaluate Warthin's tumor.

UNLABELLED: This study investigated the diagnostic accuracy of 99mTc-pertechnetate scintigraphy with lemon juice stimulation for evaluating parotid gland Warthin's tumor. METHODS: Technetium-99m-pertechnetate scintigraphy with intraoral lemon juice stimulation was used to evaluate a total of 68 parotid gland lesions clinically suspected of being Warthin's tumor in 62 patients. Twenty-three of the 68 lesions were subsequently histologically confirmed to be Warthin's tumor, whereas the remaining 45 lesions were histologically diagnosed as being other lesions. RESULTS: Technetium-99m-pertechnetate scintigraphy with lemon juice stimulation correctly diagnosed 18 of 23 Warthin's tumors as being Warthin's tumor but was unable to diagnose the other five Warthin's tumors. Further, scintigraphy correctly diagnosed 41 of 45 non-Warthin's tumors as being non-Warthin's tumor but misdiagnosed other four non-Warthin's tumors as Warthin's tumor. Thus, the sensitivity of scintigraphy for diagnosing Warthin's tumor was found to be 78%, its specificity 91% and its accuracy 87%. On the basis of prestimulation images alone, however, the sensitivity was estimated to be 65%, its specificity 93% and its accuracy 84%. CONCLUSION: For evaluating Warthin's tumor, the sensitivity of 99mTc-pertechnetate scintigraphy was relatively low, although the specificity was sufficiently high. Lemon juice stimulation improved the sensitivity markedly but decreased the specificity slightly. Thus, 99mTc-pertechnetate scintigraphy with lemon juice stimulation should be carefully performed for diagnosis of Warthin's tumor.

The use of three-phase scintigraphy for diagnosing hemangiomas of the extremities. A clinical evaluation.

Five hemangiomas were found in four patients and were assessed by three-phase blood perfusion and blood-pool scintigraphy to determine the usefulness of this method for the imaging characteristics of different types of hemangiomas of the extremities. After injecting Tc-99m RBC or Tc-99m DTPA HSA, dynamic perfusion and early and delayed pool images were obtained and analyzed. The perfusion images of one cavernous hemangioma and two venous hemangiomas showed normal activity, but blood-pool imaging showed increased activity, whereas on perfusion imaging and early blood-pool imaging, another cavernous hemangioma showed a partial increase in activity in its periphery and on delayed blood-pool imaging, diffuse increase in activity. Further, the remaining hemangioma, a mixed-type hemangioma, showed, diffuse increase in activity on both perfusion and blood-pool imaging. Thus, three-phase scintigraphy was found useful in evaluating and achieving a diagnosis of a hemangioma of the extremities.

Perfusion and blood-pool scintigraphy in the evaluation of head and neck hemangiomas.

UNLABELLED: We investigated the sensitivity and specificity of perfusion and blood-pool scintigraphy in the detection of head and neck hemangiomas and evaluated their histopathologic types. METHODS: Perfusion and blood-pool scintigraphy with 99mTc-red blood cells (RBCs) or 99mTc-human serum albumin combined with DTPA (HSA-D) were used to evaluate 51 head and neck lesions clinically suspected of being hemangiomas in 48 patients. Thirty-three of the 51 lesions were subsequently histologically confirmed to be hemangiomas, whereas the remaining 18 were histologically diagnosed as other lesions. RESULTS: Perfusion and blood-pool scintigraphy correctly diagnosed 30 of 33 hemangiomas as being hemangiomas but could not detect the remaining 3 hemangiomas. Perfusion and blood-pool scintigraphy correctly diagnosed 12 of 18 lesions as nonhemangiomas, but the remaining 6 lesions were misdiagnosed as hemangiomas. Thus, the sensitivity for detecting hemangiomas was 91%, with a specificity and accuracy of 67% and 82%, respectively. Twenty-five (89%) of 28 cavernous or venous hemangiomas demonstrated normal activity on the perfusion images and increased activity on the delayed blood-pool images, whereas the remaining 3 (11%) showed normal activity on both perfusion and blood-pool images. Finally, 5 of 5 (100%) capillary or recemose hemangiomas showed increased activity on the perfusion and blood-pool images. CONCLUSION: Perfusion and blood-pool scintigraphy demonstrated sufficiently high sensitivity but relatively low specificity for detecting head and neck hemangiomas. Additionally, perfusion and blood-pool scintigraphy can clearly differentiate between cavernous and venous hemangiomas and capillary and recemose hemangiomas and are extremely useful for the detection and evaluation of head and neck hemangiomas.

SPECT and MRI evaluations of the posterior circulation in moyamoya disease.

UNLABELLED: We evaluated the posterior circulation in patients with moyamoya disease by SPECT and MRI. METHODS: Six patients with idiopathic moyamoya disease were studied by SPECT, MRI and angiography. Patients received an injection of 555-740 MBq of 99mTc-HMPAO, after which SPECT images were taken. The cerebral-to-cerebellar activity ratio in five cerebral regions was calculated to assess the regional cerebral blood flow (rCBF). The SPECT and MRI findings were then compared with angiographic. RESULTS: Of the 12 posterior cerebral arteries (PCAs) in the six patients studied, seven PCAs (58%) in five patients had a stenotic or occluded lesion. Furthermore, rCBF in all five regions significantly decreased as the degree of steno-occlusive lesions of the PCA progressed. No significant correlation, however, was found between the steno-occlusive lesions of the internal carotid artery bifurcation and the rCBF. The rCBF significantly decreased in the absence of leptomeningeal collateral vessels from the PCA to the anterior circulation. On the basis of the MR images, the frequency of cerebral infractions significantly increased in patients with steno-occulasive PCA lesions. CONCLUSION: The rCBF in moyamoya disease decreases proportionally with the degree of steno-occlusive lesions of the PCA. The steno-occlusive PCA lesions decrease the number of leptomeningeal collateral vessels to the anterior circulation, thereby causing severe cerebral ischemia that is likely to result in infractions.

Asymptomatic arteriovenous malformation of the pancreas. Demonstration by Doppler ultrasonography and magnetic resonance imaging.

We reported a case of asymptomatic pancreatic AVM, incidentally found on routine ultrasonography and diagnosed noninvasively by means of Doppler ultrasonography and MRI. The diagnosis was confirmed by angiography. This is the first report to demonstrate the characteristics of pancreatic AVM by these two imaging techniques. They proved to be useful in identifying the vascular nature of AVM without the use of a contrast material, which is a definite advantage over DSA and CT. The quality of the image obtained was equivalent or superior to that obtained by DSA and contrast-enhanced CT. Doppler ultrasonography and MRI may serve as the primary imaging techniques of choice in suspected cases of AVM.

Pulmonary artery disease in Takayasu's arteritis: angiographic findings.

One hundred sixteen arteriographic examinations in 98 patients with Takayasu's arteritis were studied retrospectively to evaluate the extent of aortic and pulmonary disease. Stenosis was the most frequent finding in the aorta and its branches, but occlusion, dilatation, and aneurysms were also seen. Adventitial vascular structures, consistent with dilated vasa vasorum, were observed in five patients (5%) and systemic artery-pulmonary artery communication was seen in six (6%). Twenty-one (70%) of 30 patients who had pulmonary arteriography were shown to have pulmonary artery involvement. Upper lobe pulmonary arterial branches showed abnormalities most frequently; segmental branches, followed by subsegmental branches, were most often involved. The frequency of abnormal findings on pulmonary arteriograms correlated with the number of involved brachiocephalic vessels. Stenotic lesions in the aorta and its branches progressed in five (45%) of 11 patients, and those in the pulmonary artery progressed in one (33%) of three cases. Takayasu's arteritis characteristically involves the systemic and pulmonary arteries, and the extent of arteritis in the major branches of the aortic arch appears to correlate with pulmonary arterial involvement. Both thoracic and abdominal aortographic studies and pulmonary arteriography are necessary to properly diagnose the extent of the disease, and angiography should be repeated for appropriate patient follow-up.

Comprehensive analysis of perfusion scintigraphy in Takayasu's arteritis.

One hundred eighty perfusion lung scans of 120 patients with Takayasu's arteritis were retrospectively evaluated. Lung scans were abnormal in 76% of the patients. Lung scans could be classified into four groups, according to the pattern of perfusion defects. Early involvement occurred in the upper lobes, and the middle and lower lobes were involved at a later stage. The data obtained by physiological examination (spirography and arterial blood gas analysis) showed a weak relationship with the severity of perfusion lung scan findings. In addition, repeated lung scans were found to be easy and reliable in the follow-up period of pulmonary artery involvement.

Effects of isosorbide dinitrate on exercise capacity in cardiac patients--relationship between oxygen uptake responses and hemodynamic effects.

Acute effects of oral isosorbide dinitrate on exercise capacity were evaluated in 14 patients with chronic heart disease measuring the anaerobic threshold and left ventricular function during exercise. A symptom-limited exercise test was performed on a bicycle ergometer with work rates increased by 1W every 6 seconds. Left ventricular function was continuously monitored with a computerized cadmium telluride detector following the intravenous injection of technetium-labeled red blood cells. Thirty minutes after the control exercise test, patients were given isosorbide dinitrate, 5 mg orally. The second exercise test was performed 30 min later. Isosorbide dinitrate improved the anaerobic threshold from 715.4 +/- 172.9 to 774.9 +/- 173.5 ml/min (p less than 0.01) and ejection fraction at peak exercise from 36.7 +/- 11.6 to 39.9 +/- 12.3% (p less than 0.05). However, there was no significant change in maximum work rate or peak oxygen uptake. Those patients for whom isosorbide dinitrate resulted in a 10% or greater improvement in the anaerobic threshold had both higher pre-treatment ejection fractions and greater increases in peak exercise ejection fraction following isosorbide dinitrate. Measurements of the anaerobic threshold and left ventricular function during exercise may be useful in the evaluation of the efficacy of vasodilators in cardiac patients.

Beat-to-beat evaluation of cardiac function during recovery from upright bicycle exercise in patients with coronary artery disease.

The purpose of this study was to evaluate the time course of cardiac function during recovery from upright bicycle exercise in patients with coronary artery disease. Twelve patients with coronary artery disease performed a symptom-limited exercise test on a cycle ergometer. Left ventricular function was continuously monitored during exercise and recovery with a computerized cadmium telluride detector following the intravenous injection of technetium-labeled red blood cells. Although the end-diastolic volume (153.4 +/- 76.1 ml) and end-systolic volume (100.5 +/- 67.3 ml) at the end of exercise were significantly higher than the respective resting values, stroke volume (52.8 +/- 16.1 ml) and ejection fraction (38.0 +/- 12.2%) were not different from the respective resting values. The recovery of cardiac output was relatively slow compared with that of heart rate, because stroke volume rose sharply early in recovery. The rise in stroke volume was chiefly a result of a significant decrease in end-systolic volume between 1 and 4 minutes of recovery. These changes may result from an immediate afterload reduction coupled with a relatively slow decrease in sympathetic stimulation. The time course of cardiac function during recovery from exercise in cardiac patients is substantially different from that of normal subjects and may be a sensitive way to evaluate the peripheral vascular function and deteriorated cardiac function in cardiac patients.

Radionuclide lymphoscintigraphy performed on the mastectomized chest wall.

Lymphatic flow in the anterior chest wall of 64 patients who underwent surgery for breast carcinoma was studies on images of lymphoscintigraphy using 99mTc-rhenium colloid. Scintigraphic images taken 4 hours after the intradermal injection of radionuclides along both sides of the surgical wound frequently made it possible to visualize the contralateral axillary lymph nodes. In particular, among 20 patients with local chest wall recurrence after the mastectomy, the contralateral axillary nodes were demonstrated in 13. Stimulated lymphatic flow seems to be manifested around the site of local recurrence over the chest wall. On the precise analysis of lymphographic images, faint lymphatic drainages were occasionally identified up to the contralateral axillary lymph nodes at various levels of the anterior chest wall. It is essential that the radiation field be made large towards the area including the downstream of the lymphatic flow. Additionally, accumulation of radionuclides in the lymph nodes appeared to be slowly impaired by the postoperative irradiation after the completion of radiotherapy.

[Comparison of three pathologic classifications (Rappaport, LSG and Working Formulation) for the treatment of non-Hodgkin's lymphoma].

Comparison of three pathologic classifications (Rappaport, LSG and Working Formulation) was made for 292 cases of non-Hodgkin's lymphoma who were treated at the Department of Radiology, Tokyo Medical and Dental University, from 1952 to 1984. The Working Formulation was found to be the most convenient classification for the treatment of non-Hodgkin's lymphoma in Japan. There were two remarkable characteristics in the cases of non-Hodgkin's lymphoma classified by the Working Formulation. They were better case distribution having a strong relation to clinical prognosis and fewer high-grade cases in Waldeyer's ring lymphoma.

Diagnosis of aneurysmal bone cyst of the mandible. A report of two cases with emphasis on scintigraphic approaches.

Aneurysmal bone cyst is rarely found in the mandible, and roentgenographic diagnosis of this condition is not easily made. In this report, the diagnostic value of bone scintigraphy and radionuclide angiography and CT imaging in two cases of aneurysmal bone cyst of the mandible are discussed. Bone scintigraphy with Tc-99m MDP demonstrated ring-like or doughnut-pattern accumulation of radioactivity, which corresponded to the expansile character of the bony lesion. The accumulation of radioactivity was intensive in the peripheral region despite the fact that the lesion was benign. Furthermore, the central rarefaction showed that the lesion was cystic. Radionuclide angiography with Tc-99m HSA, including blood pool scan, did not detect radioactive concentration. Thus bone scintigraphy and radionuclide angiography were found to be essential in the differential diagnosis of aneurysmal bone cyst from other forms of tumor, especially hypervascularized tumor and central hemangioma of the mandible.