Endovascular treatment of tumor-induced axillary artery hemorrhage.

Hemorrhage caused by tumor invasion of the axillary artery is a rare, but serious complication. A 70-year-old female with a history of inflammatory breast cancer was diagnosed with hypovolemic shock caused by arterial bleeding into the left axilla. After successful reanimation an emergency arteriography was performed. The bleeding site was localized in the proximal part of the axillary artery. A self-expanding endoluminal graft was positioned across the lesion. The final angiography showed a correct placement of the stent with excellent distal flow, and no signs of bleeding. On the seventh day, the patient was discharged with ambulatory follow up.

Successful surgical treatment of a combined abdominal and thoracic impalement injury.

Accidents do occur during the performance of different domestic chores in the garden. The resulting injuries can lead to serious morbidity and, in some cases, they can be fatal. We present a case of trauma, in a 69-year old man, caused by a fall from a tree on a vertical metal rod in his garden. The rod entered the abdominolumbal region on the right side making an exit above the left clavicle. On arrival, he was in a stable circulatory condition. A chest X-ray (Fig. ), thoracic and abdominal sonography followed by chest and abdominal CT scan (Figs. - , ) were performed and they showed no severe injury of the heart, lung, bronchi, liver and right kidney. He underwent an emergent surgical intervention by a team of cardiothoracic, vascular and abdominal surgeons. Longitudinal sternotomy and laparotomy allowed us to remove the metal rod carefully with no severe signs of injuries of abdominal and thoracic organs. There were no surgical postoperative complications.

Echo enhanced ultrasound: a new valid initial imaging approach for severe acute pancreatitis.

AIM: This prospective study aimed to compare the accuracy of echo enhanced ultrasound with spiral computed tomography (CT) in assessing acute pancreatitis and to explore the correlation between ultrasound findings and clinical outcome. METHODS: Thirty one patients (24 men and 7 women, median age 39 years, range 19-67 years) with acute pancreatitis were investigated by contrast enhanced CT and echo enhanced ultrasound within 72 hours after admission. Echo enhanced ultrasound (with intravenous injection of 2.4 ml SonoVue, pulse inversion technique, mechanical index 0.1 to 0.2, Siemens Elegra) was performed following conventional ultrasound. Balthazar's grading system was used to measure CT and ultrasound severity indices (CTSI and USSI). Correlations between CTSI and USSI and between USSI and clinical parameters were tested by Spearman's rank correlation coefficient. RESULTS: A strong correlation was demonstrated between CTSI and USSI (r = 0.807, p<0.01). Ultrasound correlated with the following: the Ranson score (r = 0.401, p<0.05), C-reactive protein levels 48 hours after admission (r = 0.536, p<0.01), duration of hospitalisation (r = 0.422, p<0.05), and clinical outcome regarding morbidity, including local and systemic complications (r = 0.363, p<0.05). Based on CT findings as the gold standard, sensitivity, specificity, positive predictive value, and negative predictive value of ultrasound for detecting severe acute pancreatitis based on imaging criteria (Balthazar score D or E and/or presence of hypoperfusion compatible with necrosis and/or SI>/=3) were, respectively, 82% (95% CI 61 to 93), 89% (95% CI 57 to 98), 95% (95% CI 75 to 99), and 67% (95% CI 39 to 86). CONCLUSION: Echo enhanced ultrasound produces excellent results in the staging of acute pancreatitis severity. The procedure is cheaper and has fewer contraindications than CT. Further multicentre studies need to be performed before including the method in the diagnostic algorithm of patients with acute pancreatitis.

[Comparison of four digital and one conventional radiographic image systems for the chest in a patient study with subsequent system optimization]. / Vergleich von vier digitalen und einem konventionellen Röntgenaufnahmesystem für den Thorax mittels einer Patientenstudie mit nachfolgender Systemoptimierung.

PURPOSE: Using a patient study to prove the clinical relevance of a comparison of five different radiographic systems for the chest conducted with an anthropomorphic chest phantom. Depending on the results, it was tested whether the performance of a modern digital system with a transparent imaging plate can be improved by changing the post-processing of the image. METHOD: Chest radiographs of patients were taken with a CsI/aSi-flat panel detector (FDR), transparent imaging plate (tDLR), selenium drum detector (DSR), conventional storage phosphor plate (DLR) and asymmetrical screen-film-system (aFFS), and compared using image criteria scoring (ICS) and visual grading analysis (VGA) for anatomical structures (modified criterions of the EUR 16 260 EN guidelines). After optimizing the post processing, the images of the tDLR-system were evaluated once more in a phantom ROC study and patient VGA study. RESULTS: The flat panel detector-system proved to meet best the anatomical image quality criteria, followed by DSR, tDLR, aFFS and DLR. The modified post processing of the tDLR-images resulted in a significantly better detection of simulated pathological lung-structures, but improved the perceptibility of anatomical structures only slightly. CONCLUSIONS: The results of the patient VGA study and the phantom ROC study are similar and considered valid. The new digital imaging systems with flat panel detector and transparent imaging plate provide the best image quality of the tested radiographic devices for chest imaging, assuming that all system components are attuned and optimized for the type of structure to be detected. Image processing is of primary importance for system optimization.

[Interventional and vascular surgical management for inflammatory arrosion hemorrhage from visceral arteries following pancreatic surgery]. / Entzündliche Arrosionsblutungen aus ViszeralarterienInterventionelles und gefässchirurgisches Management nach vorwiegend pankreaschirurgischen Eingriffen.

Spontaneous or postoperative hemorrhage into the abdominal cavity due to inflammatory vessel arrosion represents an uncommon but menacing situation. According to the literature, such hemorrhage is associated with a lethality of nearly 2%. Therapeutical options include reoperation and interventional radiological techniques such as endovascular catheter techniques with stent graft implantation or the embolization of vessels. We report on the management of seven cases with hemorrhage either from the gastroduodenal artery ( n=5) following pancreatic surgery for pancreatic carcinoma, liposarcoma, and chronic pancreatitis or from the common hepatic artery ( n=1) and the superior mesenteric artery ( n=1) following chronic pancreatitis. The present article describes our experiences with stent graft implantation (hemobahn prosthesis) in four cases. Based on these experiences, we see the advantages of stent grafts in primary hemostasis without any contact to infected tissue and the preservation of regular perfusion. However, further clinical data are required focussing on indication, technical success rates, stent-related complications, and long-term outcome.

[Chest radiography: ROC phantom study of four different digital systems and one conventional radiographic system]. / Thoraxübersichtsaufnahme: ROC-Phantomstudie an vier verschiedenen digitalen und einemkonventionellen Röntgenaufnahmesystem.

PURPOSE: To compare the diagnostic quality of five different radiographic systems used in chest radiography for visualization of differently configured, clinically relevant pathologic pulmonary structures. MATERIALS AND METHODS: Four digital detector systems using as detection unit a CsI/aSi-based flat panel detector, a transparent imaging plate, a selenium detector and a conventional storage phosphor plate were analyzed for this study, as well as an asymmetrical film-screen system. The analyzed imaging material consisted of radiographs of an anthropomorphic chest-phantom with superimposed simulated pulmonary structures. The images were evaluated for different pathologic structures by a newly developed multiple structure ROC (ms-ROC). RESULTS: The performance of each system was found to have a strong structure-related variability. The flat panel detector system had the best overall performance. The theoretical advantage of the 4k-matrix of the transparent imaging plate over the 3k-matrix of the flat panel detector was only confirmed for reticular structures. CONCLUSIONS: In addition to comparing the image quality of the different systems, this study shows that the performance of a radiographic system depends on the structure to be analyzed. The modified ROC (ms-ROC) provides valid results with less effort.

A case of spinal glioblastoma multiforme: immunohistochemical study and review of the literature.

A 31-year old female underwent subtotal resection of a spinal glioblastoma multiforme (GBM) at level D 10/11 in June 1997. Immunohistochemistry revealed increased MIB-1 labeling index and accumulation of p53 protein. Routine MRI in February 1998 showed multiple tumors of the lumbar spinal cord. At open biopsy, diffuse infiltration of multiple radices was seen. Histologically and immunohistochemically, the tumor was similar to the primary. In May 1998, MRI revealed multiple intracranial metastases and meningeal involvement. The patient died in June 1998, 13 months after the onset of symptoms. The lifes of patients with spinal gliomas are not endangered by direct compression of the brain stem, and systemic metastases are extremely uncommon with gliomas. Yet, survival times in the reported case and in the literature are not better than with cerebral localization. Analysis of the present case and a survey of the literature indicate that CSF involvement and consecutive intracranial seeding determine the prognosis of patients with spinal GBM. Thus, regular monitoring of CSF-cytology and/or spinal MRI appear to be advisable in spinal GBM.

Prefrontal enlargement of CSF spaces in agoraphobia: a qualitative CT-scan study.

1. This CT study was designed to assess brain morphology in 21 patients with agoraphobia and 21 normal control subjects matched for age and sex. 2. Internal and external CSF spaces were evaluated by qualitative assessment on a 3-point scale (normal, questionable, abnormal). 3. Patients showed bilateral enlargement of prefrontal CSF spaces (p < .05). The rating abnormal" was given in the left hemisphere to 6 (28.6%) of the patients, to 4 (19%) of the patients in the right hemisphere, but to none (0%) of the normal controls. 4. These findings suggest that alterations in brain morphology are involved in the etiology of agoraphobia.

[Quantitative assessment of brain morphology with CT in agoraphobia]. / Qualitative Untersuchung der Hirnmorphologie im CT bei Agoraphobien.

This CT study was designed to assess brain morphology in agoraphobia. 21 patients and 21 normal control subjects matched in age and sex were investigated. Frontal and parietooccipital cortex, temporal cortex, lateral ventricles and third ventricle were evaluated by qualitative assessment on a 3-point scale (normal, questionable, abnormal). Patients showed significant bilateral enlargement of prefrontal cortical cerebrospinal fluid (CSF) spaces (p < .05). The rating "abnormal" was given to none (0%) of the normal controls, but to 6 (28.6%) of the patients in the left hemisphere, and to 4 patients (19%) in the right hemisphere, respectively. No qualitative differences were seen in the temporal cortex, lateral ventricles and third ventricle. These findings support the hypothesis that alterations in brain morphology are involved in the etiology of agoraphobia. The lack of a correlation between CSF enlargement and duration of illness suggests that prefrontal CSF enlargement is a neurobiological vulnerability marker in agoraphobia.

[Qualitative evaluation of brain structure in CT in panic disorders]. / Qualitative Bewertung der Hirnstruktur im CT bei Panikstörungen.

This CT study was designed to assess brain morphology in panic disorder with and without agoraphobia. Twenty-one patients and 21 normal control subjects matched for age and sex were investigated. Frontal and parieto-occipital cortex, temporal cortex, lateral ventricles and 3rd ventricle were evaluated by qualitative assessment on a 3-point scale (normal, questionable, abnormal). Patients showed significant bilateral enlargement of cortical cerebrospinal fluid (CSF) spaces (p < 0.01). The rating "abnormal" was given to none (0%) of the normal controls, but to 7 (33.3%) of the patients. Explorative analysis showed that these abnormalities were predominantly located in prefrontal regions. No qualitative differences were seen in the temporal cortex, lateral ventricles or third ventricle. These findings support the hypothesis that alterations in brain morphology are involved in the etiology of panic disorder. The lack of a correlation between CSF enlargement and duration of illness suggests that frontal CSF enlargement is a neurobiological vulnerability marker in panic disorder.

Hippocampal malformation as a cause of familial febrile convulsions and subsequent hippocampal sclerosis.

OBJECTIVE: One hypothesis proposes that a pre-existing alteration of medial temporal lobe structures contributes to febrile convulsions and subsequent hippocampal sclerosis (HS) in patients with temporal lobe epilepsy (TLE) and antecedent febrile convulsions. It is possible that such a structural alteration does not always lead to convulsions and may also be present in clinically unaffected relatives. METHODS: We tested this hypothesis by MRI investigation of 23 members of two families, of whom 13 had experienced febrile convulsions and 10 had not. One member of each family with febrile convulsions subsequently developed TLE. We compared the right/left ratios of hippocampal volumes (RHV) with 23 age- and sex-matched controls. Additionally, two independent raters assessed hippocampal signal intensity and pattern in T2- and fluid-attenuated inversion recovery images. RESULTS: Both TLE patients showed left HS. All subjects with febrile convulsions who did not develop epilepsy and six clinically unaffected relatives also showed asymmetric RHV (>3 standard deviation) but a normal hippocampal signal intensity. In all of these subjects, the left hippocampus was smaller. Visual inspection of these smaller hippocampi revealed blurred internal pattern or flat hippocampal bodies or both in one family and smaller hippocampal heads in the other. The pattern of HS in TLE patients showed a structural correlation with the abnormalities seen in their relatives. One subject with febrile convulsions had additional subcortical heterotopias. CONCLUSION: These findings suggest a subtle, pre-existing hippocampal malformation that may facilitate febrile convulsions and contribute to the development of subsequent HS.

[Dangerousness of blank fright guns and salute rifles]. / Zur Gefährlichkeit von Schreckschussgewehren und Salutwaffen.

According to the German law salute-fire guns altered weapons with a barrel length of more than 60 cm. They have inside the barrel special constructions, which are guiding the gunshot residues under high pressure to the muzzle. Therefore they own an high potential of injury, like blank-cartridge guns with short barrels.

Frontal CSF enlargement in panic disorder: a qualitative CT-scan study.

Brain morphology was assessed qualitatively in CT scans of 21 patients with panic disorder and 21 normal control subjects. Patients showed significant bilateral enlargement of frontal cerebrospinal fluid (CSF) spaces. These findings suggest that alterations in brain morphology are involved in the etiology of panic disorder.