Angioleiomyoma in the soleus muscle.

We present a case of angioleiomyoma, a benign angiomatous soft tissue tumor in a 52-year-old patient. We empha- size that small nodular tumors showing hypervascularity on MRI or ultrasound may be malignant and should be treated with tumor excision.

Fibrolamellar hepatocellular carcinoma in a 65-year-old woman: CT features.

A 65-year old woman with recurrent deep vein thrombosis underwent a CT scan of the upper abdomen for detection of underlying malignancy. A fibrolamellar hepatocellular carcinoma with extrahepatic subdiaphragmatic satellite lesion was found. This uncommon tumor has distinct clinical, pathological, radiological and prognostic features and therefore it is important to distinguish it from benign liver tumors, especially FNH, and from other malignant liver tumors such as conventional HCC. Though the tumor characteristically occurs in younger patients, our case proves that older patients can also be affected.

CT colonography with fecal tagging after incomplete colonoscopy.

The objective of this study was to evaluate dietary fecal tagging (FT) as a cleansing method prior to CT colonography (CTC) in patients with incomplete conventional colonoscopy (CC). After written informed consent was obtained, 24 patients had standard colonoscopic preparation (ScCl), and 25 patients had FT as cleansing method. Segmental distention, fluid levels, fecal residues, tagged appearance of fluid levels, and residual stool were evaluated. Mann-Whitney U test was used to test for significant differences between FT and ScCl groups. Compared with ScCl, FT improved distention (p=0.001), reduced the amount of fluid (p=0.043), but suffered from residual stool (p=0.046). A clear correlation was found between distention and fluid. No differences were found in stool size between FT and ScCl. FT showed a good labeling of fecal residues, and acceptable labeling of fluid levels. Compared with ScCl, FT reduces fluid, favors distention, but suffers from fecal residues. The tagged nature of these residues, however, allows differentiation from polyps.

Claudication type lower limb pain in an athlete without atherosclerotic risk factors: a case of cystic adventitial disease of the popliteal artery.

Cystic adventitial disease (CAD) of popliteal artery is a rare cause of lower limb claudication. Since its first description in 1947 only about 323 cases have been reported in the literature. We report the case of a 45 year old man with CAD of the popliteal artery causing progressive left lower leg claudication detected by US and Doppler US and characterized with spiral CT angiography. No communication with the knee joint could be demonstrated.

Diverticular disease in CT colonography.

The aim of this study was to evaluate findings on CT colonography (CTC) in patients with diverticular disease. In a retrospective analysis of 160 consecutive patients, who underwent CTC and conventional colonoscopy (CC), patients with diverticular disease were retrieved. The CTC images were compared with CC and, if possible, with pathology. Findings on both 2D and 3D images are illustrated with emphasis on diagnostic problems and the possible solutions to overcome these problems. Several aspects of diverticulosis were detected: prediverticulosis (3%); global (55.6%); and focal wall thickening (4%) caused by thickened haustral folds, fibrosis, inflammation and adenocarcinoma; diverticula (52%); pseudopolypoid lesions caused by diverticular fecaliths (39%); inverted diverticula (1.2%); and mucosal prolapse (0.6%). Solutions to overcome pitfalls are described as abdominal windowing, content of the pseudopolypoid lesion, comparison of 2D and 3D images, prone-supine imaging and the aspect of the pericolic fat. In this series there were equivocal findings in case of mucosal prolapse (0.6%) and focal wall thickening (4%). Diverticulosis is a challenge for CTC to avoid false-positive diagnosis of polypoid and tumoral disease. Knowledge of possible false causes of polypoid disease and comparison of 2D and 3D images are necessary to avoid false-positive diagnosis. In case of equivocal findings additional conventional colonoscopy should be advised whenever a clinically significant lesion (> or = 1 cm) is suspected.

Optimisation of colon cleansing prior to computed tomographic colonography.

Colon preparation technique is a major determinant factor for patient compliance and polyp detection in computed tomographic colonography (CTC). The purpose of this study is to compare three different colon cleansing techniques in terms of patient discomfort, sensitivity and specificity. The following colon cleansing methods were compared in 20 patients each: 1. standard colonoscopy cleansing (ScCl) the day of the examination, based on polyethylene glycol (PEG), 2. a slightly reduced cleansing (RcCI) the day prior to the examination, based on a combination of diet, bisacodyl and a reduced intake of PEG, and 3. a cleansing with dietary fecal tagging (FT) the day prior to the examination, based on a combination of diet, bisacodyl, magnesium citrate and a dedicated barium suspension. ScCl resulted in a clean colon, but produces fluid levels hampering a complete CTC and possibly resulting in false negative diagnosis. RcCl reduced the problem of fluid levels, but was faced with the problem of fecal residues, resulting in false positive diagnosis. FT offered the possibility to obtain a dry colon, with labelled fecal residues, thus reducing false positive findings. Optimisation of the diet and replacement of PEG by magnesium citrate in FT reduced the preparation related discomfort and improved the final opinion. FT is the preferred colon cleansing technique because, compared to ScCl, fluid levels are reduced, and compared to RcCl, differentiation between faecal residues and polyps is improved. Moreover, FT reduces preparation related discomfort, compared to both RcCl and ScCl.

Percutaneous treatment of acute multiple limb ischemia.

This study evaluates the use of pulse spray pharmacomechanical thrombolysis (PSPMT) in combination with a low dose urokinase infusion and a possible secondary percutaneous treatment in the management of acute multiple limb ischemia. A retrospective analysis of 185 patients treated with PSPMT revealed eight patients with acute simultaneous ischemia of more than 1 limb. Seven patients presented with acute ischemia of both lower limbs; one patient presented with acute ischemia of the left arm and both lower limbs. All patients were treated using a combination of PSPMT and low dose urokinase infusion. The combination of PSPMT and low dose urokinase infusion was completely successful in 6 cases. In 1 patient with bronchogenic carcinoma PSPMT failed and immediate surgical thrombectomy was performed. In the other patient we obtained clot dissolution with thrombolysis in one leg, residual clots at the popliteal level in the other leg however had to be removed by surgical embolectomy. Embolism was the cause of the occlusion in 6 patients. Atherosclerotic disease appeared to be the underlying cause in the other 2 patients. Atherosclerotic disease was treated with balloon angioplasty and stenting. In the 8 patients with multiple limb ischemia, combination of PSPMT, low dose urokinase infusion, and possibly secondary treatment was useful and constituted a valuable alternative to open surgery. Acute occlusion of the abdominal aorta and acute leg ischemia have a high mortality and amputation rate with variable results in treatment. The use of thrombolysis has reduced the necessity of surgery in arterial occlusive disease and simplifies the treatment of native artery occlusion. Especially in patients with long and multi-level occlusions with poor outflow, thrombolysis seems to be the treatment of choice. In our analysis of 8 cases with acute multiple limb ischemia we review our experience with the combination of pulse spray pharmacomechanical thrombolysis (PSPMT), low dose continuous urokinase infusion and a possible subsequent percutaneous treatment of the obstructing lesion. The final purpose was to investigate if this combination is a successful and safe method in the treatment of acute multiple limb ischemia.

Diagnosis and treatment of expanding haematoma of the lateral abdominal wall after blunt abdominal trauma.

We report a rare case of an expanding post-traumatic lateral abdominal wall haematoma. A superselective arteriogram of the deep circumflex iliac artery showed extravasation from the ascending branch, urging emergency therapy. Microcoil and Gelfoam embolisation was successfully performed. Haematomas of the abdominal wall can be divided in the common rectus sheath haematomas and the rare haematomas of the lateral abdominal wall. Differentiating both entities is essential, since there is a strong difference in their vascular supply. The typical vascular supply of the lateral abdominal wall is discussed, with emphasis on the ascending branch of the deep circumflex iliac artery.

Localized benign fibrous mesothelioma mimicking a malignant tumor of the pleura.

A case of benign fibrous pleural mesothelioma is reported. Imaging studies as well as clinical features suggested malignant pleural mesothelioma. The lesion was judged resectable and no metastases were found. At surgery it was found to be a benign pleural fibrous mesothelioma. Because of the considerable overlap of imaging characteristics between the two entities, the authors conclude that determination of resectability rather than differentiation between benign and malignant mesothelioma should be the primary goal to be achieved by imaging techniques.

Synovial cyst of the lumbar spine. A case report.

Intraspinal ganglions or synovial cysts most frequently involve the L4-L5 level and the adjacent facet joint reveals characteristic alterations of osteo-arthritis. These cysts usually present with pain, but without additional sensory or motor findings. They cannot be diagnosed on the basis of conventional radiology; myelography shows a filling defect adjacent to the affected facet joint, and the differential diagnosis includes several common and uncommon entities. The CT appearance is however strongly characteristic, showing a cystic structure with occasionally a calcification within its wall. There often is compression of the adjacent dural sac or nerve roots.