Contrast-enhanced multi-shot echo-planar FLAIR in the depiction of metastatic tumors of the brain: comparison with contrast-enhanced spin-echo T1-weighted imaging.

BACKGROUND: The usefulness of fast fluid-attenuated inversion-recovery (FLAIR) sequences after administration of contrast medium (f-FLAIR (+)) has been shown in depicting brain tumors including metastases and meningeal carcinomatosis. Contrast-enhanced multi-shot echo-planar FLAIR (Ms-EPI-FLAIR (+)), comprising combined sequences of f-FLAIR (+) and Ms-EPI, may provide the advantages of f-FLAIR (+) along with rapid acquisition. PURPOSE: To compare Ms-EPI-FLAIR (+) with post-contrast spin-echo T1-weighted imaging (SE-T1WI (+)) in the depiction of brain metastases. MATERIAL AND METHODS: In 14 patients with metastatic tumors of the brain, spin-echo precontrast T1-weighted imaging (SE-T1WI (-)), fast spin-echo T2-weighted imaging (FSE-T2WI), fast-FLAIR, SE-T1WI (+), and Ms-EPI-FLAIR (+) were acquired. For qualitative evaluation of SE-T1WI (+) and Ms-EPI-FLAIR (+), receiver operating characteristic (ROC) analysis was performed in two different readers. For quantitative analysis, the intensity ratios (intensity of tumor divided by intensity of peritumoral region) in SE-T1WI (+) and Ms-EPI-FLAIR (+) were compared. RESULTS: Although pre-contrast f-FLAIR detected 84 of 106 tumors, Ms-EPI-FLAIR (+) detected 98 of 106 tumors. In the ROC analysis for observers A and B, Az values in SE-T1WI (+) did not differ from values in Ms-EPI-FLAIR (+). Quantitatively, the intensity ratio in Ms-EPI-FLAIR (+) also did not differ from that in SE-T1WI (+). CONCLUSION: Detectability of brain metastases with Ms-EPI-FLAIR (+) is almost similar to that with SE-T1WI (+). Ms-EPI-FLAIR (+) could be an alternative to SE-T1WI (+) in the depiction of brain metastases.

Venous Anatomy of the Sphenoparietal Sinus: Evaluation by MR Imaging.

SUMMARY: The termination of the superficial middle cerebral vein (SMCV) has been described as entering or being partially equivalent to the venous sinus coursing under the lesser sphenoid wing, which has classically been called the sphenoparietal sinus. However, the recent literature reports that the SMCV is not connected to the sphenoparietal sinus. In this study, the venous anatomy was evaluated to clarify the anatomy of the sphenoparietal sinus and the termination of the SMCV. Magnetic resonance imaging (MRI) was performed on 1.5-T superconductive units using a three-dimensional fast spoiled gradientrecalled acquisition in the steady state (3-D fast SPGR) sequence with fat suppression in a total of 48 sides of 24 patients. Coronal source images and reconstructed axial images were displayed on the Advantage Window Console, and connections to the cavernous sinus were then evaluated for the venous sinus coursing under the lesser sphenoid wing (hereafter called the sinus of the lesser sphenoid wing), the middle meningeal vein, and the SMCV. The following findings were observed bilaterally in all patients. The sinus of the lesser sphenoid wing was connected medially with the cavernous sinus and laterally with the anterior branch of the middle meningeal vein near the pterion. The anterior branch of the middle meningeal vein entered the bony canal laterally above the junction with the sinus of the lesser sphenoid wing and coursed along the inner table of the skull or emerged into the diploic vein, indicating its parietal portion. Although the termination of the SMCV had several patterns, the SMCV was not connected with the sinus of the lesser sphenoid wing in any of the patients. The sphenoparietal sinus is considered to consist of the sinus of the lesser sphenoid wing and the parietal portion of the anterior branch of the middle meningeal vein; these were identified as venous structures distinct to the SMCV.

Balloon occlusion test of the internal carotid artery: correlation with stump pressure and 99mTc-HMPAO SPECT.

PURPOSE: To evaluate the correlation of stump pressure during balloon occlusion test and relative cerebral blood flow (relative CBF) as measured by 99mTc-hexamethylpropyleneamine oxime (99mTc-HMPAO) single-photon emission computed tomography (SPECT) after test occlusion. MATERIAL AND METHODS: Balloon occlusion test of the internal carotid artery (ICA) was performed in 25 patients. The count ratio of occluded hemisphere to non-occluded hemisphere was calculated on 99mTc-HMPAO SPECT. The ratio of mean stump pressure to mean arterial pressure during carotid occlusion during the balloon occlusion test was compared with the count ratio of 99mTc-HMPAO SPECT. RESULTS: Two patients failed to tolerate even brief carotid occlusion. The other 23 patients showed no ischemic deficit during occlusion of the ICA. In 13 of these 23 patients, the ratios of mean stump pressure to mean arterial pressure were more than 50%, and the count ratios on SPECT were more than 85%. In 10 of 23 patients, the ratios of mean stump pressure to mean arterial pressure were less than 50%, and the count ratios on SPECT were variable. CONCLUSION: Maintenance of a mean stump pressure of 50% or more of the mean systemic pressure during test occlusion indicates adequate cerebral blood flow during carotid occlusion.

Air trapping on computed tomography images of healthy individuals: effects of respiration and body mass index.

AIM: To evaluate the relationships of changes in the lung area during respiration and of individual body mass index (BMI) to air trapping on expiratory computed tomography (CT) in young non-smoking adults of either gender. METHODS: The volunteers were 10 women and 10 men (mean age 25.7 years) who were healthy lifelong non-smokers. We obtained both end-inspiratory and end-expiratory CT images at three levels: the upper, middle and lower lung. The ratio of cross-sectional lung area upon expiration to cross-sectional lung area upon inspiration (lung area ratio) was determined for each lung at each of the three levels. In cases showing air trapping, we calculated the percentage of area of air in relation to the total lung area in each section. BMI was calculated for each participant. RESULTS: Air trapping was present in dependent areas of the lungs of 6 women and 5 men. The mean percentage of area of air trapped was statistically greater for men (9.8+/-9.2%) than for women (4.9+/-5.2%). The mean lung area ratio was 0.52+/-0 14 among volunteers with air trapping (66 sections) and 0.69+/-0.12 among those without air trapping (54 sections) (p < 0.001). At each lung level, the mean lung area ratio was greater in individuals with air trapping than in those without. Mean BMI was also greater in these people (p = 0.009). CONCLUSION: Change in the respiratory lung area and BMI contribute to development of air trapping.

Postoperative three-dimensional CT angiography after cerebral aneurysm clipping with titanium clips: detection with single detector CT. Comparison with intra-arterial digital subtraction angiography.

AIM: To assess the significance of three-dimensional computed tomography angiography (3D-CTA) in detecting remnant necks after cerebral aneurysm clipping. MATERIALS AND METHODS: A total of 59 patients (77 aneurysms) underwent surgery using titanium clips. Two blinded observers independently evaluated the presence of neck remnants on shaded-surface display (SSD) imaging, volume rendered (VR) imaging, and intra-arterial digital subtraction angiography (IADSA). RESULTS: Mean sensitivity and specificity for detecting neck remnants were 50.0 and 74.2% for SSD imaging, 61.5 and 82.8% for VR imaging, and 92.3 and 92.2% for IADSA, respectively. Receiver operating characteristic (ROC) analysis revealed excellent diagnostic performance for IADSA [mean area under ROC curve (Az)=0.97], and good diagnostic performance for 3D-CTA (Az=0.70 and 0.76 for SSD and VR, respectively). Specificity of VR was better than that SSD (p=0.082), however, there was no significant difference between them. CONCLUSION: Use of 3D-CTA techniques can facilitate postoperative evaluation.

Carotid-cavernous fistula associated with an intracranial lesion caused by cortical venous reflux.

SUMMARY: Digital subtraction angiography (DSA) and magnetic resonance imaging (MRI) findings in 20 patients with carotid-cavernous fistula (CCF; 3 direct CCFs and 17 indirect CCFs) were retrospectively reviewed to evaluate venous drainage patterns that may cause intracerebral haemorrhage or venous congestion of the brain parenchyma. We evaluated the relationship between cortical venous reflux and abnormal signal intensity of the brain parenchyma on MRI. Cortical venous reflux was identified on DSA in 12 of 20 patients (60.0%) into the superficial middle cerebral vein (SMCV; n=4), the uncal vein (n=2), the petrosal vein (n=2), the lateral mesencephalic vein (LMCV; n=1), the anterior pontomesencephalic vein (APMV; n=1), both the APMV and the petrosal vein (n=1) and both the uncal vein and the SMCV (n=1). Features of venous congestion, such as tortuous and engorged veins, focal staining and delayed appearance of the veins, were demonstrated along the region of cortical venous reflux in the venous phase of internal carotid or vertebral arteriography in six of 20 patients (30.0%). These findings were not observed in the eight CCF patients who did not demonstrate cortical venous reflux. MRI revealed abnormal signal intensity of the brain parenchyma along the region with cortical venous reflux in four of 20 indirect CCF patients (20%). Of these four patients, one presented with putaminal haemorrhage, while the other three presented with hyperintensity of the pons, the middle cerebellar peduncle or both on T2- weighted images, reflecting venous congestion. The venous drainage routes were obliterated except for cortical venous reflux in these four patients and the patients without abnormal signal intensity on MRI had other patent venous outlets in addition to cortical venous reflux. CCF is commonly associated with cortical venous reflux. The obliteration or stenosis of venous drainage routes causes a converging venous outflow that develops into cortical venous reflux and results in venous congestion of the brain parenchyma or intracerebral haemorrhage. Hyperintensity of brain parenchyma along the region of cortical venous reflux on T2-weighted images reflects venous congestion and is the crucial finding that indicates concentration of venous drainage into cortical venous reflux.

Successful treatment of a ruptured infected aneurysm of the lumbar artery with transcatheter embolization.

We report a patient who had an infected aneurysm of the lumbar artery caused by prolonged psoas abscess-forming spondylitis due to methicillin-resistant Staphylococcus aureus and who was treated successfully with transcatheter arterial embolization. This case suggests that an infected aneurysm can be treated successfully by transcatheter arterial embolization in emergent situations (active bleeding or septicemia) even if surgery is contraindicated.

Portal flow into the liver through veins at the site of biliary-enteric anastomosis.

The aim of this study was to establish the role played by jejunal veins in hepatopetal flow after biliary-enteric anastomosis and to evaluate the helical CT features of hepatopetal flow through the anastomosis. We retrospectively analyzed helical CT images of the liver in 31 patients with biliary-enteric anastomosis who underwent hepatic angiography with (n=13) or without (n=18) CT arterial portography within 2 weeks of the CT examination during the last 4 years. Arterial portography showed hepatopetal flow through small vessels located (communicating veins) between the elevated jejunal veins and the intrahepatic portal branches in two (9%) of 22 patients with a normal portal system. Helical CT showed focal parenchymal enhancement around the anastomosis in these two patients. All nine patients with extrahepatic portal vein occlusion (100%) had hepatopetal flow through the anastomosis, and four of the nine had decreased portal flow. CT revealed small communicating veins in two of these four patients. In five patients with normal portal perfusion despite extrahepatic portal vein occlusion, CT detected dilated communicating veins and elevated jejunal veins. The presence of communicating veins and/or focal parenchymal enhancement around the anastomosis indicates hepatopetal flow through the elevated jejunal veins.

Segmental high intensity on T1-weighted hepatic MR images.

BACKGROUND: We investigated the diagnostic importance of segmental high-intensity (SHI) areas not corresponding to mass lesions on T1-weighted magnetic resonance (MR) images. METHODS: We conducted a retrospective investigation of hepatic MR images obtained from 634 patients during a 4-year period at our institution. Images were compared with findings reported in the patients' medical records. There were 16 patients (2.5%) with SHI areas not corresponding to a mass lesion. We compared MR images with plain computed tomographic (CT) scans (n = 16), angiograms (n = 12), and histologic findings (n = 10). RESULTS: The segments with intrahepatic bile duct dilatation showed hyperintensity on T1-weighted images. In six of 16 patients, the biliary duct was more dilated in the area of hyperintensity than in areas without hyperintensity. The SHI areas appeared as areas of low attenuation (n = 13), high attenuation (n = 1), or isoattenuation (n = 2) on plain CT scans. Histologically, these areas showed ductular proliferation and deposition of bile pigment within the hepatocytes. CONCLUSION: Segmental areas of increased signal intensity on T1-weighted images were probably due to intrahepatic cholestasis.

Transvenous embolization of dural arteriovenous fistula of the cavernous sinus. Fistulous points and route of catheterization.

SUMMARY: We reviewed magnetic resonance (MR) images and digital subtraction angiograms (DSA) from eight patients with dural arteriovenous fistula of the cavernous sinus (DAVFCS) to clarify the fistulous points and to evaluate the venous access routes into the cavernous sinus for transvenous embolization (TVE). Multiplanar reconstruction of the MR images was achieved using three-dimensional fast spoiled gradient-recalled acquisition in the steady state (3-D fast SPGR) after the intravenous administration of gadopentetate dimeglumine (Gd-DTPA). TVE was performed using microcoils via the inferior petrosal sinus (IPS) using the transfemoral approach in five patients, via the facial vein and superior ophthalmic vein (SOV) using the transfemoral approach in 1 patient, and by SOV puncture in two patients. Most fistulas were detected in the posterior portion of the cavernous sinus or in the posterior intercavernous sinus in all of the patients. Fistulas identified as hyperintense dots or lines on contrast-enhanced 3-D fast SPGR images and were replaced with the microcoils. Target embolization of the fistulas was feasible in three patients treated via the SOV and in one patient treated via the IPS. Contrast- enhanced 3-D fast SPGR can help to identify the fistulous points of DAVFCS. Precise identification of fistulous points and selection of the adequate access route are mandatory for efficient TVE of DAVFCS.

CT fluoroscopy-guided catheterization of the celiac and mesenteric arteries for concurrent CTHA and CTAP.

We describe a technique for computed tomographic (CT) fluoroscopy-guided celiac artery or superior mesenteric artery (SMA) catheterization for use with CT hepatic arteriography or CT arterial portography, respectively. Patients underwent conventional hepatic angiography to define the anatomy and to place a catheter within the celiac artery or the SMA. Subsequently, the catheter was repositioned in the target vessels under CT fluoroscopy. Our success rate was 94%.

[A patient with Moyamoya-like vessels after radiation therapy for a tumor in the basal ganglia].

A patient with Moyamoya-like vessels after radiation therapy for treatment of a tumor in the basal ganglia is reported. He was diagnosed as Down syndrome at birth. He had a tumor in the left basal ganglionic region at 12 years of the age. The tumor increased in size at age 14. He underwent cerebral angiography, which did not show a stenosis nor occlusion of the internal carotid artery, anterior cerebral artery, nor the middle cerebral artery. He received radiation therapy with a total dose of 56 Gy. He presented a dressing apraxia at age 19. MRI showed cerebral infarction in the left temporo-occipital region. Right internal carotid angiography revealed a severe stenosis of the internal carotid artery and anterior cerebral artery as well as a severe stenosis of the middle cerebral artery on the right side. Moyamoya-like vessels were seen in the basal ganglionic region. Left internal carotid angiography also showed a stenosis of the internal carotid artery and anterior cerebral artery as well as a severe stenosis of the middle cerebral artery on the left side. Moyamoya-like vessels were seen in the basal ganglionic region. Leptomeningeal anastomose and transdural anastomose were bilaterally seen. These arterial occlusion and stenotic phenomenon corresponded to a previous radiation field. These Moyamoya-like vessels with arterial stenosis and occlusion were thought to be due to radiation-induced vasculopathy, because a previous cerebral angiography showed a normal caliber of cerebral arteries. This patient showed that patients with radiation therapy in their early childhood should be carefully observed considering the possibility of this phenomenon.

Dural arteriovenous fistula of the cavernous sinus with cortical venous reflux of the posterior fossa via a bridging vein.

We describe a patient who had a dural arteriovenous fistula of the cavernous sinus with cortical venous reflux into the lateral mesencephalic vein and cerebellar hemispheric veins via a bridging vein connected with the basilar plexus. The fistula and reflux disappeared after transvenous embolization using interlocking detachable coils.

Supratentorial astrocytomas and oligodendrogliomas treated in the MRI era.

BACKGROUND: There is at present no consensus on the policy for the treatment of patients with low-grade gliomas (LGGs). METHODS: This report is a retrospective multi-institutional study of 100 patients (ages 16-65 years) with astrocytoma (grade II), oligodendroglioma, anaplastic oligodendroglioma and anaplastic oligoastrocytoma of the supratentorial areas which were treated with surgery and postoperative radiotherapy at five university hospitals in northern Japan between 1990 and 1997 when MRI was routinely used to determine the target volume. Most patients were irradiated with 50-60 Gy. The target volume usually covered the areas with T2 prolongation of MRI with a margin of 2 cm. RESULTS: The disease-specific 5-year survival rate was 87.4% for patients with oligodendroglioma and 75.3% for patients with astrocytoma. Survival for patients with astrocytoma in the MRI era appears to be improved compared with historical controls in the literature. Patients with astrocytoma aged 40 years and under had a significantly better disease-specific survival rate than those over 40 years (P < 0.05) and patients with oligodendroglioma and oligoastrocytoma showed a similar tendency. Patients with astrocytoma who had over 50% of their tumor removed had a significantly better survival rate than those who had less than 50% removed (P < 0.05). Chemotherapy appeared to improve the disease-specific survival rate of patients with oligodendroglioma but not that of patients with astrocytoma. CONCLUSION: Oligodendroglioma has a more protracted course of disease progression than astrocytoma. This particular feature and the sensitivity of LGGs to chemotherapy as well as their relevant prognostic factors, such as age, histopathology and amount of tumor removal, should be taken into account before any decision on treatment methods for LGGs is made.

Pulmonary CT findings in acute mercury vapour exposure.

AIM: We describe the pulmonary computed tomography (CT) findings in acute mercury poisoning. MATERIALS AND METHODS: Initial (n= 8) and follow-up (n= 6) chest CT examinations in eight patients exposed to mercury vapour while cutting pipes in a sulphuric acid plant were reviewed. Of the eight patients, two were asymptomatic and had normal CT results, two were asymptomatic but had abnormalities on CT, and four had both acute symptoms and positive CT results. The patients were all men whose ages ranged from 37 to 54 years (mean, 49 years). RESULTS: Poorly defined nodules were present in five of six patients with positive CT findings, present alone in two patients or as part of a mixed pattern in three. They were random in distribution. Alveolar consolidation (n= 3) and areas of ground-glass opacity (n= 4) were observed and were more prominent in the most severely affected patients with the highest blood and urine level of mercury, predominantly in the upper and/or middle zone. These abnormal findings on CT resolved with (n= 1) or without (n= 5) steroid therapy. Pathological findings (n= 1) demonstrated acute interstitial changes predominantly with oedema. CONCLUSION: We report CT findings in eight patients acutely exposed to mercury vapour. The pulmonary injury was reversible on CT in these cases. Hashimoto, M. (2001). Clinical Radiology56, 17-21.

Comparison of thallium-201 and gallium-67 imaging in evaluation of head and neck tumors.

PURPOSE: 201Tl imaging was compared with 67Ga imaging in the detection of malignant head and neck tumors. METHOD: Eighteen patients with tumors in the head and neck region underwent both planar and SPECT imaging using 201Tl-chloride and 67Ga-citrate. The detection of primary tumors and lymph node (LN) metastases by visual evaluation was compared between 201Tl and 67Ga imaging. Additionally, quantitative analysis of the SPECT images was performed in eight patients. RESULTS: On visual evaluation, primary tumor uptake was detectable in 100% on the 201Tl SPECT images compared with 44% on the 67Ga SPECT images. The sensitivity, specificity, and accuracy of 201Tl in detecting LN metastases were higher than those of 67Ga SPECT; however, there was no statistical difference between 201Tl and 67Ga. The tumor-to-background ratio was significantly higher on 201Tl SPECT than on 67Ga SPECT. CONCLUSION: This study suggested that 201Tl could be useful in the evaluation of malignant tumors in the head and neck region.

Germ cell tumors of the central nervous system originating from non-pineal regions: CT and MR features.

CT and MR findings were retrospectively reviewed in 12 patients with germ cell tumors originating from the non-pineal regions. Cystic or necrotic components were seen in 6 patients. Of 4 germinomas, 2 showed mixed density on the CT. The MR signal intensity of the tumor was non-specific. Of 8 germinomas, 4 were inhomogeneously enhanced on postcontrast CT and T1-weighted MR images. CT and MR features of germinomas originating from non-pineal regions frequently differ from those of germinomas originating from the pineal region. The mass of the tumor often appeared cystic and inhomogeneously enhanced following contrast infusion.