Arteriovenous malformation in a patient with Bannayan--Zonana syndrome.

Bannayan-Zonana syndrome (BZS) is a genetic disorder with autosomal dominant inheritance characterized by macrocephaly and multiple hamartomas of mesodermal origin. Here we present a patient with BZS manifested by many of the classic features, as well as a high-flow upper extremity arteriovenous malformation (AVM). Although this rare syndrome was initially described in 1971, to our knowledge, this is the first report showing an association of AVM with BZS and the first report of this syndrome in the radiologic literature.

Renal pseudotumors due to fat necrosis in acute pancreatitis.

Retroperitoneal fat necrosis is a well-known complication of acute pancreatitis. We describe an unusual case of fat necrosis presenting as multiple, bilateral renal pseudotumors in a patient with acute pancreatitis. The imaging findings on CT and MR are discussed.

Suspected deep venous thrombosis: is US of both legs necessary? [ comment].

PURPOSE: The first purpose was to test the assumption that ultrasound (US) examination of the asymptomatic leg was unnecessary. The second was to confirm the absence of deep venous thrombosis (DVT) in patients with bilateral symptoms. MATERIALS AND METHODS: Four hundred eighty-eight patients were evaluated at a peripheral vascular laboratory for signs and symptoms of DVT. All patients then underwent bilateral color Doppler US of their leg veins. RESULTS: Ninety-four patients had no lower extremity symptoms. Of these, 73 had no DVT, 11 had unilateral DVT, and 10 had bilateral DVT. Of 245 patients with unilateral symptoms, 180 had no DVT, 44 had ipsilateral DVT, three had contralateral DVT, and 18 had bilateral DVT. Of 149 patients with bilateral symptoms, 114 had no DVT, 10 had unilateral DVT, and 25 had bilateral DVT. CONCLUSION: The frequent finding of bilateral DVT and unsuspected contralateral DVT in patients with unilateral symptoms, and the even more frequent finding of DVT in patients with bilateral symptoms, clearly indicates that both categories of patients need to be evaluated with bilateral US.

Isolated intrathoracic injury with air bag use.

The restrained (air bag and seatbelt) driver of a vehicle involved in a high-speed motor-vehicle accident sustained a tear of the thoracic aorta with no signs of external injury. Air bag deployment may mask significant internal injury, and a high index of suspicion is warranted in such situations.

Utilization patterns with inferior vena cava filters: surgical versus percutaneous placement.

PURPOSE: To determine whether more inferior vena cava (IVC) filters were used after interventional radiologic placement methods became available, and if so, whether this increase could be due to expansion of indications. PATIENTS AND METHODS: A retrospective analysis of the number of filters placed, the method of placement used, the indications for placement, and patient survival was performed during the 3 years before and the 3 years after 1989, the first year filters were placed percutaneously at the authors' institution. RESULTS: From 1986 through 1988, 35 filters were all placed by surgeons in the operating room. From 1990 through 1992, 201 filters were all placed by radiologists in the special procedures suite. In the surgery group, 13 of 35 filters (37%) were placed for contraindications to anticoagulation therapy, 12 (34%) were placed for complications of anticoagulation, and nine (26%) were placed for recurrent thromboembolic disease despite anticoagulation. One filter was placed because of a free-floating thrombus in the IVC. In the radiology group, 98 of 161 patients (60%) underwent placement for contraindications to anticoagulation, 25 (16%) experienced complications of anticoagulation, 28 (17%) experienced recurrent thromboembolic disease, and nine (6%) had a free-floating thrombus. The 6-month survival in patients treated before 1989 was 80% versus 43% after 1989. CONCLUSION: At the authors' institution, filters are now placed exclusively by interventional radiologists. The overall indications for placement remain unchanged. The increase in utilization appears primarily related to more frequent placement in severely ill patients who may not experience considerably improved survival but may benefit from a substantial reduction in the risk of hemorrhagic complications.

Case report 872. "Ancient" schwannoma (degenerated neurilemoma).

A case of an ancient schwannoma was presented. The rare occurrence of this tumor has resulted in only a few reported cases with descriptions of its features on imaging. Our patient's tumor, like one previously reported case, demonstrated calcification on the plain film - a finding not associated with other histologic types of schwannomas. Angiography revealed the tumor to be hypervascular. Evaluation by MRI demonstrated a lobulated, encapsulated soft tissue mass containing several cystic areas that corresponded histologically to areas of necrosis. Hypertrophied blood vessels were seen in the periphery of the tumoral mass. Too few ancient schwannomas have been reported to conclude whether or not radiographic evidence of soft tissue calcification is characteristic of this histologically distinctive subtype of schwannoma. However, since calcification is seen histologically as part of the degenerating process, its presence on plain films could be a feature of this tumor. Furthermore, the presence of cystic areas on MRI is not surprising given the pathological changes that occur in this tumor. We suggest that a diagnosis of ancient schwannoma be considered when a patient presents with a hypervascular soft tissue mass containing amorphous calcification on plain films and cystic areas on MRI. Despite the nonspecificity of these imaging findings, this point is relevant because each of these features suggests the presence of a malignant mass. Awareness of the possibility of a benign ancient schwannoma could obviate unnecessary radical surgery.

Embolization to control iatrogenic ureteral hemorrhage: a case report.

Gross hematuria following percutaneous or endourological intervention is well known and widely documented. We report an unusual case of angiographically documented hemorrhage from a ureteral branch that was injured by cystoscopic removal of a Double-J stent, and subsequent successful transcatheter embolization. This case demonstrates the important role of angiographic diagnosis and therapy in the management of iatrogenic hemorrhage.

Not so rapid progression of peripheral vascular disease after diagnostic angiography.

It was recently reported that peripheral vascular disease may progress so rapidly after diagnostic angiography that most likely the diagnostic procedure is in some way responsible. Because flow-limiting arterial stenoses often become complete occlusions within hours or days of the diagnostic procedure, it was recommended that angioplasty be performed immediately after diagnostic angiography to avoid this complication. The authors attempted to confirm these findings before implementing this recommendation. In fact, they did not confirm the findings. Among 96 flow-limiting stenoses considered for angioplasty, the procedure was performed in 31 on the same day. Among the remaining 65 cases, in 64 the stenosis did not occlude and angioplasty was successfully performed. Only one stenosis was discovered to have thrombosed, and this occurred 3 weeks after diagnostic angiography. These results indicate that there is not such rapid progression of peripheral vascular disease after diagnostic angiography. It is not necessary to perform angioplasty of stenotic lesions emergently, and treatment is not impaired by electively scheduling the patient for the next available day.

Idiopathic arterial calcification of infancy: a case with prolonged survival.

We describe a patient with idiopathic arterial calcification of infancy and the following unusual features of the disease: (1) prolonged survival until age 11 years, (2) discordance between the extent of vascular calcification and clinical manifestations of arterial luminal occlusion, (3) a large area of myocardial calcification, (4) symptoms of cerebral-vascular insufficiency, and (5) spontaneous resolution of hypertension.

A case of life-threatening gastrointestinal hemorrhage in an infant with AIDS.

This is the first reported case of an infant with acquired immune deficiency syndrome (AIDS) and cytomegalovirus (CMV) infection that presented with massive life-threatening lower intestinal hemorrhage. Arteriography was useful in localizing a bleeding source prior to operation.

Osteoarthropathy of patients undergoing long-term hemodialysis.

Maintenance hemodialysis, while capable of prolonging life, is an incomplete substitute for the patient's native functioning kidneys. Recently, it has become clear with time that long-term survivors of hemodialysis develop an osteoarthropathy differing from classic secondary hyperparathyroidism. The radiographic appearance includes erosive or destructive changes of articular surfaces, bone cysts, osteopenia, and periarticular calcific deposits. The most important clinical factor related to the development of the disease is increasing duration of hemodialysis. Although amyloid appears to be a causative factor, the exact etiology and treatment remain uncertain. It is important that the radiologist be aware of this entity and not mistake it for secondary hyperparathroidism, a variant of rheumatoid arthritis or infection.

Primary renal angiosarcoma mimicking a renal cell carcinoma.

Primary renal angiosarcoma is a very rare malignant tumor that closely mimics the more common renal cell adenocarcinoma (hypernephroma) in radiologic appearance. Both tumors are hypervascular masses and the diagnosis must be confirmed histologically. However, in the presence of a tumor with a capsular blood supply, and in the absence of venous invasion, the diagnosis of renal angiosarcoma may be suggested, especially in a patient with a new onset of consumption coagulopathy.

Contrast venography: reassessment of its role.

To compare contrast venography with noninvasive methods, 353 patients clinically suspected of having deep venous thrombosis were examined with venography and independently with combined Doppler flow sounds and plethysmography. Noninvasive examinations had a sensitivity of 96% and a specificity of 90%. Positive noninvasive tests had a 94% predictive value, and negative noninvasive tests had a 93% predictive value. The overall accuracy of the noninvasive tests was 94% (331 of 353) compared with venography. Since venography itself may be subject to misinterpretation, noninvasive examinations should be the preferred initial method for diagnosing deep venous thrombosis. Venography should be reserved for situations that require additional diagnostic confirmation.

Spondyloarthropathy from long-term hemodialysis.

Twenty-six patients undergoing long-term hemodialysis who had hand and wrist abnormalities were examined for the presence of concurrent spinal disease. Six patients (23%) were found to have spinal disease on radiographs. In four, the findings resembled those of a destructive spondyloarthropathy, and in two, a less destructive erosive arthritis. A review of the spinal radiographs of 31 patients with normal hands and wrists revealed no such abnormalities. Postmortem examinations of two patients with spondyloarthropathy demonstrated extensive deposition of beta-2 microglobulin, an amyloid-like substance. The authors conclude that the disease is similar in both areas and represents a skeletal response to chronic renal failure and long-term hemodialysis. The disease may occur more frequently with an increased duration of hemodialysis, in one area of the skeleton if another area is already affected, and is probably not infectious if multiple areas are involved.

MR appearance of bilateral, spontaneous patellar tendon rupture in systemic lupus erythematosus.

Bilateral spontaneous patellar tendon rupture is an unusual complication in patients with systemic lupus erythematosus. The ability of magnetic resonance to detect these tendon abnormalities is demonstrated.

Osteoarthropathy of the hand and wrist in patients undergoing long-term hemodialysis.

Radiographs of the hand and wrist in 81 patients who had undergone hemodialysis for a minimum of 5 years (mean, 7.8 years) were reviewed. In 32 patients arthritic changes were found, consisting of articular erosions, joint space narrowings, periarticular cysts, and osteopenia. Seven of the 32 patients had periarticular calcific deposits. The frequency and severity of the radiographic findings increased with increasing duration of dialysis. It appears that in addition to the well-recognized secondary hyperparathyroidism there is another commonly occurring osteoarthropathy (40% in this series) related to long-term hemodialysis.

Noninvasive venous examinations as a screening test for pulmonary embolism.

Blood clots that cause pulmonary embolism are reputed to arise in the lower extremities in 95% of cases and, therefore, testing with noninvasive venous studies has been recommended as a screening method. We evaluated plethysmography results and Doppler venous flow sounds for their concordance with pulmonary angiograms in a group of patients with suspected pulmonary embolism, and for their concordance with venograms in a second group of patients with suspected deep venous thrombosis. Fifty patients had both pulmonary angiograms and noninvasive venous studies. Of 16 patients with positive noninvasive studies, ten had angiograms positive for pulmonary embolism, and six had negative angiograms. Of 34 patients with negative noninvasive studies, 16 had positive pulmonary angiograms and 18 had negative angiograms. The positive predictive value was 63% and the negative predictive value was 53%. By contrast, in 125 patients with suspected deep venous thrombosis, the positive and negative predictive values of noninvasive studies were 94% and 92%, respectively. In this retrospective study, positive noninvasive examinations were useful clinically, but noninvasive venous studies were frequently negative in patients with documented pulmonary embolism and cannot be used to exclude this diagnosis.