Severe life-threatening hemoperitoneum from posttraumatic avulsion of a pedunculated uterine leiomyoma.

Uterine leiomyomas are common tumors in women, and most of their complications are well known. Rupture of a uterine leiomyoma is an unusual source of severe hemoperitoneum. The cause seems to be spontaneous rupture of a leiomyoma vessel or is secondary to abdominal trauma. Herein, we describe the case of a 46-year-old woman who had a history of uterine myomas and came to the emergency department with acute abdominal pain after she fell while jogging. The patient's hemodynamic parameters were stable. An ultrasound examination and computed tomography scan showed multiple uterine myomas and free fluid in the peritoneum without signs of splenic rupture. Laparoscopy was performed, which revealed active bleeding from the base of a pedunculated myoma. The patient required transfusion of 2 units of packed red blood cells, and a subtotal hysterectomy via laparotomy was performed, with an uneventful postoperative course. Because surgical management is needed in an emergency, physicians should be aware of this rare but severe complication in patients with known uterine myomas.

[Current indications for uterine artery embolization to treat postpartum hemorrhage]. / Place actuelle de l'embolisation artérielle dans la prise en charge des hémorragies graves du post-partum immédiat.

Uterine artery embolization is an interventional radiology technique successfully used for more than 30 years in the management of gynecological or obstetrical hemorrhage. Precise indications for uterine artery embolization to treat postpartum hemorrhage have been recently published. Uterine artery embolization is indicated in case of uterine atony despite medical treatment particularly after vaginal delivery, in case of vaginal thrombus or cervical tear after failed surgical repair. Embolization can also be discussed in case of persistent hemorrhage after arterial ligation or hysterectomy. Finally, arterial embolization can be attempted in case of placenta accreta to avoid hysterectomy. In all situations, pluridisciplinary management of patients with involvement of interventional radiologists, anesthesiologists and obstetricians is mandatory. Early transportation of patients for embolization should be discussed taking into consideration time of onset of hemorrhage, expected transfer time and treatment options available on site. For validated indications, success rates of arterial embolization as high as 80% can be expected in experienced hands.

[Laparoscopic repair of an incomplete post obstetrical uterine rupture. About one case]. / Réparation laparoscopique d'une rupture utérine incomplète post-obstétricale. A propos d'un cas.

The rate of incomplete uterine ruptures is unknown. These ruptures are usually asymptomatic but may cause chronic pelvic pain and/or intermenstrual bleeding. The conservative surgical repair techniques described in the literature are often practised by vaginal, combined (vaginal and laparoscopic) or hysteroscopic way. We propose an exclusive laparoscopic repair technique with satisfactory anatomical and functional short-term results.

[Interest of modern imagery for conservative management of a placenta percreta]. / Prise en charge conservatrice d'un placenta percreta. Apport des nouvelles techniques d'imagerie.

The placenta percreta is a rare form of anomaly of placental insertion threatening the maternal and foetal lives. The incidence of abnormal placental adhesion is correlated to frequency of caesarean sections and advanced maternal age. Patients who are at high risk should be identified during pregnancy by ultrasound examination with Color Doppler looking for characteristic features. The practice of MRI in case of echographic suspicion may be useful, particularly in posterior placentas. A late diagnosis, in an emergency context, leads generally to hysterectomy and even to partial resection of neighbour organs. Thus, we report the case of a conservative management associating uterine embolisation following an elective caesarean delivery at 36 weeks gestation. In postpartum, the placental involution was followed clinically and by imagery. In our case, a total abdominal hysterectomy was performed on the fifth postoperative week because of a severe antibiotics resistant infection. No blood transfusion was required and the postoperative period was uneventful. This clinical case aims to show, through an analysis of the recent data of the literature, the interest of modern imagery to select patients with suspected placenta percreta that would be suitable candidates for conservative management.

Differentiation between multiple liver hemangiomas and liver metastases of gastrinomas: value of enhanced MRI.

PURPOSE: Hepatic metastases of neuroendocrine tumors are known to mimic hemangiomas on nonenhanced SE MR sequences. The usefulness of MR examination with gadolinium injection to identify lesions was prospectively evaluated. METHOD: Nine patients with multiple liver metastases of gastrinomas were compared with six patients showing multiple liver hemangiomas. Patients underwent unenhanced T2-weighted SE, T1-weighted SE, and FLASH sequences, followed by enhanced sequential FLASH sequences and a 5 min delayed T1-weighted SE sequence. RESULTS: On T2-weighted SE sequence, all hemangiomas displayed the same typical morphology as a sharply defined, homogeneous, high signal intensity lesion, but this pattern was also observed for some or all of the lesions in seven of nine patients with gastrinoma metastases. Dynamic FLASH sequences were accurate for lesions larger than 2 cm, hemangiomas displaying a nodular peripheral enhancement with centripetal filling in, and metastases displaying either an initial homogeneous or a regular peripheral enhancement. Precise assessment of lesions smaller than 2 cm remained equivocal. Delayed T1-weighted. SE sequence (performed at least 5 min after Gd-chelate injection) was the most accurate technique to identify metastases by showing hypo- or isointensity signal, whereas all hemangiomas were hyperintense. CONCLUSION: Postcontrast delayed T1-weighted sequence is the primary technique to differentiate equivocal cases of hemangiomas from metastases of gastrinoma.

Screening of renal artery stenosis: assessment with magnetic resonance angiography at 1.0 T.

The results of MR angiography at 1.0 T with digital intraarterial angiography in the screening of patients with suspected renal hypertension were compared. In this first phase of the study, 10 volunteers underwent examination with both two-dimensional (2D) with traveling saturation time-of-flight (TOF) magnetic resonance angiography (MRA) with various parameters to develop a protocol for evaluation of the renal arteries. In the second phase, 36 patients with suspected renovascular hypertension underwent both 2D TOF MRA and intraarterial digital angiography to evaluate the clinical value of MRA. The degree of stenosis was graded with a two-point scale. In volunteers, using 2D acquisitions C/N ratios indicated the best flip angle as being 55 degrees (p = .02). MRA showed 100% (70/70) of all main arteries and 86% (6/7) of all accessory renal arteries seen on angiography. MRA had a sensitivity of 94% (15/16) and a specificity of 98% (60/61) for detection of stenoses of greater than 50% present in 14 patients. 2D-TOF MRA at 1.0 T shows promise in the noninvasive diagnosis of patients with suspected renovascular hypertension.

Advances in the assessment of clinically localized prostate cancer.

OBJECTIVE: We review the advances in pathology, biology, and radiology which could improve the detection of extracapsular prostate cancer preoperatively. METHOD: The experiences of others are compared to ours to give a topical overview of advances in the assessment of clinically localized prostate cancer. RESULTS: Despite new technologies, such as colour Doppler and endorectal magnetic resonance imaging, radiology does not enhance the ability to detect small invasion through the prostatic capsule. Biopsy features are one of the new fields of investigation. The number of positive sextant biopsies and the analysis of periprostatic spaces on biopsies appear to be major prognosis factors. In our experience, capsular perforation on biopsy is very powerful with respect to the proportion of positive biopsies ( > 66.7%) and serum PSA ( > 25 ng/ml, polyclonal assay) to predict biological progression after radical prostatectomy. The utility of the proportion of invaded tissue on biopsy is still debated. CONCLUSIONS: Despite technical improvements, the staging of clinically confined prostate cancer is still a major issue. The best hope comes from the study of biopsy features in addition to PSA.

Iliac artery patency before and immediately after percutaneous transluminal angioplasty: assessment with time-of-flight MR angiography.

PURPOSE: To assess the efficacy of magnetic resonance (MR) angiography of iliac arteries before and immediately after percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS: In 14 patients with 22 diseased iliac artery segments (external or common), axial two-dimensional time-of-flight MR angiography was performed. Images were reconstructed with a maximum-intensity-projection (MIP) algorithm. MR angiography was performed 1-4 days after diagnostic digital angiography and 6-24 hours after PTA. Findings obtained before and immediately after PTA were compared for number and location of significant (ie, > 50%) stenoses, length and diameter of balloon to be employed, and diameter of the stenotic artery after PTA. Linear regression analysis was performed. RESULTS: Sensitivity and specificity of MR angiography for determination of significant stenoses were 95% and 97%, respectively. Before PTA, balloon dimensions depicted on MR angiograms and digital angiograms were well correlated (r = .76, P < .05). After PTA, MR angiograms and digital angiograms provided similar findings in all but one case. CONCLUSION: MR angiography helped determine if PTA is indicated and depicted iliac artery patency after PTA.

Pulmonary MR angiography at 1.0 T: early results with k-space segmented and post-contrast TurboFLASH two-dimensional time-of-flight sequences.

PURPOSE: To evaluate the combined performance of two time-of-flight methods in imaging the pulmonary arteries. MATERIALS AND METHODS: This study was prospectively conducted in 28 patients suspected for pulmonary embolism (PE). Sixteen patients were free of pulmonary vascular disease, and 12 had pulmonary vascular disease as demonstrated by pulmonary angiography. To reduce artifacts caused by cardiac and respiratory motion, MR images were acquired in all subjects using bi-dimensional (2D), gradient-recalled echo (GRE), breath-hold techniques. Sagittal thin (6-mm) sections obtained with ECG gating, k-space segmentation and incremented flip-angles (TONE), and coronal thick (15-mm) sections obtained after a unique injection of Gadolinium chelate were used. RESULTS: High quality images were obtained in all 16 (100%) subjects free of pulmonary disease with both techniques, and in 10 and 12 (87% and 100%) patients suspected for pulmonary artery disease with sagittal and coronal Gd-enhanced MRA, respectively. In patients free of pulmonary disease, TONE images exhibited distal pulmonary arteries with 2.1 subsegmental divisions on average, whereas Gd-enhanced TurboFLASH images were the most accurate to identify proximal pulmonary arteries within the mediastinum, even if only 0.8 subsegmental divisions were seen on average. A correct diagnosis of pulmonary embolism was obtained in all cases but one, with use of both MRA techniques, with an overall accuracy of 86%. CONCLUSION: The association of segmented sagittal GRE images and coronal first-pass Gd-enhanced GRE images can provide information upon normal and diseased pulmonary arteries within the mediastinum until subsegmental pulmonary branches, even in patients with short-breathing. Further studies of patients with various pulmonary artery diseases will confirm whether this technique makes pulmonary MRA feasible in clinical routine situations.

Pulmonary time-of-flight MR angiography at 1.0 T: comparison between 2D and 3D tone acquisitions.

The purpose of this study was to compare the performance of 2D vs. 3D time-of-flight (TOF) methods in imaging the normal pulmonary arteries with commercially available 1.0 T equipment. The study was conducted in 20 volunteers and 7 patients with suspected pulmonary embolism (PE). To reduce artifacts caused by cardiac and respiratory motion, MR images were acquired in volunteers using two-dimensional (2D), gradient-recalled echo (GRE), breath-hold techniques, and three-dimensional (3D) acquisitions. Sagittal thin (6-MM) segmented k-space 2D sections obtained with cardiac gating during systole (turboFLASH, TR/TE9/6 ms, 14 segments of 9 lines) and incremented flip-angles (TONE), and 50-mm 3D volume TONE acquisitions with 32 partitions (FISP, TR/TE34/10ms) were successively performed. In the second phase of the study, patients were examined only with the 3D technique. Images of volunteers were qualitatively and quantitatively analyzed. S/N ratios were statistically compared by means of the paired-sample Wilcoxon ranked-signed test, a value of p < .05 being significant. In volunteers, 3D acquisitions displayed significantly more segment-order pulmonary arteries on average than did 2d acquisitions displayed significantly more segment-order pulmonary arteries on average than did 2D acquisitions (2.95 +/- 0.64 vs. 2.2 +/- 0.85, respectively; p < .01). Moreover, the signal intensity of arteries within the lungs was less homogeneous in the 2D than in the 3D technique, with a signal intensity ratio between peripheral and proximal arteries of 63% +/- 7% and 73% +/- 2%, respectively (p < .05). In patients, no erroneous diagnoses were obtained using the 3D technique. 3D images of normal lungs provide MR angiograms of better quality than do 2D images, and require less contribution from subjects because they are performed in free breathing. Ongoing improvements in MR sequences and further studies are now necessary to assess the value of 3D TONE MRA in the diagnosis of PE.

[Biliary complications after liver transplantation. Contribution of imaging--percutaneous treatment]. / Complications biliaires du transplanté hépatique. Apport de l'imagerie--traitement percutané.

Biliary complications are observed in 7 to 20% of orthotopic liver transplantations. Biliary strictures and fistulas are the commonest complications, usually at the site of anastomoses, or more rarely at a distance. The entire transplant biliary tract may be affected, particularly in the case of hepatic artery thrombosis. These lesions are due to multifactorial ischaemic phenomena. Mechanical complications can occur after insertion of a Kehr drain. Mucoceles of the cystic duct, responsible for extrinsic bile duct compression, are much less common. The diagnosis is based on medical imaging, as the clinical signs are often non-specific. Ultrasonography has limited sensitivity as a first-line examination. Opacification of the bile ducts is therefore essential at the slightest doubt, as it has a sensitivity of 100% and allow assessment of the lesions. Transhepatic cholangiography is preferable to retrograde opacification due to the risks infection. CT scan is useful in the case of fistula to assess fluid collections. Percutaneous treatment avoids the need for open surgery in about 1/3 of cases. Strictures can be dilated by means of inflatable balloons, via a percutaneous or retrograde approach. Intra-abdominal collections can be drained percutaneously.