Search

Objective To determine the immediate and delayed complications of percutaneous adrenal biopsy and any relationship between biopsy methods and complications. Materials and methods Medical records and radiological examinations of 83 percutaneous adrenal biopsy were reviewed. Indication for biopsy, inpatient/outpatient status, lesion size and location, imaging modality used, needle type, size, approach and number of passes, biopsy results, immediate complications, and delayed complications were recorded. Results Computed tomography was used in 79 cases (95%) and ultrasound in 4 (5%). The biopsy approach was posterior in 37 cases, transhepatic in 33, transpancreatic in 9, anterior in 2, transsplenic in 1, and lateral in 1. The total complication rate was 8.4% and was slightly higher for the transhepatic approach (12%) than the posterior approach (8%). Seven complications occurred: two pneumothoraces, two pain, one perinephric hemorrhage, one subcapsular and intrahepatic hematoma, and one hepatic needle-tract metastasis. The posterior approach was complicated by the two pneumothoraces and perinephric blood; the transhepatic was used in the other four. Five of the complications occurred with 22 gauge needles. Conclusion Percutaneous adrenal biopsy is a safe procedure. Complications occurred in 7 of our patients (8.4%).

Objective and methods To evaluate the spectrum of pelvic CT findings in patients who have had radical prostatectomy, we retrospectively evaluated the pelvic CT of 17 patients after surgery for prostate cancer. All patients were thought to be clinically free of local recurrence of carcinoma. Results The bladder base was retropubic in 100%, the levator sling was well delineated in its entirety in only 88%, and fat was clearly demonstrated between the rectum and bladder base in only 44%. Unsuspected findings in this group included soft tissue density structures in the resected bed of the seminal vesicles (88%) and a transversely oriented, soft tissue density bar between the bladder base and rectum (53%). A variety of symmetric abnormalities are commonly seen on postprostatectomy pelvic CT. Conclusion Seminal vesical-like soft tissue structures are routinely visualized, and a horizontal bar of soft tissue in the rectovesical space is commonly demonstrated. These structures should not be confused with local tumor recurrence.

Pneumoperitoneum detected on plain radiographs following blunt abdominal trauma is nearly pathognomonic of bowel perforation and usually mandates exploratory laparotomy. To determine the significance of computed tomography (CT)-detected pneumoperitoneum, we reviewed the clinical records and imaging studies of all trauma patients in our hospital over a seven-year period whose abdominal CT scans showed free intraperitoneal gas. Patients who had penetrating injuries or peritoneal lavage prior to CT were excluded. Of the 18 patients who met these inclusion criteria, surgically confirmed bowel injury was found in only four (22%). In the remaining 14 patients, no evidence of gastrointestinal perforation was found by exploratory laparotomy (2 patients), diagnostic peritoneal lavage (4 patients), GI studies and clinical follow-up (6 patients), or clinical follow-up alone (5 patients). Seven patients had a pneumothorax as a possible cause for pneumoperitoneum. Two additional patients were on mechanical ventilation. Unlike pneumoperitoneum seen on plain film, CT-detected pneumoperitoneum is not pathognomonic of bowel perforation. While laparotomy is not mandatory in the non-surgically explored patient, close clinical observation is essential, and additional diagnostic tests such as peritoneal lavage or radiographic contrast studies can be beneficial to confirm the absence of intestinal injury.

Renal leiomyoma is a challenging diagnostic and therapeutic condition. It is clinically similar in presentation and radiographic appearance to its malignant counterpart, leiomyosarcoma. We review 30 cases of clinically diagnosed leiomyoma of the kidney from the literature, including 4 new cases with emphasis on the computerized tomography findings. Computerized tomography may locate a renal leiomyoma serendipitously in an asymptomatic patient. If the lesion is peripheral or in the parapelvic area and a plane can be seen between the tumor and kidney a capsular tumor, such as a leiomyoma of the kidney, might be considered in addition to the more common renal cell carcinoma. Renal leiomyomas have a variable radiographic pattern from that of a pure cystic to a mixed solid/cystic to an entirely solid lesion. Renal leiomyomas usually are sharply demarcated from the surroundings. Although computerized tomography cannot distinguish a renal leiomyoma from other benign or malignant renal processes the presence of invasion can virtually eliminate this benign tumor as a diagnosis. Since a preoperative diagnosis cannot be made, management involves renal exploration and radical nephrectomy in the larger lesions with a renal-sparing operation possible in selected cases. After treatment patients have a uniformly excellent prognosis.

A woman presented with acute bilateral loin pain and anuria. An unenhanced spiral CT revealed bilateral renal obstruction and a calculus within the left ureter. After the insertion of a stent into the left ureter, a diuretic renal scan and a contrast-enhanced CT scan showed a calculus at the anastomosis of a right transureteroureterostomy and relief of the obstruction. This case illustrates bilateral obstructive uropathy caused by a solitary ureteric calculus.

In select patients with pancreatitis, pancreatectomy may be the only alternative for treatment of abdominal pain. Segmental autotransplantation of the distal pancreas to the thigh has been shown to be successful in preventing or reducing the severity of diabetes following pancreatectomy. We present the postoperative anatomy and potential complications identified on cross-sectional imaging.

Parapelvic renal cysts are benign ubiquitous lesions of the renal sinus frequently demonstrated on CT and ultrasonography. Occasionally a renal parenchymal mass will grow so that its epicenter is within the renal sinus. We report two cases of surgically proven cystic renal cell carcinoma centered in the renal sinus with no apparent connection to the renal parenchyma. Cystic renal cell carcinoma must be excluded whenever a parapelvic cyst with atypical features is encountered on cross-sectional imaging studies.

We present 2 computed tomography cases of adult asymptomatic patients whose adrenal glands contained nonfocal collections of fat diffusely distributed throughout the limbs. Although no pathological proof is available, this pattern of fat distribution corresponds to a well-described pathological entity, lipomatous adrenal metaplasia.

Computed tomography (CT) was used to evaluate 15 rabbits with experimentally induced liver abscesses. The animals were examined both before and after intravenous contrast injection. After sacrificing the animals, postfreeze CT scans were made to mark the abdomen for 1-cm thick whole body sections for correlating the gross pathology with the results of the CT scans. CT detected 15 abscesses in 13 of the 14 rabbits with true positive lesions. Ten abscesses less than 1.4 cm in diameter were not detected by CT. Contrast agent enhancement was helpful in 70% of the studies. These abscesses have characteristics similar to human liver abscesses, but there was more gas and calcium in the experimentally induced abscesses than is encountered in humans with hepatic abscesses. The model and its CT characteristics appear well suited for future studies in the diagnosis and treatment of liver abscesses.

Paramediastinal masses adjacent to the aorta require a diagnostic evaluation to differentiate between tumor and aneurysm. It has been suggested that neoplasm may enhance sufficiently to be confused with a vascular structure or that a clot filled aneurysm may simulate a neoplasm by not filling with contrast medium. Five patients, two with thoracic aneurysms, two with malignancy, and one with a malignancy and an aortic dissection, are presented in whom bolus injection computed tomography (CT) was able to distinguish between aneurysm and mass. The CT examination also accurately visualized the point of communication of the aneurysm with the aorta, defined the relationship of the aneurysm to vital mediastinal structures for planning surgical resection, and helped plan the approach for percutaneous transthoracic needle aspiration when tumor was suspected. Bolus injection CT represents a rational alternative to aortography for mediastinal paraaortic masses.

Thirteen patients with benign angiomatous lesions of the extremities were evaluated by CT. The relationship of the lesion to specific muscle groups and fascial planes was defined better by CT than on plain radiography or angiography. Computed tomography without contrast enhancement demonstrated well circumscribed masses of lower attenuation value than the surrounding muscle. Eight of the 11 patients who received intravenous injection of contrast material showed characteristic punctate or curvilinear structures within the mass, which had attenuation values similar to normal blood vessels. The characteristic CT features of benign angiomatous lesions of the extremities are presented.

Radiographic assessment of the patellofemoral joint (PFJ) is problematic because conventional views are cumbersome, difficult to standardize, and not reliable for displaying this joint with flexion of the knee less than about 30 degrees. We used computed tomography (CT) to obtain conveniently a direct transaxial view of the PFJ in ten normal human volunteers at different 0 degree, 20 degrees, and 45 degrees of knee flexion and during both contraction and relaxation of the quadriceps muscle. From the CT images we measured femoral trochlear angle, patellar centralization, femoral trochlear depth, and patella tilt angle. In full extension, with the quadriceps muscle relaxed, 19 of 20 knees showed the patella well centered in the femoral trochlear groove. The tilt and centralization of the patella were largely unchanged at 20 and 45 degrees of knee flexion with quadriceps contraction. CT appears to be an optimal method of studying the PFJ. The normal relationships described in this report can be the basis for evaluating patients with known or suspicious history of recurrent subluxation or dislocation of the patella.

Malignant melanoma is an unpredictable and often virulent cutaneous malignancy. Although computed tomography is the most sensitive method for detection of intrathoracic metastases, its value in the assessment of abdominal spread has not been fully defined. We evaluated the sites of CT-identified metastases in 70 patients with pathologically confirmed malignant melanoma. Results were correlated with Clark's level, Breslow thickness, site of the primary, and clinicopathologic stage. CT detected enlarged abdominal or pelvic lymph nodes in 75% of patients with Clark's level 5 lesions but only in 24% and 33% of those with level 3 and 4, respectively. Patients with deep primary lesions of the lower extremities had a high frequency of pelvic node metastases. Liver and splenic metastases were detected in up to 25% of patients with level 4 or 5 melanoma. Adrenal and subcutaneous metastases were frequently discovered as were unsuspected nodules at the lung bases.

One hundred nineteen patients with renal trauma documented at laparotomy or by an abnormal excretory urogram were followed up sufficiently to allow assessment of their postinjury course. One-fourth of these patients had a laparotomy and Gerota's fascia was opened; one-fourth had a laparotomy and Gerota's fascia was not opened; and one-half had no laparotomy. Gerota's fascia was opened only after vascular control of the renal pedicle was obtained. Nonetheless, the loss of renal tissue in this group was high. Twenty-three of 34 patients (68%) required nephrectomy or partial nephrectomy, indicating the severity of their renal injuries. The loss of renal tissue was low in the two groups in which Gerota's fascia was not opened. Six of 85 patients (7%) developed complications eventually requiring nephrectomy or partial nephrectomy; an additional three patients (4%) demonstrated loss of renal tissue on followup urograms, the loss being minimal in all three cases. The relatively low morbidity in these 85 patients indicates that their original renal injuries were, for the most part, less serious than the injuries in the group in which Gerota's fascia was opened. This low morbidity also indicates that retroperitoneal hematomas in the area of the kidney which are nonexpanding, contained, and nonpulsatile need not be routinely explored.

Following baseline CT scans, splenic subcapsular hematomas were produced in dogs by direct splenic trauma. The CT scans of the spleen were obtained one to two hours before and after administration of IV contrast media and one, two, seven, 14 and 28 days following splenic trauma. Variations in the CT image of the hematomas was correlated with time and alterations in the chemical and histologic nature of the hematoma. Initially, the hematomas were isodense with the normal spleen and identified only following IV contrast administration. The initial number of hematomas identified by CT decreased to about half after seven to 14 days and then remained stable. Analysis of the hematomas revealed an initial increase in hemoglobin which was followed by a decrease. Dry weight increased, then decreased; lipid content decreased over time; and calcium content showed no appreciable change. The CT appearance of splenic subcapsular hematomas is dependent on the age of the hematoma. CT scans done soon after trauma should be performed following administration of intravenous contrast media, while less acute hematomas should be apparent without contrast media. Changes in attenuation values of hematomas appear due to a reduction in hemoglobin content and an increase in water content of the hematoma.

Although the potential for splenic injury during left sided thoracentesis or percutaneous renal biopsy is well known, its occurrence has been rarely reported. In a 1 year period we used computed tomography to detect acute splenic, perisplenic, and intraperitoneal hemorrhage in three patients after percutaneous diagnostic and therapeutic procedures in the lower chest and upper abdomen. One patient was asymptomatic, the second developed left upper quadrant pain, and the third required emergency splenectomy.

Urachal carcinoma arises in the clinically silent extraperitoneal space between the bladder apex and the umbilicus. Computed tomography was used to correctly diagnose and stage urachal cancer in two patients. In one case a mass was localized to the bladder wall and immediate juxtavesical region; in the other case an advanced locally invasive lesion was seen to engulf and fistulize loops of small bowel and extend through the umbilicus. Urachal carcinoma has a highly characteristic appearance and location on CT images.

Four criteria have been described to differentiate ascites from pleural effusion by computed tomography (CT). These four signs (the diaphragm sign, the displaced crus sign, the interface sign, and the bare area sign) were compared in a retrospective blinded analysis in 52 patients with ascites, right pleural effusion, or both ascites and right pleural effusion. There were limitations with each of the four criteria. Each of the individual criteria was reliable when only one abnormal fluid collection, either pleural effusion or ascites, was present. When both a right pleural effusion and ascites were present, none of the four criteria reliably identified both fluid collections. The combined use of the four criteria, however, led to a correct identification of all the abnormal fluid collections.

Intrahepatic portal veins may be identified on routine computed tomography (CT) of the liver. These venous structures appear as linear and branching, low-density regions in the liver which appear to converge at the porta hepatis. Intrahepatic portal veins may simulate the appearance of dilated intrahepatic bile ducts. Venous structures may be distinguished from dilated bile ducts by their obliteration following intravenous infusion of urographic contrast agents. CT numbers of portal veins tend to be somewhat higher than those of dilated bile ducts, but enough overlap of values exists to make reliance upon these numbers in an individual case suspect.

The potential role of computed tomography (CT) in the detection of acute renal ischemia was assessed in nine mongrel dogs. Ischemia was produced by inflation of a balloon catheter in the main renal artery, with scans performed before, during, and after a 60-minute period of ischemia. A small but consistent increase in the attenuation value of ischemic renal parenchyma was observed. When intravenous contrast material was given, the ischemic kidney was markedly less enhanced than the contralateral, nonischemic kidney. By using the contralateral kidney for comparison, the ischemic kidney could be identified with or without the use of a contrast agent. Although calculations of mean pixel values were necessary when a contrast agent was not injected, the abnormal kidney could be easily recognized from the CT images themselves when intravenous contrast material was given. Because of the consistency with which the abnormalities were observed, we recommend a clinical trial of CT in suspected acute renal ischemia.

The value of computed tomography in the diagnosis and management of lesions of the musculoskeletal system is being determined. Illustrative cases including a lipoma of the thigh, osteochondroma of the hip, simple cyst of the ilium, recurrent liposarcoma of the lumbar spine, desmoid tumor in the gluteal region, and postoperative interspace infection of the lumbar spine are presented to indicate the potential value of this procedure in the diagnosis and planning of treatment of musculoskeletal lesions.

Conventional radiographic assessment of the patellofemoral joint (PFJ) is often unsatisfactory for a variety of technical and theoretical reasons. Using a simple device designed to allow easy and reproducible control of knee flexion, we used computed tomography (CT) to evaluate the PFJ in 10 normal volunteers and five patients with a history suggestive of recurrent subluxation or dislocation of the PFJ. At full extension of the knee the patients with a history of malalignment showed an abnormal patellar centralization and tilt compared with those of the normal volunteers. The abnormalities were absent or less pronounced on images obtained at 20 and 45 degrees of knee flexion.

The intra-arterial administration of vasodilator drugs (acetylcholine, histamine, isoproterenol, adenosine triphosphate, bradykinin, and isoxsuprine hydrochloride) induced reversible depression in the maximal contractile force of the intermittently stimulated gastrocnemius-soleus muscles in the cat. In general, blood flow to the muscles was held constant and perfusion pressure was observed. The agents were effective in depressing the muscle at doses the same as those required to produce dilatation in the resting muscle. Increase in blood flow during infusion could reverse the depression. Atropine, in amounts sufficient to block the hypotensive action of intravenously administered acetylcholine, prevented the muscle depressant action of the latter, while leaving unaffected the action of histamine. Further experiments, utilizing mainly acetylcholine as the prototype, were performed to test the hypothesis that the depressant effect on the gastrocnemius was closely related to a vascular action of the drugs. Evidence serving both to exclude neuromuscular blockade and to support a vascular effect was adduced from three sets of observations. 1) In vitro tests of blocking action of acetylcholine and histamine on nerve-muscle preparations indicated that any such action would require doses several hundred times greater than those effective in the cat gastrocnemius. 2) Under conditions where dependency of contractile force on blood flow varied, comparison of the effects of acetylcholine to d -tubocurarine and decamethonium on the cat gastrocnemius showed that when dependency on flow was reduced the effect of acetylcholine was also, while neuromuscular blockade was affected little. 3) A decrease occurred in the I 131 clearance rate from the gastrocnemius parallel to the reduction in muscle force from acetylcholine, while a much smaller, or delayed, reduction in rate occurred when force was reduced equally by d -tuboeurarine. A redistribution of blood flow within the muscle and associated connective tissue may account for the results.

Pancreatic pseudocysts are a well-known complication of pancreatitis and may occur in unusual locations. We report a case of a child with hereditary pancreatitis who developed a subcapsular pseudocyst of the left kidney. The constellation of findings of calcific pancreatitis and a left renal subcapsular fluid collection should raise the possibility of a subcapsular pseudocyst.

Pelvic lipomatosis is a rare, benign disease in which the characteristic roentgenographic findings may mimic those of pelvic malignancy. In the past more than two-thirds of reported cases have been explored surgically for diagnosis. We present 2 cases to demonstrate how the definitive diagnosis of pelvic lipomatosis can be made with the aid of computed tomography to avoid invasive techniques.

Retroperitoneal hemorrhage caused by a renal tumor is usually due to a renal cell carcinoma or angiomyolipoma. The authors report a case of computed tomographic (CT) demonstration of renal metastases from choriocarcinoma with an associated perinephric hemorrhage. The CT features indicated the acute nature of the hematoma and its confinement within the extracapsular compartment of the perirenal space.

A case of malignant teratoma of the thyroid gland is presented. Computed tomography identified an inhomogeneous mass with dense calcifications involving the thyroid gland and compressing the upper airway. Enlarged, peripherally enhancing lymph nodes in the neck and mediastinum suggested its malignant etiology.