The subclavius posticus muscle: an unusual cause of thoracic outlet syndrome.

We present the case of a 30-year-old female, complaining of thoracic outlet compression symptoms caused by a supernumerary muscle, the subclavius posticus, accompanied by a caudally inserted middle scalenus muscle on the second rib. This rare anatomic variant was clearly shown on CT angiography and MRI images and surgical treatment was successful. As first described by Rosenmuller in 1800, subclavius posticus is a supernumerary muscle originating from the cranial surface of the sternal end of the first rib, running laterodorsally beneath the clavicle, and inserting into the superior border of the scapula. Its role in thoracic outlet syndrome has been seldom demonstrated in living patients nor described in imaging, although it is theoretically easily recognizable on modern imaging modalities. It should be taken into account during workout of patients with thoracic outlet syndrome, since it can be potentially treated.

[Massive iatrogenic haemothorax treated by lidocaïne-adrenaline intercostal injection]. / Hémothorax iatrogène massif jugulé par injection intercostale de lidocaïne-adrénaline.

INTRODUCTION: Massive haemothorax is a relatively rare complication of thoracocentesis or the placement of tube thoracostomy. It is principally caused by intercostal vessel injury. The therapeutic approach consists in pleural drainage and sometimes thoracotomy for haemostasis. CASE REPORT: We describe a frail 72 year old patient, who developed a massive haemothorax occurring after a tube thoracostomy placing, persisting despite second pleural drainage, and complicated by deep haemodynamic shock. He was considered to have a very high risk of mortality if surgery was undertaken. Haemorrhage was totally stopped after intercostal instillation of lidocaïne-adrenaline. CONCLUSION: This case report suggests a role for pleural vasoconstrictor injection as initial treatment in case of persistent pleural haemorrhage caused by intercostal vessel injury.

[Hydatid disease diagnosed following a pulmonary embolism]. / Une hydatidose diagnostiquée à l'occasion d'une embolie pulmonaire.

Hydatidosis is a parasitic disease found worldwide, particularly in Mediterranean countries, caused by Echinococcus granulosis infection. Humans are an intermediate and accidental host in the cycle of this parasite. The hydatid pulmonary arterial embolism is extremely rare, usually arising in the heart or the liver. We report a case of hydatid pulmonary embolism explored with multidetector scanner and MRI, and confirmed at pathology of the operative specimen. To our knowledge, this is the first case of inaugural hydatid pulmonary arterial embolism found on CT scan establishing the diagnosis of the disease in a patient who had no other location of hydatid cyst.

[Limb fractures: ultrasound imaging features]. / Aspect échographique des fractures des extrémités.

US, a non-irradiating imaging modality, is complementary to radiographs in the evaluation of limb fractures. US may in some cases demonstrate or suggest the presence of a fracture without corresponding abnormality on radiographs, or confirm or exclude a possible fracture detected on radiographs. Knowledge of the US features of fractures is necessary. In this article, the different direct and indirect US findings of fractures will be reviewed, with radiographic correlation. Direct findings include cortical discontinuity or irregularity. Indirect findings include subperiosteal or juxtaphyseal hematoma suggesting cortical or physeal fractures respectively.

[Unusual location of a parathyroid adenoma: the carotid sheath]. / Localisation atypique d'un adénome parathyroïdien: la gaine carotidienne.

We report the imaging features of an occult parathyroid adenoma with unusual location in the carotid sheath. Our patient presented with primary hyperparathyroidism. Following negative neck ultrasound and scintigraphy, exploratory neck dissection with partial thyroidectomy was performed twice over a 2 day period without biological response. Cervical and mediastinal CT and MRI were performed with no result. Digital angiography showed a tumoral blush supplied by the left inferior thyroid artery and located in close contact with the carotid artery. Venous sampling of the neck confirmed the left location of the adenoma and a third surgical intervention found the adenoma embedded in the left carotid sheath. This is an unusual case of parathyroid adenoma that necessitated the use of several imaging techniques.

[Pseudoaneurysm of the abdominal aorta due to retroperitoneal lymph nodes, diagnosed by Doppler ultrasound and treated by embolization]. / Faux anévrysme de l'aorte abdominale naissant dans un magma ganglionnaire: diagnostic par écho doppler et traitement par embolisation.

OBJECTIVE: To report a case of pseudoaneurysm of the abdominal aorta due to retroperitoneal enlarged lymph nodes. MATERIALS AND METHODS: A 40 years old patient, with known sarcoma and metastatic retroperitoneal lymph nodes was referred for abdominal ultrasound because severe abdominal pain after defecation. RESULTS: The Doppler examination revealed magma of retroperitoneal lymph nodes surrounding the abdominal aorta inside of which a saccular collection of circulating blood, communicating with the aorta, was detected. The spectrum registered in the channel revealed a bidirectional flow compatible with a pseudoaneurysm. MR angiography confirmed the diagnosis. Successful occlusion was done by coil embolization. CONCLUSION: Pseudoaneurysms of the abdominal aorta are very rare. We report the first case of pseudoaneurysm arising in retroperitoneal lymph nodes. Diagnosis by Doppler ultrasound allowed a rapid treatment by embolization.

Role of contrast-enhanced color Doppler ultrasonography and dynamic flow in the evaluation of hepatic tumors treated with radiofrequency.

The contribution of contrast-enhanced color Doppler ultrasonography (CDUS) and dynamic flow (DF) (Toshiba) in the evaluation following treatment of hepatic tumors with radiofrequency (RF) is discussed. Twenty-seven patients with 34 hepatic tumors were included in this prospective study. The treated tumors measured 10-58 mm in diameter (mean diameter 29 mm). Two tumors were treated twice and one three times, comprising a total of 38 target lesions treated with RF and evaluated by 127 contrast-enhanced CDUS. The results of CDUS follow-up were compared to those of the dynamic MRI at 2 months, 4 months, 6 months and 1 year. Before RF, the injection of Levovist raised the number of vascularized lesions seen with unenhanced Doppler from 44% to 79%. All the non-vascularized lesions were metastases. Twenty-four hours after RF, four tumors presented an enhancement with Levovist, in which two were insufficiently treated lesions. Twenty-one treated tumors have been followed-up jointly by CDUS and MRI at the same time at 2 months, 20 at 4 months, 12 at 6 months and nine at 1 year. Compared to the MRI and the evolution, the CDUS presented a sensitivity of 100% and a specificity of 90% for the detection of progressive recurrence. The preliminary results show that the CDUS is useful to confirm the absence of detectable vascularity after treatment with RF ablation, whereas the presence of enhancement must be confirmed by MRI.

[Three-dimensional renal angiography]. / Angiographie rénale tridimensionnelle.

The usefulness of three-dimensional angiography is not fully established except for neurovascular diseases. We report a case of significant renal artery stenosis not shown on conventional angiography because of its orientation along the axial plane, where 3D imaging allowed complete analysis of the lesion leading to endovascular treatment.

Adenomyoma of the ampullary region: imaging findings in four patients.

BACKGROUND: We report the imaging features of adenomyoma of the distal common bile duct (CBD) and increase awareness of this rare benign disease. METHODS: Four patients (age range = 66-71 years) with abdominal pain and biliary obstruction had spiral computed tomography (CT) and cholangiography with or without papilla biopsy. Two patients also had endoscopic ultrasound. RESULTS: The CT appearance of adenomyoma was that of a rounded, well-circumscribed, soft tissue mass in the ampullary region, which appeared on cholangiography as a well-defined intraluminal filling defect or caused abrupt and regular stenosis of the CBD. Unfortunately, none of our patients was diagnosed before surgery, and cephalic duodenopancreatectomy was performed in all of them. CONCLUSION: Although imaging findings are not specific, their presence should raise the possibility of a benign tumor. If a proper preoperative diagnosis is made, cephalic duodenopancreatectomy can be avoided.

[Reversed carotid filter for the prevention of distal emboli during an iliac recanalization]. / Filtre carotidien inversé pour la protection des embolies distales lors d'une recanalisation iliaque.

We describe the use of a carotid filter in preventing distal emboli during the recanalization of an occluded left iliac stent two months earlier. The filter was reversed and introduced through an ipsilateral 6 French sheath along its 0.014" guidewire and placed against the occluded stent. The stent is recanalized using a hydrophilic guidewire controlaterally and a new stent was inserted into the old one. The filter was retracted into the introducer by pulling cut the special 0.014 guidewire, with a 0.018" diameter tip, and the whole system was removed via the left common femoral artery. Many emboli were found in the removed filter. We noted that the recanalization of an occluded stent causes more distal embolization than the native iliac artery. This technique allows placing the filter between the embolic lesion and the distal arterial territory, without passing through the lesion, especially since fibrinolysis may not be efficient in 2-months-old occlusions.

Percutaneous radiofrequency thermoablation as an alternative to surgery for treatment of liver tumour recurrence after hepatectomy.

BACKGROUND: Radiofrequency (RF) current, converted into heat through ion agitation and friction, can destroy liver tumours by means of coagulation necrosis. This study assessed whether percutaneous RF ablation is a useful and safe technique for the treatment of liver tumour recurrence after hepatectomy. METHODS: Forty-seven patients presenting with local recurrence after hepatectomy for malignant tumours (29 with colorectal secondaries) were treated with percutaneous RF ablation instead of repeat hepatectomy. RF thermal ablation was performed under image guidance for 12-15 min. This group represented 63 per cent of 75 patients treated with curative intent for liver recurrence in the same time interval. The other 28 patients underwent repeat hepatectomy. RESULTS: The mean(s.d.) number of liver metastases destroyed was 1.4(0.7) (range 1-3) and their diameter was 21(8) (range 9-35) mm. Twenty-six patients presented with liver recurrence at least once but up to three times after the initial RF application. Incomplete local RF treatment was observed in six of 47 patients. Fifteen patients developed extrahepatic recurrence. The mean(s.d.) interval between RF ablation and the last follow-up visit was 14.4(10.1) (range 5.5-40) months. One death and three major complications occurred. Survival rates at 1 and 2 years were 88 and 55 per cent respectively. A retrospective study of the authors' database over two similar consecutive periods showed that RF ablation increased the percentage of curative local treatments for liver recurrence after hepatectomy from 17 to 26 per cent and decreased the proportion of repeat hepatectomies from 100 to to 39 per cent. CONCLUSION: Percutaneous RF treatment increases the number of patients eligible for curative treatment. It should be preferred to repeat hepatectomy when feasible and safe because it is less invasive. Repeat hepatectomy is indicated only when percutaneous RF ablation is contraindicated or fails.

Percutaneous radiofrequency ablation of hepatic tumors during temporary venous occlusion.

OBJECTIVE: We evaluated the feasibility, tolerance, and efficacy of percutaneous hepatic vein or segmental portal branch balloon occlusion during radiofrequency ablation of hepatic malignancies. SUBJECTS AND METHODS: Ten tumors were treated by percutaneous radiofrequency ablation during balloon occlusion of a hepatic vein (n = 8) or a segmental portal branch (n = 2). Venous occlusion was undertaken because the tumor was in contact with a hepatic vein (n = 3) or a portal branch (n = 1); because the tumor exceeded 35 mm in width (mean, 44 mm), which was considered the maximum size amenable to ablation in a single session (n = 2); or because of both large size and contact with a hepatic vein (n = 3) or a portal branch (n = 1). RESULTS: Vascular occlusion was always technically possible. Radiofrequency was delivered to one to three locations (mean, 1.9 locations) with a cluster electrode. The largest axis of radiofrequency-induced lesions after ablation with the cluster needle-between 42 and 51 mm (mean, 49 mm)-was always larger than the targeted tumor. These sizes were statistically larger than in a matched control group of patients who underwent radiofrequency ablation without vascular occlusion (p < 0.0003). After a mean follow-up of 12.6 months, CT and MR imaging revealed complete destruction of nine tumors after a single radiofrequency ablation treatment; one tumor required three treatments to achieve ablation. Five patients are tumor-free 12-18 months (mean, 14.4 months) after the first radiofrequency ablation treatment, and five developed new liver metastases. CONCLUSION: Temporary hepatic vein or portal branch occlusion during radiofrequency ablation can safely facilitate the treatment of large tumors or tumors in contact with the walls of large vessels.

Pseudoaneurysm and aortobronchial fistula after surgical bypass for aortic coarctation: management with endovascular stent-graft.

PURPOSE: To report the endovascular repair of an aortobronchial fistula at the distal anastomosis of a complex thoracic graft. CASE REPORT: A 61-year-old man operated 18 years prior for aortic coarctation presented with hemoptysis. An aortobronchial fistula was suspected, but spiral computed tomography and angiography showed only a small pseudoaneurysm at the distal anastomosis without revealing the fistulous tract. A Talent stent-graft was successfully deployed through a femoral access, but the large delivery system injured the external iliac artery, producing a retroperitoneal hemorrhage. Prompt balloon occlusion of the aorta and subsequent bypass graft repair of the arterial injury prevented serious sequelae. The patient recovered without further complications. Follow-up imaging to 2 years has documented exclusion of the pseudoaneurysm with no hemoptysis or signs of new false aneurysm formation. CONCLUSIONS: Endovascular exclusion of anastomotic pseudoaneurysms even in complicated cases can be an efficient treatment option, but the procedure must be carefully planned and executed in order to achieve good results.

In vitro evaluation of a new rotational thrombectomy device: the Straub Rotarex catheter.

PURPOSE: To evaluate the efficacy of a new rotational thrombectomy device, and the procedure-related risk of particle embolization. METHODS: The experiments were performed in transparent silicone tubes. The conditions of flow were as close as possible to physiological parameters. Distal embolization was detected by a mesh of nylon filters. RESULTS: The Straub Rotarex catheter was able to remove all clots. The mean number of migrating particles larger than 1000 microm was 0.17 (+/- 0.38), the mean number of 400-1000 microm migrating particles was 1.08 (+/- 1.04). The mean intervention time was 67 (+/- 37) sec. The mean volume of collected liquid was 96.6 (+/- 24.7) ml. CONCLUSION: The in vitro results suggest that the Straub Rotarex catheter is able to remove large volumes of thrombus with a limited risk of embolization. The main limitation of our model is the absence of adhesion of the clot to the tube.

Long-term results of endovascular stent placement in the superior caval venous system.

PURPOSE: To present the long-term results in superior caval stenting for symptomatic obstruction. METHODS: Forty-nine stents were placed in 30 patients: 16 (53%) with malignant lesions, five (17%) with benign lesions and nine (30%) hemodialysis patients. Self-expandable stents were deployed on a first-line basis. Patients were followed clinically as well as by various imaging techniques and survival analysis was performed. RESULTS: Stent deployment was possible in all cases. Reocclusion was seen in 13 patients, of whom eight belonged to the hemodialysis group. Primary and secondary patency rates for malignant, benign and hemodialysis patients were respectively 74%, 50% and 22%, and 74%, 75% and 56% at 1 year. We had 7% complications and one death from iatrogenic superior vena cava injury. CONCLUSION: Primary stenting of superior caval obstruction is a first-choice treatment method achieving good mid-term patency. Patients with hemodialysis shunts must be closely monitored for early reintervention.

[An unusual cause of acute myelopathy: a dural arteriovenous fistula at the craniocervical junction]. / Une cause exceptionnelle de myélopathie aiguë: la fistule artério-veineuse durale à la jonction cranio-rachidienne.

BACKGROUND: Dural arteriovenous fistulas (DAVF) account for 10% to 15% of all intracranial arteriovenous malformations. Since the first case published by Woimant et al. in 1982, many type V DAVF, i.e. with spinal venous drainage, have been reported. Fistulas located at the craniocervical junction (CCJ) however, are exceptional and only 10 cases of CCJ fistulas associated with myelopathy have been described. CASE REPORT: The authors present a 36-year-old male patient without previous medical history, suffering from acute myelopathy. Cervical MRI showed multiple serpiginous flow-voids along the cord surface and cerebral angiography disclosed a dural fistula of the CCJ fed by the right posterior meningeal and occipital arteries. The venous drainage was directed caudally towards the perimedullary veins. Embolization through the occipital artery, using cyanoacrylate, was performed and resulted in complete cure of the malformation with rapid clinical recovery. DISCUSSION: The authors discuss the pathophysiology and clinical consequences of intracranial DAVF with myelopathy (named V, m+), that are usually identical to those of spinal dural fistulas and related to intramedullary venous hypertension. Early treatment is essential to reverse the patient's myelopathy. Embolization, if technically possible, is the preferred treatment and cyanoacrylate remains the best embolic agent. Following glue deposition, systemic high-dose steroids should be administered to prevent edema. CONCLUSION: In conclusion, this is the first case of DAVF of the foramen magnum causing myelopathy to be detected early and cured by glue embolization alone, with rapid and total clinical recovery.

[Endocrinologic recovery after treatment of an intrasellar aneurysm]. / Récupération endocrinienne après cure d'un anévrisme intrasellaire.

OBJECTIVE: Cavernous intrasellar aneurysms are rare, but may be clinically mistaken for an hypophyseal tumor, thus the need for a preoperative diagnosis. CLINICAL PRESENTATION: We report on a 60-year-old woman suffering from retroorbital headache, diplopia and decreased visual acuity, along with hyperprolactinemia and both gonadotropic and thyreotropic deficencies. Computed tomography revealed a sellar mass with superior extension, but MR raised the possibility of a cavernous aneurysm, that was confirmed by arteriography, avoiding a disastrous transsphenoidal surgery. DISCUSSION: Intracavernous aneurysms are known having a benign course, but serious meningeal hemorrhage can occur in 1.4% of cases and carotid-cavernous fistulae in 8% of patients, warranting treatment. Medial development is rare and may be responsible for endocrinologic manifestations. Neurosurgical approach remains hazardous, and endovascular occlusion represents the method of choice. CONCLUSION: Intracavernous aneurysm must be taken into consideration in the differential diagnosis of pituitary masses because it has a completely different management.

[Acute cholecystitis using computed tomography: usefulness of the trabeculation of the peri-cholecystic adipose tissue]. / Cholécystite aiguë en tomodensitométrie: utilité de la trabéculation de la graisse périvésiculaire.

PURPOSE: To evaluate the significance of pericholecystic fat stranding on CT, and to compare it to other CT findings in patients with acute cholecystitis. MATERIALS AND METHODS: The CT examinations of 14 patients with proven acute cholecystitis were retrospectively reviewed and evaluated for the presence of findings consistent with this diagnosis. RESULTS: The most common CT finding was stranding of the pericholecystic fat (13 patients), followed by gallbladder distension (11 patients). Pericholecystic or perihepatic fluid was present in 6 patients in association with severe acute cholecystitis (6 patients) and biliary peritonitis (2 patients). CONCLUSION: Stranding of the pericholecystic fat was the most common CT findings in patients with acute cholecystitis, followed by gallbladder distension.