Search

This report establishes and details the clinical concept of the subperitoneal space and the subpleural space as components of the continuum formed by the subserous space. The subserous space is an anatomic plane formed in the embryo that persists during development into the adult. This is the basis of the thoracoabdominal continuum. The embryologic development is presented from the viewpoint not of the contents and their relationships within the developing coelomic cavity but rather that of a continuous space deep to the lining serous membrane. Clinical material is presented that illustrates different disease processes that can directly spread in either direction within this continuum. This unifying concept provides an understanding of the pathogenesis of direct spread of disease processes within and between the thorax and abdomen.

T he purpose of this article is to define the anatomic relationships of the continuum of the intraperitoneal and extraperitoneal tissues of the abdomen and pelvis called the subperitoneal space and to establish the clinical usefulness in identifying the direct spread of disease by modem imaging techniques. In clinical practice and in diagnostic imaging of the abdomen and pelvis, it has been useful to distinguish between intraperitoneal and extraperitoneal organs, structures. and compartments. Concepts introduced and established over the past two decades regarding the spread and localization of the full range of disease processes in the abdomen and pelvis have been universally adopted [1-5]. Whether of inflammatory, malignant, or traumatic origin, spread and localization are determined by dynamic and anatomic features related to the peritoneal mesenteries and ligaments. the peritoneal recesses. and the three extraperitoneal spaces and their continuity with pelvic compartments. On the basis of pathogenesis and recognized anatomic avenues of dissemination, characteristic imaging features often lead to uncovering an occult primary site and to anticipating sites of extension, thereby permitting accurate prognosis and appropriate management. Nonetheless, instances are encountered in which the sites of the presence or extension of disease states in the abdomen and pelvis appear paradoxical. Our recent experience leads to the unifying conclusion that, indeed, intraperitoneal and extraperitoneal structures constitute an anatomic continuum (the embryologic development ordains that the mesenchyme beneath the peritoneum is a substrate in continuity throughout the body) and that these anatomic planes of continuity serve as pathways for the spread of disease. The holistic paradigm conceptualizes the abdomen and pelvis as a single space interconnected by planes. In acknowledging this continuum deep in relation to the peritoneum with its subserous connective tissue, we have designated this the subperitoneal space (Fig. I ). Thus, it is essential to recognize that this space and its discrete planes of continuity provide the avenues for bidirectional spread of disease between intraperitoneal and extraperitoneal sites and structures [6-14].

The subperitoneal space is the continuous space interconnecting the peritoneum and retroperitoneum and the abdominal organs. This report expands the concept of direct spread of disease via the subperitoneal space to include direct extension into the solid abdominal viscera (i.e., liver, kidneys, and spleen). Discussion of the anatomy, case presentations, and imaging with computed tomography, ultrasound, and magnetic resonance are presented. This unifying concept provides an understanding for direct spread of disease presenting clinically or being imaged within a solid abdominal organ.

The designation of the subperitoneal space emphasizes the continuum of the potential space of extraperitoneal and intraperitoneal areolar tissue traversed by blood vessels, lymphatics, and nerves. Across its root, the subserous connective tissue of the small bowel mesentery is anatomically continuous with that deep to the posterior parietal peritoneum. There is thereby provided an avenue of spread from multiple sites to and from the small bowel mesentery and its relationships. These include perforated lesions of the bowel, pancreatitis, lymphoma, neuroblastoma, leiomyosarcoma of small bowel, and hemorrhage of retroperitoneal and pelvic origin.

Neuroblastoma, a malignant tumor of neural crest origin, is the most common extracranial solid tumor in children. In 1971 Evans et al. introduced a clinical staging for neuroblastoma. Over sixty percent of patients present with neuroblastoma beyond stage I. Despite more aggressive therapy there has been only minimal improvement in survival. Since 1978, all patients with neuroblastoma have had CT scanning as part of their initial evaluation at our institution. Children with abdominal neuroblastoma beyond stage I form the basis of this report. Selected cases illustrating the permeative nature of neuroblastoma and the mechanism of direct abdominal spread by CT scanning are presented. The tumor originates in the retroperitoneum and spreads to the abdominal aorta where it gains access to the subperitoneal space via the celiac axis and superior mesenteric artery. These vessels course from the aorta to their ultimate destination within their peritoneal folds. These folds form the interconnecting space (subperitoneal space) between the retroperitoneum and the peritoneal organs. Such scanning is extremely sensitive in detecting neuroblastoma with early infiltration into adjacent tissues and contiguous spread through abdominal spaces. The clinical implications of the permeative nature of neuroblastoma and the mechanism of contiguous abdominal spread are discussed.

The direct spread of intraabdominal disease via peritoneal folds is clearly demonstrated with computed tomography (CT). This extensive network of peritoneal folds can be conceptualized as the subperitoneal space. These subperitoneal communications within the abdomen are described and demonstrated by CT scans and a schematic drawing. Direct spread of disease within and between abdominal compartments is illustrated with selected clinical cases stressing the CT imaging method.

Computed tomography (CT) was used in the management of four patients with periorbital inflammation. These patients were selected for CT scanning because of the difficulty, on clinical examination alone, in determining the degree of orbital disease. The CT scans confirmed the presence and defined the location of an orbital abscess in three patients and eliminated the presence of an abscess in the fourth. On the basis of this experience, CT scanning is recommended in the evaluation of children with periorbital inflammation in whom proptosis, ophthalmoplegia, or loss of visual acuity develops, or in whom severe eyelid edema prevents adequate eye examination.

ALTHOUGH idiopathic dilatation of the main pulmonary artery had been described in several previous reports1 2 3 4 5 6 7 8 9 10 11 12 it was not until 1949 that Greene et al.13 laid down criteria fo...

Pneumomediastinography has proved to be an excellent radiological method for studying the size, extent, and gross anatomical characteristics of mediastinal masses (1, 2, 5, 10, 11). It has also been employed successfully in estimating thymic size in autoimmune diseases and in studying the response of the thymus gland after steroid therapy (9, 11). To our knowledge there have been two European papers and a single American paper which discuss the results of pneumomediastinography in evaluating bronchogenic carcinoma (1, 6, 10). The purposes of this report are to describe the recent modifications of our original method of pneumomediastinography (2) and to relate our experience with this procedure in evaluating 64 instances of suspected bronchogenic carcinoma. We shall emphasize the rationale for and the technical details of successful pneumomediastinography and also describe radiological principles and criteria for the interpretation of pneumomediastinograms. Rationale Using injection technics, Marchand exam...

“Scalloping” is used to describe that change in the configuration of the vertebrae, in which there exists an exaggeration of the normal slight concavity of the dorsal surface of the body. Scalloping in association with a locally expanding mass in the spinal canal is well recognized. There are other less well known causes of this type of vertebral deformity. This paper will present a retrospective study in which examples of scalloping were collected from our files and from the literature and were classified according to the pathogenic mechanisms involved. Our aim is to bring a sense of order to a subject which is discussed in a rather fragmentary manner in the literature. Examples from the various groups will be illustrated, and hypotheses regarding the mechanisms of scalloping will be offered. In formulating a classification of scalloped vertebrae, we have taken into consideration the pathogenic mechanisms by which the configuration of bones may be altered. An abnormal configuration might result either pr...

A radiolucent linear shadow can be seen on plain radiographs in the right upper quadrant of 30% of patients. The surface anatomy of the liver and its associated ligaments were studied in the cadaver, clinically, and in surgical patients to determine the cause of this shadow. From these studies it is concluded that the shadow is cast by the fat that normally surrounds the ligamentum teres hepatis. The soft-tissue “mass” that the fat shadow demarcates should not be interpreted as a pathological process.

This report expands the concept of the subperitoneal space (SS) as the potential conduit for direct spread of disease in the abdomen to include the female pelvis. The normal anatomy of the SS in the lower abdomen, the female pelvis, and its uninterrupted continuation between the abdomen and pelvis are demonstrated by several imaging modalities. Surgically proven cases of bidirectional spread of disease between the abdomen and female pelvis are reported. The unifying concept of the interrelationship formed by the SS provides an understanding of the basic concepts of the pathways of direct spread of disease and the pathogenesis of the clinical presentation of disease distant from its site of origin.

The formation of the coelomic cavity during fetal life divides the abdomen into two major parts—the peritoneal cavity and the retroperitoneum. Classically, the retroperitoneum is further subdivided by its fascial planes into three components: the perirenal space containing the kidneys and the adrenal glands; the anterior pararenal space containing the pancreas, the duodenum, and the ascending and descending colon; and the posterior pararenal space deep to the transversalis fascia continuing around the flank [1,2]. Caudad to the perirenal space the anterior and posterior pararenal spaces become confluent. These divisions of the retroperitoneum are extremely helpful for understanding the spread and confinement of disease within these spaces. This concept is also of importance in establishing the differential diagnosis of a pathologic process when the abnormality is identified within a specific space (Figs. 5-1, 5-2).

Intrinisic tumors of the spinal cord arise from neuronal tissue, glial cells, vascular structures, and occasionally from other cellular components of the spinal medulla. Tumors which arise from the meninges and nerve root sheaths or which result from the developmental inclusion of foreign dermal, fibrous or adipose tissue within the substance of the spinal cord are not truly intrinsic tumors. As in the brain, the majority of primary intrinsic spinal cord tumors are gliomas, but the growth characteristics and effects upon the host are not the same. It is the purpose of this paper to analyze the case histories of a relatively large number of patients with primary spinal cord tumor and to evaluate the effect of radiation therapy upon the course of the disease. Incidence and Pathology It is difficult to establish definitely the relative incidence of intraspinal tumors, either in comparison with intracranial tumors or with other neurologic diseases, since necropsy material, even in large metropolitan hospitals...

THE PURPOSE of this paper is to describe the roentgen manifestations of alterations of the normal anatomy of the extraperitoneal perivisceral fat pad and to emphasize that both intra- and extraperitoneal pathologic processes can affect the e. p. f. p. Intraperitoneal Disease A. Fluid: Intraperitoneal fluid in the upper abdomen frequently manifests itself radiologically by collecting adjacent to the properitoneal fat line as a linear density, displacing the colon medially and thinning the properitoneal fat. This shadow has been called the “flank stripe” (5). In addition, the medial margin of the “hepatic angle” may be lost (Fig. 1). What is the explanation for the loss of the hepatic angle by intraperitoneal fluid if the shadow of the hepatic angle is cast by the liver's contrasting with extraperitoneal Iat?3 The great pliability of the e. p. f. p. explains this finding. The intraperitoneal fluid fills the peritoneal recess about the posterior inferior portions of the liver, widening and blunting it. The f...

THE delineation of the normal structures and pathologic processes within the mediastinum is one of the most difficult aspects of chest roentgenology. The anatomic complexity of the mediastinal contents and their similar radiologic densities preclude precise x-ray visualization. Barium esophagography,1 , 2 overpenetrated films3 , 4 and vertical and horizontal laminagraphy,5 as well as the complicated contrast technics of angiocardiography and opacification of the azygos vein and superior vena cava,6 , 7 are widely employed to improve the radiologic study of the mediastinal structures. Theoretically, the introduction of gas as a contrast material into the various soft-tissue planes of the mediastinum, pneumomediastinography, should be the ideal . . .

Reports of isolated congenital mitral insufficiency have been sparse. We have had theunusual opportunity of studying 16 cases. This congenital lesion as noted in these sixteen patients has presented with a clinical finding hitherto unreported which we think is presumptively diagnostic. The murmurs noted in these patients differ from those of mitral insufficiency of other etiologies. The regurgitant murmur has a marked distribution and intensity over the left posterior thorax which is most likely due to a congenitally widely dilated mitral valve ring. The pulmonary artery wedge pressure or left atrial pulse contours have been found to be of value in the diagnosis. The single most important diagnostic test has been selective left ventricular angiography.

IN 1812 Meckel described the congenital diverticulum of the small intestine that now bears his name. Although this lesion has been discovered in 1 or 2 per cent of various autopsy series, notoriously the roentgenographic demonstration of Meckel's diverticulum is not frequently accomplished.1 2 3 4 Up to 1958 no more than 30 or 40 cases so diagnosed had been reported.5 6 7 8 9 10 11 12 13 14 Many physicians, including radiologists, have commented upon the infrequency of the roentgenologic diagnosis and have made statements such as the following: "Roentgenologic examinations have been demonstrated as practically useless in attempts to visualize the lesion [Meckel's diverticulum]...."15 16 17 18 19 20 This report will serve to . . .

We were interested to read of Dr. DeNicola's experience with ultrasound in a patient with orbital cellulitis. We have no personal experience with this technique and know of no studies using it for this particular clinical problem. It does seem, however, that orbital sonography should define proptosis and displacement of the globe and establish the presence of any sizeable intraorbital mass (abscess). However, we doubt that sonography has the resolution to provide the detailed information about sinus disease and its relationship to orbital disease that computed tomography (CT) can.

• Sixty-four infants with birth weights of 500 to 1,500 g were studied to determine the incidence and outcome of intracranial hemorrhage. Thirty-seven (58%) had hemorrhage and of these 60% died. Of the survivors, progressive hydrocephalus requiring treatment developed in only two infants. Serial computerized tomographic scans with measurement of ventricular-brain width ratios were found to be useful in objectively evaluating hydrocephalus. Review of perinatal data showed no association of maternal or obstetrical factors with neonatal hemorrhage but the infants who had intracranial bleeding showed a high incidence of low Apgar scores, respiratory distress syndrome, acidosis, hypoxia, apnea, hypotension, seizures, and requirement for respiratory support. Multiple regression analysis of potentially causative factors assigned importance to low gestational age, respiratory distress syndrome, birth asphyxia (low Apgar score), and vaginal delivery. ( Am J Dis Child 134:855-859, 1980)