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4i i
Letters i;:;:‘
.
.
Diaphragmatic Rupture Due to Blunt Trauma: Sensitivity of Plain Chest Radiographs The article by Gelman et al. [1] describes various important findings seen with diaphragmatic rupture. Although informative, it uses the term “elevation of hemidiaphragm” as one of the findings associated with diaphragmatic rupture. Of course it is not the diaphragm but the lung base that is elevated (the diaphragm has been ruptured). This term is commonly misused in radiology practice. For example, often when someone is referring to the possibility of subpulmonic pleural effusions, elevated hemidiaphragm is used; again, of course, it is not the diaphragm that is elevated but the lung base. On chest radiographs, the location of the diaphragm can only be inferred on the
basis of air in adjacent
lung. If the lung base is elevated,
diaphragm
of numerous
is only
one
possible
causes,
improves
credibility
of radiologists
to other
including
physicians.
Masonic
of Maryland
Medical
System
Baltimore,
Maryland
21201
REFERENCES 1 . Gelman R, Mirvis SE, Gens D. Diaphragrnatic rupture due to blunt trauma: sensitivity of plain chest radiographs. AJR 1991 156:51-57 2. Fataar 5, Schulman A. Diagnosis of diaphragmatic tears. Br J Radiol
1979:52:375-381
dia-
When
Bottle
Medical Chicago,
Cap
Ingestion
I wish to amplify
a
lung base is elevated, it should be described as such, and a differential diagnosis that can include elevated diaphragm should be given. Myron D. Kirshenbaum Illinois
University
an elevated
phragmatic rupture and hernia, subpulmonic pleural effusion, subdiaphragmatic process, and even diaphragmatic mass. Communication is one of the greatest responsibilities of radiologists, and using terminology that is as anatomically correct as possible indicates radiologists’ thorough understanding ofthe films they are interpreting and
hemidiaphragm for routine reporting, as we find that our physicians understand this term and its implications. Russel Gelman Stuart E. Mirvis David Gens
Center
the observation
of Brandser
and Smith [1] that
the childproof caps on medicine bottles can become esophageal foreign bodies. A 62-year-old man had the habit of placing all his pills on a bottle cap and then using the cap to throw the pills to the back of his throat
for
ingestion.
He had
done
this
many
times.
On the
day
of admission, he inadvertently lost hold of the cap and swallowed it along with his pills. This caused a sticking sensation in the throat and some
difficulty
in swallowing.
A lateral
soft-tissue
view
of the
neck
IL 60657
REFERENCE 1 . Gelman A, Mirvis SE, Gens D. Diaphragrnatic rupture due to blunt trauma: sensitivity of plain chest radiographs. AJR 1991:156:51-57
Reply
We appreciate the comments of Dr. Kirshenbaum on our article [1]. Of course, he is correct when he reminds us that it is actually the lung base that is elevated when the diaphragm is ruptured. The elevation of the lung base is the result of herniation of abdominal viscera through the diaphragmatic defect. This causes the “pseudodiaphragm effect” [2] on plain radiographs, where elevation of the apparent hemidiaphragm is visualized. The term “elevated lung base” is technically
correct,
but we prefer
to use
the term
elevated
apparent
Fig. 1.-A swallow
show
and B, Frontal pill-bottle
(A) and lateral (B) spot films cap lodged in lower hypopharynx.
from
a barium
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4i 2
LETTERS
and a subsequent barium swallow (Fig. 1 ) confirmed the presence of the pill cap in his hypopharynx. The cap was removed via endoscopy, and the patient was discharged the next day. In this particular case, the patient had ingested the entire cap, which did not have an inner plastic liner. This case illustrates once again the risk involved if someone uses
a pill cap or similar small object to help him or her swallow
several
pills at one time. An inner plastic liner may dislodge from the main part of the cap as discussed in the previous report [1 ],or the patient may swallow the entire cap as illustrated by this case. Patients should
be encouraged to swallow their pills one at a time. If they feel the need to ingest several pills all at once, they should be advised to use something
safe, such as a teaspoon
or a tablespoon. Arizona
Health
Tim B. Hunter Sciences Center Tucson, AZ 85724
REFERENCE 1. Brandser E, Smith C. Childproof cap on medicine esophageal foreign body (letter). AJR 1991:156:201
bottles
as risk for
Reply The
habit
widespread.
of using This
caps
bottle
practice
can
for
have
pill ingestion potentially
may
be quite
dangerous
conse-
quences, as illustrated by our case and the case of Dr. Hunter. Again, we think that the practice of using medicine bottle caps for the ingestion of medication should be discouraged. Eric Brandser Claire Rush-Presbyterian-St.
Luke’s
Medical
Chicago,
Gallbladder
Function
in Patients
with Spinal
Smith Center
IL 60612
Cord
Injury
August
1991
completeness of the SCI in any subject is never given. A simple grading system is not applied, and the number of subjects with incomplete SCI, and thus with potentially normal or only minimally impaired gallbladder function, is not recorded. Data from these patients would, of course, only serve to “normalize” the SCI group and obscure any true differences. Again, a type II error would have been committed. (4) Serial sonography has not been unequivocally established as the most accurate and reproducible method of assessing gallbladder emptying or contractility. Changes in estimates of gallbladder volumes based on sonographic findings do not reflect gallbladder volumes as accurately as does cholescintigraphy, nor does sonography at 1 0-mm intervals for only 60 mm adequately show closely spaced or delayed changes in motility or emptying. (5) Using the ellipsoid method, an assumption-rich, geometric computation, to calculate gallbladder volumes has not been validated in patients with SCI and thus may be misleading. (6) The text is inconsistent in accounting for the total number of paraplegic patients with injury below T10. Two such paraplegics are inexplicably lost from the study between the first paragraph of page 522, line 8, and the fourth line of the third paragraph of the Discussion section (page 522). Although the total number of SCI patients remains at 26, only two patients are now reported as having injuries below TiO, and a 50% decrease in the number of the paraplegic patients apparently has taken place. On which sample population of paraplegics were the authors’ calculations and conclusions based? In summary, we remain unconvinced that gallbladder contractility is normal in SCI patients and solicit comments from Nino-Murcia et al. and, if possible, from the reviewers on our interpretation or understanding of this study. Jack L. Segal Norah Milne University of California, Irvine Irvine, CA 92717 Veterans Affairs Medical Center Long Beach, CA 90822 REFERENCES
In “Gallbladder Contractility in Patients with Spinal Cord Injuries: A Sonographic Investigation” [1], which appeared in the March 1990, issue ofAJR, Nino-Murcia et al. conclude that gallbladder contractility in patients with spinal cord injuries is normal and unchanged from that observed in an able-bodied control population. We think that the conclusions of Nino-Murcia et al. are tenuous and are not supported by the data presented in the paper. Their conclusions are inconsistent with our current understanding of the impact of spinal cord injury
(SCI)on the upper gastrointestinaltract
AJR:157,
[2] and contradict
the findings
of research that has shown significant impairment of gallbladder function in patients with cervical SCI (Milne et al., paper presented at the annual meeting of the Society of Nuclear Medicine, June 1987; Chassin-Kaplan et al., paper presented at the annual meeting of the American Spinal Injury Association, May 1988). We think that the results and conclusions of Nino-Murcia et al. are questionable for the following reasons: (1) It is grossly misleading to lump together and homogenize the data obtained from quadriplegic and paraplegic subjects. Paraplegic patients with low injuries (Ti 1 and below) who are likely to have normal gallbladder function and gastric emptying made up 25% of the paraplegic population and 15% of the total SCI study group. Small but significant differences between quadriplegic patients and able-bodied controls or paraplegic subjects could thus easily be obfuscated, resulting in the acceptance of a false null hypothesis and the commission of a type II error. (2) Studying a single SCI population composed of both patients with new injuries and patients with chronic injuries of more than 1 year duration as Nino-Murcia et al. did can be both incorrect and misleading. (3) The
1 . Nino-Murcia M, Burton D, Chang P, Stone J, Perkash I. Gallbladder contractility in patients with spinal cord injuries: a sonographic investigation. AJR 1990;154:521-524
2. Segal JL, Milne N, Brunnemann normalization of impaired gastric terology 1987:82(1 1):1143-1148
SR, Lyons KP. Metoclopramide-induced emptying
in spinal
cord injury.
Gastroen-
Reply We would like have raised, in the our data excluding volume of patients which
was
to respond to the questions Drs. Segal and Milne order in which they were raised. (1) We reanalyzed the four low lesions. The mean gallbladder resting with spinal cord injury (SCI) was 20 ml (SE = 2.3),
significantly
different
from
the
mean
resting
volume
of the
normal control group (p = .01 ). The mean gallbladder residual volume of SCI patients was 1 0 ml (SE = 1 .0); this was not significantly different from that of the normal control group (p = .61). The mean emptying time of the gallbladder in SCI patients was 43 mm (SE =
3.3); this was not a significant difference from the normal control group (p = .31). Thus, SCI patients do not show significant differences in gallbladder contractility from a normal population. The observed difference in the ejection fraction reflects the lower resting gallbladder volume in SCI patients [1]. Great care was taken to minimize a type II error. The experimental design using matched controls, and the number of patients studied was specifically selected to achieve 95% power (beta error = 0.05) for a 5% one-tailed test, with a critical effect size of 0.4. Such a critical effect size roughly
LETTERS
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AJR:157, August 1991
corresponds to a minimal difference of about 3 ml in gallbladder volume and 1 0 mm in emptying time, numbers that are well within 1 SD of the measured normal mean values. (2) Damage to the autonomic nervous system becomes stable within 6 months of the injury. Thus, using patients whose injuries occurred 6 months or more before the study is scientifically correct. (3) All SCI patients had complete lesions.
(4) The
key
parameter
with
respect
to our
measuring
3
4i
Fig. 1.-CT
scan with contrast
material shows two defined, hypodense, ing hepatic lesions.
large, wellnonenhanc-
system
is its reproducibility, not its absolute accuracy, as our experimental design included a matched control group. Only the “relative” observed differences
in measured
changes
absolutely
accurate
determinations
published
literature
[2,
3]
in volume
are
of volume
supports
this
important;
actual
are unimportant.
view
of
the
The
reproducible
standard in using sonography to measure gallbladder volumes. (5) We have no reason to suspect that using sonography to measure gallbladder volume would be any different in SCI patients than in the normal population or in any other patient. (6) Drs. Segal and Milne did detect a typographic error: The number of patients with lesions below Ti 0 was four, not two. For these reasons, we stand by our conclusions as stated in the original
article
[1]. Matilde
Nino-Murcia Inder
Stanford
University
Affairs
School CA 94305
Stanford,
Veterans
Perkash
Medical
Medical
Center
Palo Alto, CA Paul University
of Iowa
Hospital
94304
diagnosis
hepatocellular
of lesions
carcinoma,
with
this
Clinics
appearance
hepatoblastoma,
and
primary
lymphoma
[31.
of the liver
Moreover,
the
results
the
liver
uation
have values
discrete
masses
without
or other
intrinsic
characteristics
significant
variation
Sonographic 1011
measurement
3. Everson GT, Braverman of real-time contraction.
Primary
DZ, Johnson ML, Kern F Jr. A critical evaluation
ultrasonography
for
Gastroenterology
Liver
RA, Lawson TL, Kishk SA, Kern MK. volume. AJR 1985:145:1009-
of gallbladder
the
study
of gallbladder
volume
and
setting described of the liver.
A Diagnostic
C. Mohan S. S. Alurkar 0. P. Sharma S. H. Advani
suspected
until
it is proved
by
biopsy.
In our
experience,
right-sided
nal pain, and hepatomegaly for 1 month. Serum zymes were elevated: aspartate aminotransferase
protein
aminotransferase
King-Armstrong and
well-defined,
(SGPT),
units/dl
carcinoembryonic hypodense,
79
lU/I;
and
(1 91 7 U/I). Serum antigen
nonenhancing
were
abdomi-
levels of liver en(SGOT), 1 24 lU/I;
alkaline
phosphatase,
levels
normal.
lesions
Needle biopsy showed diffuse non-Hodgkin differentiated lymphocytic type. The patient combination chemotherapy.
1 . Kayano H, Katoyarna cular lymphornatosis.
Hospital
400 012, India
I. Primary hepatic lymphoma presenting as intravasArch Pathol Lab Med 1990;1 14:580-584
2. Osborne BM, Butler JJ, Guarda LA. Primary liver lymphoma: cases and review of literature. Cancer 1985;56:2902-291 0
Doppler Disease
Sonography
report of ten
CT
in the
of alpha-fetoshowed liver
(Fig.
two 1).
lymphoma of the poorly had a good response to
in Osler-Weber-Rendu
disease,
ectasia,
is a vascular
Hepatic
involvement
disease
or with
hereditary
autosomal
is characterized
the duplex Doppler telangiectases.
A 46-year-old
a case that illustrates this point. A 53-year-old man had had nausea, vomiting,
alanine
Memorial
REFERENCES
Osler-Weber-Rendu
primary lymphoma of the liver should be suspected when a patient has increased serum levels of liver enzymes, normal serum levels of alpha-fetoprotein and carcinoembryonic antigen, and CT findings of one or two nonenhancing hypodense lesions in the liver. We describe
270
Tata Bombay
Dilemma
Only 53 cases of primary lymphoma of the liver have been reported [1]. These lesions usually are misinterpreted as hepatocellular carcinoma, hepatoblastoma, or metastasis. Primary lymphoma of the liver is not
of here
3. Boechat Ml, Kangarloo H, Ortega J. et al. Primary liver tumors in children: comparison of CT and MR imaging. Radiology 1988;169:727-732 4. Zornoza J. Ginaldi S. computed tomography in hepatic lyrnphoma. Radiology 1981;1 38:405-410
1980:83:773-776
Lymphoma:
in atten-
[4J. The detection
REFERENCES
2. Dodds WJ, Grosh WJ, Darweesh
of pathologic
examination of biopsy specimens of primary or large cell lymphomas can be misinterpreted. Occasionally, frozen sections have artifacts that distort large cell lymphoma so that it assumes a carcinomatous appearance [2]. As in our case, most cases of primary lymphoma of
Iowa City, IA 52242 and colleagues
1 . Nino-Murcia M, Burton 0, Chang P. Stone J, Perkash I. Gallbladder contractility in patients with spinal cord injuries: a sonographic investigation. AJR 1990:154:521-524
on CT
metastasis
from an unknown primary tumor [2]. Neither CT nor MR imaging has been helpful in differentiating, with certainty, these conditions from
such lesions on CT scans in the clinical suggests the diagnosis of primary lymphoma
J. Chang
and
The differential includes
findings
woman
in the
hemorrhagic dominant
by
telangiectases.
liver
in a case
was admitted
because
telangi-
transmission. We
with
report
extensive
of cardiac
failure.
Physical and radiologic examinations showed pulmonary arteriovenous fistulas and multiple gastrointestinal telangiectases. The diagnosis was Osler-Weber-Rendu disease. Results of liver function tests were as follows: alkaline phosphatase, three times higher than the normal upper limit; -y-glutamyltransferase, eight times higher than the normal three
upper times
limit; higher
and than
alanine the
normal
and
aspartate
upper
limits.
aminotransferases, Abdominal
sonogra-
phy showed a dilated hepatic artery (i 2 mm in diameter) with numerous tortuous intrahepatic branches and dilated hepatic veins. The portal vein was normal. Duplex sonography showed a high velocity
LETTERS
4i 4
AJR:157,
August
1991
3. Bourgeois N, Delcour C, Deviere J, Francois A, Lambert M, Cremer M. Osler-Weber-Rendu disease associated with hepatic involvement and high output
heart
4. cloogman
Downloaded from www.ajronline.org by Vrije Universiteit Brussel on 10/15/15 from IP address 134.184.26.108. Copyright ARRS. For personal use only; all rights reserved
graphic
failure.
findings
Bilateral
J Clin Gastroenterol
1990;12:236-237
HM, DiCapo RD. Hereditary in the liver. Radiology
Urinomas
hemorrhagic
telangiectasia:
sono-
1984; 150:521-522
in an Adult
Urinomas associated with renal trauma, iatrogenic injury, ureteric obstruction by calculus, neoplasms, renal transplants, and obstruction of the bladder outlet caused by posterior urethral valves are well known [1 ]. However, to our knowledge, bilateral urinomas in an adult and their association with urethral injury that occurred during partuFig. 1.-Osler-Weber-Rendu disease. A, Doppler waveform of hepatic vein shows high-velocity signal. B, CT scan with contrast medium shows dilated left hepatic artery (straight arrow) with dilated intrahepatic arteries and early enhancement of hepatic veins (curved arrows).
signal in the hepatic artery. Portal flow was normal. The hepatic veins had an “artenialized” pattern, with abnormal peaks indicating the communication between the hepatic arteries and the hepatic veins (Fig. 1 A). CT and hepatic angiography confirmed the hepatic arterialization and the arteriovenous fistulas by showing simultaneous enhancement of the arteries and the hepatic veins (Fig. 1 B). Osler-Weber-Rendu disease is a vascular disease with multiple manifestations. The most frequent localizations are the skin and mucosa, but all organ systems may be involved. The liver involved more often than was suspected originally [1 ]. The vascular abnormalities include telangiectases and arteriovenous fistulas, sometimes associated with fibrosis and cirrhosis [1 -3]. Sonographic findings in the liver consist of dilated common hepatic artery, multiple ectatic vascular structures with pulsations, and dilated hepatic veins [4]. Although these sonographic findings suggest vascular disease, duplex Doppler imaging can be used to confirm the diagnosis. Duplex
Doppler sonography
shows high velocity signal in the hepatic artery,
with increased arterial hepatic output; arterial signal in the intrahepatic vascular structures; and abnormal high velocity signal in the hepatic veins. This last finding mimics an arterial flow and confirms the arteriohepatic communications. We did not use color Doppler imaging in this
case, but it can be helpful by showing
rition
have
A large months
been
reported
abdominal
not
mass
after
parturition.
The
veins.
shows Doppler
large sonography
and
numerous gives
arteries
information
include
and
dilated
increased
flow, arterial signal in the intrahepatic vascular structures, normal high velocity signal in the hepatic veins. Angiography
necessary
if no treatment
noted
in a 35-year-old
apparently
had
tumors,
hematomas,
and
abscesses,
CT
woman
originated
is the
imaging procedure, particularly if dynamic-phase structions in the sagittal and coronal planes are values of urinomas are normally -1 0 H to 30 H uation usually is homogeneous as compared with and hematomas, which is heterogeneous. CT information
2.5
1 week
about
the precise
extent
and
location
most
useful
scans and reconused. Attenuation [2], and the attenthat of abscesses also gives specific
ofthe
fluid
collection
and its relationship to the kidneys, ureters, and fascial planes and compartments [1]. The indirect evidence of round cell infiltration in necrotic fat and adjacent renal fascia that form the perirenal fibrous sac, in response to the accumulated urine, is shown better on sonograms [3].
K. K. Sen Meenakshi
Thakur
0. P. Sharma Tata
high color signal in the
on
mass
after parturition. CT scans showed bilateral uniformly hypodense (10 H) encapsulated masses in the perirenal regions (Fig. i ). No enhancement of the masses was seen with contrast material. Both kidneys showed normal excretion. On sonograms, the mass on the left was anechoic; the mass on the right contained multiple linear echoes and had a thick, smooth capsule. Sonography and CT have often been used to diagnose uninoma when pseudonephromegaly has suggested tumor invasion. Other entities that must be considered in the diagnosis of perirenal uninomas
Memorial
Hospital
and
Cancer Bombay
extrahepatic and intrahepatic arteries and large hyperkinetic hepatic veins. In conclusion, conventional and Doppler sonography can be used to diagnose hepatic involvement in Osler-Weber-Rendu disease. Sonography
previously.
was
Research 400
Centre 012,
India
hepatic arterial
and abis not
is indicated. Valerie Vilgrain Yves Menu Henri Nahum HOpital Beau/on 921 18 Clichy Cedex, France Fig. 1.-Bilateral
REFERENCES 1 . Martini GA. The liver in hereditary haemorrhagic teleangiectasia: an inborn error of vascular structure with multiple manifestations: a reappraisal. Gut
1978;19:531 -537 2.
Nikolopoulos N, Xynos E, Vassilakis JS. Familial occurrence of hyperdynamic circulation status due to intrahepatic fistulae in hereditary hemorrhagic telangiectasia. Hepatogastroenterology 1988;35:167-168
urinomas.
A, Contrast-enhanced CT scan shows bilateral hypodense encapsulated perirenal masses. Mass on right extends from inferior surface of right lobe of liver to right iliac fossa, displacing renal parenchyma inferomedially Smaller mass on left displaces left kidney cephalad and anteromedially. Capsule of mass on right is slightly thicker than that of mass on left and is smooth and shows noticeable enhancement. Ureters are displaced medially and bowel loops anteriorly. B, Sonogram shows possible secondary infection on left side.
AJR:157,
August
LETTERS
1991
4i 5
REFERENCES
Downloaded from www.ajronline.org by Vrije Universiteit Brussel on 10/15/15 from IP address 134.184.26.108. Copyright ARRS. For personal use only; all rights reserved
1 . Land
EK, Glorioso
L Ill. Management
of urinornas
by percutaneous
drain-
age procedures. Radio! C!in North Am 1986;24:551-559 2. Healy ME, Teng 55, Moss AA. Uriniferous pseudocyst: computed tomegraphic findings. Radiology 1984:153:757-762 3. Feinstein KA, Fernbach 5K. Septated urinomas in the neonate. AJR 1987;149:997-1 000
Fallopian
Tube
Nomenclature
Dr. Thurmond both on her review article [1 ] on selective and fallopian tube recanalization and on her original to these techniques. I would make one semantic ob-
I commend salpingography contributions servation. Throughout subject, there proximal and authors define
her article,
and
I think
communications
incorrect,
use
on this
of the
terms
as they refer to the fallopian tubes. Almost all proximal as the uterine or cornual end of the tube and
distal
as the ampullary,
distal
and in most recent
iS a confusing,
fimbriated,
or ovarian end. This is the opera-
tom’s perception during catheterization and injection of contrast medium. However, even the term retrograde catheterization, used by some authors, but not Thurmond, implies that the uterine end of the fallopian
tube
is the distal
Ferris Beth Harvard
Israel
M. Hall Hospital
Medical Boston,
AS. Selective
salpingography
and fallopian
tube
C Natural
History
studied.
Thefossils
02215
recanalization.
AJR 1991;156:33-38
in axial
detail
and
bones
Growth
Dr. Hall for taking
point
refreshing
that
the feminist in this
I take
the
male
Oregon
Health
Sciences Portland,
Previous the
enough men,
attempts
volume
of
for image we
have
brae. Vertebrae (approximately
at MR
protons
was
acquisition
used
MR
imaging
Lines
of fossilized
from a prehistoric 12 million years
dolphin from old) from the
to study
MR
images
provided
of transverse
lines,
frequently
sufficient
lines referred
and
anatomic
bands
within
to as transverse
the lines,
column
have
been
studied
osteopetrosis,
with
less
well
but
a “vertebra
have within
been
described
a vertebra”
ap-
[21. Although
also
into
the
changes spongiosa
failed
fossil
sediment
have
of bone, contains
been
producing silicon
[31. Fine silt may filter
described opaque
lines,
compounds.
particularly However,
if the these
dense compounds are deposited in an irregular pattern and therefore lack uniformity in thickness and are not circumferential. Because the deposition of artifacts is governed by gravity, the widest of these dense lines is found in the most dependent portion of fossilized bone.
because
small to produce signals strong and processing. By hydrating the specsuccessfully
planes.
pathologic
97201
too
imaging
coronal
University
in Fossil
bone
were
cylinder
of water. A 1 .0-T (Siemens Magnetom) magnet specimen in a Helmholtz surface coil. Spin-echo, T2-weighted sequences (TE 30, 90; TR 2.0; slice 2 acquisitions; 256 x 256 matrix) were obtained
recovery
deposited
Recovery
in a plastic
OR
Amy S. Thurmond
of Growth
them
status during youth described: infection; states; and poisoning, False bands and
chauvinist
of view.
MR Imaging Vertebrae
DC,
Washington,
by placing
the lines may be normal, poor nutritional and a large variety of other causes have been metabolic, neoplastic, and vitamin deficiency by either heavy metals or vitamins. lines of variable thickness representing pseudo-
point of view. I hope he finds
instance
Paleontology)
lines and bands.
growth arrest lines, stress lines, or lines of Park or Harris, have been studied extensively in the human appendicular skeleton [1]. These lines cross bone horizontally at right angles to the longitudinal trabeculae and represent a markedly thickened interconnected network of trabecular bone. The lines and bands result from resumption of growth after an episode of growth cessation. Transverse lines in the
pearance
I thank
circumferential
hydrated
to allow diagnosis (Fig. 1).
as mimicking
it equally
were
500 ml was used with the proton-density, and thickness 4.0 mm;
vertebral Reply
(Vertebrate
containing
School MA
REFERENCE 1 . Thurmond
I
end.
Standard medical convention defines proximal and distal vessels or ducts not by their proximity to the midline or the cannulating instrument, but relative to in vivo physiologic flow. Hence, the proximal inferior vena cava is more caudal. A similar problem in nomenclature arose with the introduction of ERCP (endoscopic retrograde cholangiopancreatography), and, after initial confusion, radiologists agree that the proximal pancreatic duct is located in the tail of the pancreas (where it should be, and always has been). Physiologic flow in the fallopian tube is toward the uterus, and unless we take a male chauvinistic view regarding sperm movement, the distal end of the tube is toward the uterus.
Fig. 1.-A--C, Coronal anterior near midline (B), and postenor (C) MR Images through caudal vertebrae of prehistoric dolphin show spatial relationship of (A),
verte-
the Miocene Epoch National Museum of
The
results
present feasible,
suggest
that
growth
recovery
bands
and
lines
were
in mammals during prehistoric times. If hydration of fossils is MR imaging appears to be useful for detecting skeletal
abnormalities.
James
Jeno I. Sebes W. Langston
Morris
L. Gavant
LETTERS
4i 6
University
of Tennessee, Memphis,
Bruce
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Northeast
Ohio
Youngstown,
Memphis TN 38163
Rothschild University OH 44512
REFERENCES 1 . Park EA. The imprinting Pediatrics
1964;33:81
of nutritional
disturbances
on the growing
bone.
5-862
2. Stammel CA. Multiple striae parallel to epiphyses and ring shadows around bone growth centers. AiR 1941;46:497-505 3. Decker FH, Bohrod MG. Medullary artifacts in prehistoric bones. AJR 1939;42:374-375
MR of Intraspinal with Gadopentetate
Synovial Cyst: Dimeglumine
Rim Enhancement
Silbergleit et al. [1 1 recently described uniform rim enhancement of a synovial cyst on MR after administration of gadopentetate dimeglu-
mine. Pathologically, the cyst wall was composed of fibrous connective tissue with numerous vascular foci within it. The peripheral enhancement was thought to be caused by the chronic inflammatory changes around the synovial cyst. We describe a similar case with pathologic confirmation. We think that the cyst wall functions much like scar tissue. Gadolinium diffuses rapidly across the rich vascular network into the extracellular space through discontinuous epithelial membranes, which results in early rim enhancement [2]. Our patient, a 50-year-old woman with a history of progressive lower back pain had had new might-sided radicular symptoms for 3 months. The symptoms were confirmed on physical examination. Surface-coil MR was performed on a Siemens Magnetom SP 1 .5-T unit. Routine double-echo (700/1 5, 2400/45, 2400/90) sagittal and short TRITE (600/1 5) axial images without and with gadopentetate dimeglumine showed a well-defined cystic structure intimately related to a degenerative L4-L5 facet joint on the right side. The cyst was slightly hyperintense relative to CSF on Ti - and T2-weighted images and had a hypointense rim that enhanced diffusely after administration of contrast medium. A correct preoperative diagnosis of a nonhemorrhagic synovial cyst was made. After total excision of the synovial cyst, the patient reported complete resolution of her symptoms.
AJR:157, August 1991
Synovial cysts are rare causes of intraspinal extradural masses. Most commonly, they arise from degenerative apophyseal joints, in particular at the L4-L5 level, and are associated with radicular symptoms [3, 4]. Such cysts are more prevalent in females and after the age of 50 years [1 , 3]. Synovial cysts contain watery or mucinous fluid [4]. Nonhemorrhagic synovial cysts may be isointense or hyperintense relative to CSF on spin-pulse sequences [4]. Some authors have attributed the hypointense rim to calcification or hemosiderin, but more likely it is related to the cyst membrane and surrounding inflammatory tissue [3, 4]. Differential diagnosis for a cystic dorsal extradural intraspinal mass includes extruded disk fragments, cystic neurofibromas, arachnoid cysts, and perineural cysts [4]. Rim enhancement with gadopentetate dimeglumine of recurrent disk herniation (“wrapped disc”) has been shown to be caused by peridiskal fibrosis [2]. The noninvasiveness, multiplanar capabilities, and inherent contrast characteristics of MR imaging and the additional information provided by the use of contrast medium make MR an optimal imaging technique for evaluating spinal lesions. Karl S. Chiang Ya-Yen Lee Michel E. Mawad Baylor College of Medicine Houston, TX 77030 REFERENCES 1 . Silbergleit R, Gebarski 55, Brunberg JA, McGillicudy J, Blaivas M. Lumbar synovial cysts: correlation of myelographic, CT, MR, and pathological findings. AJNR 1990;11:777-779
2. Price AC, Runge vM. MRI efficacy in spine expands with Gd-DTPA. Diagn Imaging 1989;1 1(1 1):172-177
3. Liu 55, Williams KD, Drayer BP, Spetzler RF, Sonntag VKH. Synovial cysts of the lurnbosacral spine: diagnosis by MR imaging. AJR 1990;154:163-1 66 4. Jackson
DE, Atlas
MR imaging.
SW,
Radiology
High CT Attenuation Aspergillosis
Mani
JR, Norman
D. lntraspinal
synovial
Values
in Paranasal
A i 4-year-old boy complained that his nose was blocked on the left side. He had a history of aspergillosis of the right paranasal sinuses and had had surgery for this about 8 months earlier. CT showed a soft-tissue mass in the left nasal cavity extending into the left maxillary antrum, ethmoid air cells complex, and frontal and sphenoid sinuses (Fig. i ).These mass lesions were patchy, with a
zone of lower attenuation in the periphery. Mucoperiosteal was
present
attenuation
some places. No bony destruction values of these masses on unenhanced
Fig. 1.-coronal scan
of
thickening
was seen. The CT scans were
in
CT Fig. 1.-Intraspinal synovial cyst A, Axial Ti-weighted MR image at L4-L5 level shows a heterogeneous dorsolateral mass on right Intimately related to ligamentum flavum and facet joint. Signal intensity of central area of mass Is lower than that of peripheral aspects. B, Gadolinium-enhanced axial Ti-weighted MR image at same level as A shows diffuse rim enhancement of synovial cyst
cysts:
1989;170:527-530
unenhanced
paranasal
sinuses
shows a heterogeneous soft-tissue mass with areas of high attenuation (about 90 H) in left nasal cavfty and maxillary antrum. Pcripheral rim of low attenuation represents thick mucoperiosteum.
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AJR:157,
August
LETTERS
1991
90-i 00 H. No significant enhancement was seen after administration of contrast material. The diagnosis of recurrence of aspergillosis was confirmed histologically after surgery. Limited studies have been done on the CT features of paranasal aspergillosis. Centeno et al. [i ] have described various CT features of fungal sinus disease, but the high attenuation values seen in our case have not been mentioned before. This finding probably is due to the presence of calcium salts in the Aspergillus mycelia, which was reported by Stammberger et al. [2]. The high attenuation value is an important feature that can be used to differentiate a fungal mass from neoplasm. No neoplasms have such high attenuation values on unenhanced CT scans. Tumors of bone and cartilage can have a high attenuation value, but their appearance is different. Kamlesh C. Khandelwal Rajul J. Udani Nikhil
4i7
A
B
Fig. 1.-Guard for prevention of finger-stick injuries. A, Guard protects finger from puncture when stylet is replaced. B, Device can be positioned at predetermined depth on needle accurate placement of needle into a particular body space.
stick
injuries
H. Merchant
during
1 . Centeno
RS, Benston JR, Macuso AA. cT scanning in rhinocerebral mucoromycosis and aspergillosis. Radiology 1981;140:383-389 2. Stammberger H, Jakse A, Beaufort F. Aspergillosis of the paranasal histopathology
and
clinical
aspect.
Ann
during
replacement
of
the
stylet
Oto!
1984;93:251 -256
replacement
of the
stylet
into
the
needle
(Fig.
Harvard
1 A). The
Medical
Boston,
Guard for Prevention Caused by Stylets Because
Ii], I wish
needle-stick to describe
of Finger-Stick injuries
a device
are potentially
Injuries life-threatening
that can be used to prevent
1 . Jagger J, Hunt EH, Brand-Elnaggar injury caused by various devices 1988;319 : 284-288
events needle-
J, Pearson RD. Rates in a university hospital.
are published at the discretion of the Editor and are subject to editing. to the Editor must not be more than two double-spaced, typewritten pages. One or two figures may be included. Abbreviations should not be used. See Author Guidelines, page A5. Material being submitted or published elsewhere should not be duplicated in letters, and authors Letters
must
disclose
concerning
financial a paper
associations published
device
School
MA 02215
REFERENCE
Letters Letters
of letters
in stylet
can be positioned at a desired depth on the needle to ensure accurate placement of the needle into a body space (Fig. 1 B). After use, the needle and the guard are discarded. Commercial availability in the fall is anticipated. Andrew M. Singer Beth Israel Hospital
REFERENCES
diagnosis,
occur
needles. The device is made of sterilizable, puncture-proof plastic. It is cone shaped, about 3 cm in diameter, and made so that it can be positioned at the hub end of the needle. The user’s fingers are placed beneath the device and are protected from inadvertent needle-stick injuries
Omprakash Sharma Tata Memorial Hospital Bombay 400 012, India
sinuses: X-ray Rhino! Laryngo!
that
for
or other in the AJR
reply to be published in the same issue. Opinions necessarily reflect the opinions of the Editor.
possible will
be sent
expressed
conflicts to the
of interest. authors
in the Letters
of the
paper
to the Editor
for
a
do not
of needle-stick N Eng! J Med
4i i
Letters i;:;:‘
.
.
Diaphragmatic Rupture Due to Blunt Trauma: Sensitivity of Plain Chest Radiographs The article by Gelman et al. [1] describes various important findings seen with diaphragmatic rupture. Although informative, it uses the term “elevation of hemidiaphragm” as one of the findings associated with diaphragmatic rupture. Of course it is not the diaphragm but the lung base that is elevated (the diaphragm has been ruptured). This term is commonly misused in radiology practice. For example, often when someone is referring to the possibility of subpulmonic pleural effusions, elevated hemidiaphragm is used; again, of course, it is not the diaphragm that is elevated but the lung base. On chest radiographs, the location of the diaphragm can only be inferred on the
basis of air in adjacent
lung. If the lung base is elevated,
diaphragm
of numerous
is only
one
possible
causes,
improves
credibility
of radiologists
to other
including
physicians.
Masonic
of Maryland
Medical
System
Baltimore,
Maryland
21201
REFERENCES 1 . Gelman R, Mirvis SE, Gens D. Diaphragrnatic rupture due to blunt trauma: sensitivity of plain chest radiographs. AJR 1991 156:51-57 2. Fataar 5, Schulman A. Diagnosis of diaphragmatic tears. Br J Radiol
1979:52:375-381
dia-
When
Bottle
Medical Chicago,
Cap
Ingestion
I wish to amplify
a
lung base is elevated, it should be described as such, and a differential diagnosis that can include elevated diaphragm should be given. Myron D. Kirshenbaum Illinois
University
an elevated
phragmatic rupture and hernia, subpulmonic pleural effusion, subdiaphragmatic process, and even diaphragmatic mass. Communication is one of the greatest responsibilities of radiologists, and using terminology that is as anatomically correct as possible indicates radiologists’ thorough understanding ofthe films they are interpreting and
hemidiaphragm for routine reporting, as we find that our physicians understand this term and its implications. Russel Gelman Stuart E. Mirvis David Gens
Center
the observation
of Brandser
and Smith [1] that
the childproof caps on medicine bottles can become esophageal foreign bodies. A 62-year-old man had the habit of placing all his pills on a bottle cap and then using the cap to throw the pills to the back of his throat
for
ingestion.
He had
done
this
many
times.
On the
day
of admission, he inadvertently lost hold of the cap and swallowed it along with his pills. This caused a sticking sensation in the throat and some
difficulty
in swallowing.
A lateral
soft-tissue
view
of the
neck
IL 60657
REFERENCE 1 . Gelman A, Mirvis SE, Gens D. Diaphragrnatic rupture due to blunt trauma: sensitivity of plain chest radiographs. AJR 1991:156:51-57
Reply
We appreciate the comments of Dr. Kirshenbaum on our article [1]. Of course, he is correct when he reminds us that it is actually the lung base that is elevated when the diaphragm is ruptured. The elevation of the lung base is the result of herniation of abdominal viscera through the diaphragmatic defect. This causes the “pseudodiaphragm effect” [2] on plain radiographs, where elevation of the apparent hemidiaphragm is visualized. The term “elevated lung base” is technically
correct,
but we prefer
to use
the term
elevated
apparent
Fig. 1.-A swallow
show
and B, Frontal pill-bottle
(A) and lateral (B) spot films cap lodged in lower hypopharynx.
from
a barium
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4i 2
LETTERS
and a subsequent barium swallow (Fig. 1 ) confirmed the presence of the pill cap in his hypopharynx. The cap was removed via endoscopy, and the patient was discharged the next day. In this particular case, the patient had ingested the entire cap, which did not have an inner plastic liner. This case illustrates once again the risk involved if someone uses
a pill cap or similar small object to help him or her swallow
several
pills at one time. An inner plastic liner may dislodge from the main part of the cap as discussed in the previous report [1 ],or the patient may swallow the entire cap as illustrated by this case. Patients should
be encouraged to swallow their pills one at a time. If they feel the need to ingest several pills all at once, they should be advised to use something
safe, such as a teaspoon
or a tablespoon. Arizona
Health
Tim B. Hunter Sciences Center Tucson, AZ 85724
REFERENCE 1. Brandser E, Smith C. Childproof cap on medicine esophageal foreign body (letter). AJR 1991:156:201
bottles
as risk for
Reply The
habit
widespread.
of using This
caps
bottle
practice
can
for
have
pill ingestion potentially
may
be quite
dangerous
conse-
quences, as illustrated by our case and the case of Dr. Hunter. Again, we think that the practice of using medicine bottle caps for the ingestion of medication should be discouraged. Eric Brandser Claire Rush-Presbyterian-St.
Luke’s
Medical
Chicago,
Gallbladder
Function
in Patients
with Spinal
Smith Center
IL 60612
Cord
Injury
August
1991
completeness of the SCI in any subject is never given. A simple grading system is not applied, and the number of subjects with incomplete SCI, and thus with potentially normal or only minimally impaired gallbladder function, is not recorded. Data from these patients would, of course, only serve to “normalize” the SCI group and obscure any true differences. Again, a type II error would have been committed. (4) Serial sonography has not been unequivocally established as the most accurate and reproducible method of assessing gallbladder emptying or contractility. Changes in estimates of gallbladder volumes based on sonographic findings do not reflect gallbladder volumes as accurately as does cholescintigraphy, nor does sonography at 1 0-mm intervals for only 60 mm adequately show closely spaced or delayed changes in motility or emptying. (5) Using the ellipsoid method, an assumption-rich, geometric computation, to calculate gallbladder volumes has not been validated in patients with SCI and thus may be misleading. (6) The text is inconsistent in accounting for the total number of paraplegic patients with injury below T10. Two such paraplegics are inexplicably lost from the study between the first paragraph of page 522, line 8, and the fourth line of the third paragraph of the Discussion section (page 522). Although the total number of SCI patients remains at 26, only two patients are now reported as having injuries below TiO, and a 50% decrease in the number of the paraplegic patients apparently has taken place. On which sample population of paraplegics were the authors’ calculations and conclusions based? In summary, we remain unconvinced that gallbladder contractility is normal in SCI patients and solicit comments from Nino-Murcia et al. and, if possible, from the reviewers on our interpretation or understanding of this study. Jack L. Segal Norah Milne University of California, Irvine Irvine, CA 92717 Veterans Affairs Medical Center Long Beach, CA 90822 REFERENCES
In “Gallbladder Contractility in Patients with Spinal Cord Injuries: A Sonographic Investigation” [1], which appeared in the March 1990, issue ofAJR, Nino-Murcia et al. conclude that gallbladder contractility in patients with spinal cord injuries is normal and unchanged from that observed in an able-bodied control population. We think that the conclusions of Nino-Murcia et al. are tenuous and are not supported by the data presented in the paper. Their conclusions are inconsistent with our current understanding of the impact of spinal cord injury
(SCI)on the upper gastrointestinaltract
AJR:157,
[2] and contradict
the findings
of research that has shown significant impairment of gallbladder function in patients with cervical SCI (Milne et al., paper presented at the annual meeting of the Society of Nuclear Medicine, June 1987; Chassin-Kaplan et al., paper presented at the annual meeting of the American Spinal Injury Association, May 1988). We think that the results and conclusions of Nino-Murcia et al. are questionable for the following reasons: (1) It is grossly misleading to lump together and homogenize the data obtained from quadriplegic and paraplegic subjects. Paraplegic patients with low injuries (Ti 1 and below) who are likely to have normal gallbladder function and gastric emptying made up 25% of the paraplegic population and 15% of the total SCI study group. Small but significant differences between quadriplegic patients and able-bodied controls or paraplegic subjects could thus easily be obfuscated, resulting in the acceptance of a false null hypothesis and the commission of a type II error. (2) Studying a single SCI population composed of both patients with new injuries and patients with chronic injuries of more than 1 year duration as Nino-Murcia et al. did can be both incorrect and misleading. (3) The
1 . Nino-Murcia M, Burton D, Chang P, Stone J, Perkash I. Gallbladder contractility in patients with spinal cord injuries: a sonographic investigation. AJR 1990;154:521-524
2. Segal JL, Milne N, Brunnemann normalization of impaired gastric terology 1987:82(1 1):1143-1148
SR, Lyons KP. Metoclopramide-induced emptying
in spinal
cord injury.
Gastroen-
Reply We would like have raised, in the our data excluding volume of patients which
was
to respond to the questions Drs. Segal and Milne order in which they were raised. (1) We reanalyzed the four low lesions. The mean gallbladder resting with spinal cord injury (SCI) was 20 ml (SE = 2.3),
significantly
different
from
the
mean
resting
volume
of the
normal control group (p = .01 ). The mean gallbladder residual volume of SCI patients was 1 0 ml (SE = 1 .0); this was not significantly different from that of the normal control group (p = .61). The mean emptying time of the gallbladder in SCI patients was 43 mm (SE =
3.3); this was not a significant difference from the normal control group (p = .31). Thus, SCI patients do not show significant differences in gallbladder contractility from a normal population. The observed difference in the ejection fraction reflects the lower resting gallbladder volume in SCI patients [1]. Great care was taken to minimize a type II error. The experimental design using matched controls, and the number of patients studied was specifically selected to achieve 95% power (beta error = 0.05) for a 5% one-tailed test, with a critical effect size of 0.4. Such a critical effect size roughly
LETTERS
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AJR:157, August 1991
corresponds to a minimal difference of about 3 ml in gallbladder volume and 1 0 mm in emptying time, numbers that are well within 1 SD of the measured normal mean values. (2) Damage to the autonomic nervous system becomes stable within 6 months of the injury. Thus, using patients whose injuries occurred 6 months or more before the study is scientifically correct. (3) All SCI patients had complete lesions.
(4) The
key
parameter
with
respect
to our
measuring
3
4i
Fig. 1.-CT
scan with contrast
material shows two defined, hypodense, ing hepatic lesions.
large, wellnonenhanc-
system
is its reproducibility, not its absolute accuracy, as our experimental design included a matched control group. Only the “relative” observed differences
in measured
changes
absolutely
accurate
determinations
published
literature
[2,
3]
in volume
are
of volume
supports
this
important;
actual
are unimportant.
view
of
the
The
reproducible
standard in using sonography to measure gallbladder volumes. (5) We have no reason to suspect that using sonography to measure gallbladder volume would be any different in SCI patients than in the normal population or in any other patient. (6) Drs. Segal and Milne did detect a typographic error: The number of patients with lesions below Ti 0 was four, not two. For these reasons, we stand by our conclusions as stated in the original
article
[1]. Matilde
Nino-Murcia Inder
Stanford
University
Affairs
School CA 94305
Stanford,
Veterans
Perkash
Medical
Medical
Center
Palo Alto, CA Paul University
of Iowa
Hospital
94304
diagnosis
hepatocellular
of lesions
carcinoma,
with
this
Clinics
appearance
hepatoblastoma,
and
primary
lymphoma
[31.
of the liver
Moreover,
the
results
the
liver
uation
have values
discrete
masses
without
or other
intrinsic
characteristics
significant
variation
Sonographic 1011
measurement
3. Everson GT, Braverman of real-time contraction.
Primary
DZ, Johnson ML, Kern F Jr. A critical evaluation
ultrasonography
for
Gastroenterology
Liver
RA, Lawson TL, Kishk SA, Kern MK. volume. AJR 1985:145:1009-
of gallbladder
the
study
of gallbladder
volume
and
setting described of the liver.
A Diagnostic
C. Mohan S. S. Alurkar 0. P. Sharma S. H. Advani
suspected
until
it is proved
by
biopsy.
In our
experience,
right-sided
nal pain, and hepatomegaly for 1 month. Serum zymes were elevated: aspartate aminotransferase
protein
aminotransferase
King-Armstrong and
well-defined,
(SGPT),
units/dl
carcinoembryonic hypodense,
79
lU/I;
and
(1 91 7 U/I). Serum antigen
nonenhancing
were
abdomi-
levels of liver en(SGOT), 1 24 lU/I;
alkaline
phosphatase,
levels
normal.
lesions
Needle biopsy showed diffuse non-Hodgkin differentiated lymphocytic type. The patient combination chemotherapy.
1 . Kayano H, Katoyarna cular lymphornatosis.
Hospital
400 012, India
I. Primary hepatic lymphoma presenting as intravasArch Pathol Lab Med 1990;1 14:580-584
2. Osborne BM, Butler JJ, Guarda LA. Primary liver lymphoma: cases and review of literature. Cancer 1985;56:2902-291 0
Doppler Disease
Sonography
report of ten
CT
in the
of alpha-fetoshowed liver
(Fig.
two 1).
lymphoma of the poorly had a good response to
in Osler-Weber-Rendu
disease,
ectasia,
is a vascular
Hepatic
involvement
disease
or with
hereditary
autosomal
is characterized
the duplex Doppler telangiectases.
A 46-year-old
a case that illustrates this point. A 53-year-old man had had nausea, vomiting,
alanine
Memorial
REFERENCES
Osler-Weber-Rendu
primary lymphoma of the liver should be suspected when a patient has increased serum levels of liver enzymes, normal serum levels of alpha-fetoprotein and carcinoembryonic antigen, and CT findings of one or two nonenhancing hypodense lesions in the liver. We describe
270
Tata Bombay
Dilemma
Only 53 cases of primary lymphoma of the liver have been reported [1]. These lesions usually are misinterpreted as hepatocellular carcinoma, hepatoblastoma, or metastasis. Primary lymphoma of the liver is not
of here
3. Boechat Ml, Kangarloo H, Ortega J. et al. Primary liver tumors in children: comparison of CT and MR imaging. Radiology 1988;169:727-732 4. Zornoza J. Ginaldi S. computed tomography in hepatic lyrnphoma. Radiology 1981;1 38:405-410
1980:83:773-776
Lymphoma:
in atten-
[4J. The detection
REFERENCES
2. Dodds WJ, Grosh WJ, Darweesh
of pathologic
examination of biopsy specimens of primary or large cell lymphomas can be misinterpreted. Occasionally, frozen sections have artifacts that distort large cell lymphoma so that it assumes a carcinomatous appearance [2]. As in our case, most cases of primary lymphoma of
Iowa City, IA 52242 and colleagues
1 . Nino-Murcia M, Burton 0, Chang P. Stone J, Perkash I. Gallbladder contractility in patients with spinal cord injuries: a sonographic investigation. AJR 1990:154:521-524
on CT
metastasis
from an unknown primary tumor [2]. Neither CT nor MR imaging has been helpful in differentiating, with certainty, these conditions from
such lesions on CT scans in the clinical suggests the diagnosis of primary lymphoma
J. Chang
and
The differential includes
findings
woman
in the
hemorrhagic dominant
by
telangiectases.
liver
in a case
was admitted
because
telangi-
transmission. We
with
report
extensive
of cardiac
failure.
Physical and radiologic examinations showed pulmonary arteriovenous fistulas and multiple gastrointestinal telangiectases. The diagnosis was Osler-Weber-Rendu disease. Results of liver function tests were as follows: alkaline phosphatase, three times higher than the normal upper limit; -y-glutamyltransferase, eight times higher than the normal three
upper times
limit; higher
and than
alanine the
normal
and
aspartate
upper
limits.
aminotransferases, Abdominal
sonogra-
phy showed a dilated hepatic artery (i 2 mm in diameter) with numerous tortuous intrahepatic branches and dilated hepatic veins. The portal vein was normal. Duplex sonography showed a high velocity
LETTERS
4i 4
AJR:157,
August
1991
3. Bourgeois N, Delcour C, Deviere J, Francois A, Lambert M, Cremer M. Osler-Weber-Rendu disease associated with hepatic involvement and high output
heart
4. cloogman
Downloaded from www.ajronline.org by Vrije Universiteit Brussel on 10/15/15 from IP address 134.184.26.108. Copyright ARRS. For personal use only; all rights reserved
graphic
failure.
findings
Bilateral
J Clin Gastroenterol
1990;12:236-237
HM, DiCapo RD. Hereditary in the liver. Radiology
Urinomas
hemorrhagic
telangiectasia:
sono-
1984; 150:521-522
in an Adult
Urinomas associated with renal trauma, iatrogenic injury, ureteric obstruction by calculus, neoplasms, renal transplants, and obstruction of the bladder outlet caused by posterior urethral valves are well known [1 ]. However, to our knowledge, bilateral urinomas in an adult and their association with urethral injury that occurred during partuFig. 1.-Osler-Weber-Rendu disease. A, Doppler waveform of hepatic vein shows high-velocity signal. B, CT scan with contrast medium shows dilated left hepatic artery (straight arrow) with dilated intrahepatic arteries and early enhancement of hepatic veins (curved arrows).
signal in the hepatic artery. Portal flow was normal. The hepatic veins had an “artenialized” pattern, with abnormal peaks indicating the communication between the hepatic arteries and the hepatic veins (Fig. 1 A). CT and hepatic angiography confirmed the hepatic arterialization and the arteriovenous fistulas by showing simultaneous enhancement of the arteries and the hepatic veins (Fig. 1 B). Osler-Weber-Rendu disease is a vascular disease with multiple manifestations. The most frequent localizations are the skin and mucosa, but all organ systems may be involved. The liver involved more often than was suspected originally [1 ]. The vascular abnormalities include telangiectases and arteriovenous fistulas, sometimes associated with fibrosis and cirrhosis [1 -3]. Sonographic findings in the liver consist of dilated common hepatic artery, multiple ectatic vascular structures with pulsations, and dilated hepatic veins [4]. Although these sonographic findings suggest vascular disease, duplex Doppler imaging can be used to confirm the diagnosis. Duplex
Doppler sonography
shows high velocity signal in the hepatic artery,
with increased arterial hepatic output; arterial signal in the intrahepatic vascular structures; and abnormal high velocity signal in the hepatic veins. This last finding mimics an arterial flow and confirms the arteriohepatic communications. We did not use color Doppler imaging in this
case, but it can be helpful by showing
rition
have
A large months
been
reported
abdominal
not
mass
after
parturition.
The
veins.
shows Doppler
large sonography
and
numerous gives
arteries
information
include
and
dilated
increased
flow, arterial signal in the intrahepatic vascular structures, normal high velocity signal in the hepatic veins. Angiography
necessary
if no treatment
noted
in a 35-year-old
apparently
had
tumors,
hematomas,
and
abscesses,
CT
woman
originated
is the
imaging procedure, particularly if dynamic-phase structions in the sagittal and coronal planes are values of urinomas are normally -1 0 H to 30 H uation usually is homogeneous as compared with and hematomas, which is heterogeneous. CT information
2.5
1 week
about
the precise
extent
and
location
most
useful
scans and reconused. Attenuation [2], and the attenthat of abscesses also gives specific
ofthe
fluid
collection
and its relationship to the kidneys, ureters, and fascial planes and compartments [1]. The indirect evidence of round cell infiltration in necrotic fat and adjacent renal fascia that form the perirenal fibrous sac, in response to the accumulated urine, is shown better on sonograms [3].
K. K. Sen Meenakshi
Thakur
0. P. Sharma Tata
high color signal in the
on
mass
after parturition. CT scans showed bilateral uniformly hypodense (10 H) encapsulated masses in the perirenal regions (Fig. i ). No enhancement of the masses was seen with contrast material. Both kidneys showed normal excretion. On sonograms, the mass on the left was anechoic; the mass on the right contained multiple linear echoes and had a thick, smooth capsule. Sonography and CT have often been used to diagnose uninoma when pseudonephromegaly has suggested tumor invasion. Other entities that must be considered in the diagnosis of perirenal uninomas
Memorial
Hospital
and
Cancer Bombay
extrahepatic and intrahepatic arteries and large hyperkinetic hepatic veins. In conclusion, conventional and Doppler sonography can be used to diagnose hepatic involvement in Osler-Weber-Rendu disease. Sonography
previously.
was
Research 400
Centre 012,
India
hepatic arterial
and abis not
is indicated. Valerie Vilgrain Yves Menu Henri Nahum HOpital Beau/on 921 18 Clichy Cedex, France Fig. 1.-Bilateral
REFERENCES 1 . Martini GA. The liver in hereditary haemorrhagic teleangiectasia: an inborn error of vascular structure with multiple manifestations: a reappraisal. Gut
1978;19:531 -537 2.
Nikolopoulos N, Xynos E, Vassilakis JS. Familial occurrence of hyperdynamic circulation status due to intrahepatic fistulae in hereditary hemorrhagic telangiectasia. Hepatogastroenterology 1988;35:167-168
urinomas.
A, Contrast-enhanced CT scan shows bilateral hypodense encapsulated perirenal masses. Mass on right extends from inferior surface of right lobe of liver to right iliac fossa, displacing renal parenchyma inferomedially Smaller mass on left displaces left kidney cephalad and anteromedially. Capsule of mass on right is slightly thicker than that of mass on left and is smooth and shows noticeable enhancement. Ureters are displaced medially and bowel loops anteriorly. B, Sonogram shows possible secondary infection on left side.
AJR:157,
August
LETTERS
1991
4i 5
REFERENCES
Downloaded from www.ajronline.org by Vrije Universiteit Brussel on 10/15/15 from IP address 134.184.26.108. Copyright ARRS. For personal use only; all rights reserved
1 . Land
EK, Glorioso
L Ill. Management
of urinornas
by percutaneous
drain-
age procedures. Radio! C!in North Am 1986;24:551-559 2. Healy ME, Teng 55, Moss AA. Uriniferous pseudocyst: computed tomegraphic findings. Radiology 1984:153:757-762 3. Feinstein KA, Fernbach 5K. Septated urinomas in the neonate. AJR 1987;149:997-1 000
Fallopian
Tube
Nomenclature
Dr. Thurmond both on her review article [1 ] on selective and fallopian tube recanalization and on her original to these techniques. I would make one semantic ob-
I commend salpingography contributions servation. Throughout subject, there proximal and authors define
her article,
and
I think
communications
incorrect,
use
on this
of the
terms
as they refer to the fallopian tubes. Almost all proximal as the uterine or cornual end of the tube and
distal
as the ampullary,
distal
and in most recent
iS a confusing,
fimbriated,
or ovarian end. This is the opera-
tom’s perception during catheterization and injection of contrast medium. However, even the term retrograde catheterization, used by some authors, but not Thurmond, implies that the uterine end of the fallopian
tube
is the distal
Ferris Beth Harvard
Israel
M. Hall Hospital
Medical Boston,
AS. Selective
salpingography
and fallopian
tube
C Natural
History
studied.
Thefossils
02215
recanalization.
AJR 1991;156:33-38
in axial
detail
and
bones
Growth
Dr. Hall for taking
point
refreshing
that
the feminist in this
I take
the
male
Oregon
Health
Sciences Portland,
Previous the
enough men,
attempts
volume
of
for image we
have
brae. Vertebrae (approximately
at MR
protons
was
acquisition
used
MR
imaging
Lines
of fossilized
from a prehistoric 12 million years
dolphin from old) from the
to study
MR
images
provided
of transverse
lines,
frequently
sufficient
lines referred
and
anatomic
bands
within
to as transverse
the lines,
column
have
been
studied
osteopetrosis,
with
less
well
but
a “vertebra
have within
been
described
a vertebra”
ap-
[21. Although
also
into
the
changes spongiosa
failed
fossil
sediment
have
of bone, contains
been
producing silicon
[31. Fine silt may filter
described opaque
lines,
compounds.
particularly However,
if the these
dense compounds are deposited in an irregular pattern and therefore lack uniformity in thickness and are not circumferential. Because the deposition of artifacts is governed by gravity, the widest of these dense lines is found in the most dependent portion of fossilized bone.
because
small to produce signals strong and processing. By hydrating the specsuccessfully
planes.
pathologic
97201
too
imaging
coronal
University
in Fossil
bone
were
cylinder
of water. A 1 .0-T (Siemens Magnetom) magnet specimen in a Helmholtz surface coil. Spin-echo, T2-weighted sequences (TE 30, 90; TR 2.0; slice 2 acquisitions; 256 x 256 matrix) were obtained
recovery
deposited
Recovery
in a plastic
OR
Amy S. Thurmond
of Growth
them
status during youth described: infection; states; and poisoning, False bands and
chauvinist
of view.
MR Imaging Vertebrae
DC,
Washington,
by placing
the lines may be normal, poor nutritional and a large variety of other causes have been metabolic, neoplastic, and vitamin deficiency by either heavy metals or vitamins. lines of variable thickness representing pseudo-
point of view. I hope he finds
instance
Paleontology)
lines and bands.
growth arrest lines, stress lines, or lines of Park or Harris, have been studied extensively in the human appendicular skeleton [1]. These lines cross bone horizontally at right angles to the longitudinal trabeculae and represent a markedly thickened interconnected network of trabecular bone. The lines and bands result from resumption of growth after an episode of growth cessation. Transverse lines in the
pearance
I thank
circumferential
hydrated
to allow diagnosis (Fig. 1).
as mimicking
it equally
were
500 ml was used with the proton-density, and thickness 4.0 mm;
vertebral Reply
(Vertebrate
containing
School MA
REFERENCE 1 . Thurmond
I
end.
Standard medical convention defines proximal and distal vessels or ducts not by their proximity to the midline or the cannulating instrument, but relative to in vivo physiologic flow. Hence, the proximal inferior vena cava is more caudal. A similar problem in nomenclature arose with the introduction of ERCP (endoscopic retrograde cholangiopancreatography), and, after initial confusion, radiologists agree that the proximal pancreatic duct is located in the tail of the pancreas (where it should be, and always has been). Physiologic flow in the fallopian tube is toward the uterus, and unless we take a male chauvinistic view regarding sperm movement, the distal end of the tube is toward the uterus.
Fig. 1.-A--C, Coronal anterior near midline (B), and postenor (C) MR Images through caudal vertebrae of prehistoric dolphin show spatial relationship of (A),
verte-
the Miocene Epoch National Museum of
The
results
present feasible,
suggest
that
growth
recovery
bands
and
lines
were
in mammals during prehistoric times. If hydration of fossils is MR imaging appears to be useful for detecting skeletal
abnormalities.
James
Jeno I. Sebes W. Langston
Morris
L. Gavant
LETTERS
4i 6
University
of Tennessee, Memphis,
Bruce
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Northeast
Ohio
Youngstown,
Memphis TN 38163
Rothschild University OH 44512
REFERENCES 1 . Park EA. The imprinting Pediatrics
1964;33:81
of nutritional
disturbances
on the growing
bone.
5-862
2. Stammel CA. Multiple striae parallel to epiphyses and ring shadows around bone growth centers. AiR 1941;46:497-505 3. Decker FH, Bohrod MG. Medullary artifacts in prehistoric bones. AJR 1939;42:374-375
MR of Intraspinal with Gadopentetate
Synovial Cyst: Dimeglumine
Rim Enhancement
Silbergleit et al. [1 1 recently described uniform rim enhancement of a synovial cyst on MR after administration of gadopentetate dimeglu-
mine. Pathologically, the cyst wall was composed of fibrous connective tissue with numerous vascular foci within it. The peripheral enhancement was thought to be caused by the chronic inflammatory changes around the synovial cyst. We describe a similar case with pathologic confirmation. We think that the cyst wall functions much like scar tissue. Gadolinium diffuses rapidly across the rich vascular network into the extracellular space through discontinuous epithelial membranes, which results in early rim enhancement [2]. Our patient, a 50-year-old woman with a history of progressive lower back pain had had new might-sided radicular symptoms for 3 months. The symptoms were confirmed on physical examination. Surface-coil MR was performed on a Siemens Magnetom SP 1 .5-T unit. Routine double-echo (700/1 5, 2400/45, 2400/90) sagittal and short TRITE (600/1 5) axial images without and with gadopentetate dimeglumine showed a well-defined cystic structure intimately related to a degenerative L4-L5 facet joint on the right side. The cyst was slightly hyperintense relative to CSF on Ti - and T2-weighted images and had a hypointense rim that enhanced diffusely after administration of contrast medium. A correct preoperative diagnosis of a nonhemorrhagic synovial cyst was made. After total excision of the synovial cyst, the patient reported complete resolution of her symptoms.
AJR:157, August 1991
Synovial cysts are rare causes of intraspinal extradural masses. Most commonly, they arise from degenerative apophyseal joints, in particular at the L4-L5 level, and are associated with radicular symptoms [3, 4]. Such cysts are more prevalent in females and after the age of 50 years [1 , 3]. Synovial cysts contain watery or mucinous fluid [4]. Nonhemorrhagic synovial cysts may be isointense or hyperintense relative to CSF on spin-pulse sequences [4]. Some authors have attributed the hypointense rim to calcification or hemosiderin, but more likely it is related to the cyst membrane and surrounding inflammatory tissue [3, 4]. Differential diagnosis for a cystic dorsal extradural intraspinal mass includes extruded disk fragments, cystic neurofibromas, arachnoid cysts, and perineural cysts [4]. Rim enhancement with gadopentetate dimeglumine of recurrent disk herniation (“wrapped disc”) has been shown to be caused by peridiskal fibrosis [2]. The noninvasiveness, multiplanar capabilities, and inherent contrast characteristics of MR imaging and the additional information provided by the use of contrast medium make MR an optimal imaging technique for evaluating spinal lesions. Karl S. Chiang Ya-Yen Lee Michel E. Mawad Baylor College of Medicine Houston, TX 77030 REFERENCES 1 . Silbergleit R, Gebarski 55, Brunberg JA, McGillicudy J, Blaivas M. Lumbar synovial cysts: correlation of myelographic, CT, MR, and pathological findings. AJNR 1990;11:777-779
2. Price AC, Runge vM. MRI efficacy in spine expands with Gd-DTPA. Diagn Imaging 1989;1 1(1 1):172-177
3. Liu 55, Williams KD, Drayer BP, Spetzler RF, Sonntag VKH. Synovial cysts of the lurnbosacral spine: diagnosis by MR imaging. AJR 1990;154:163-1 66 4. Jackson
DE, Atlas
MR imaging.
SW,
Radiology
High CT Attenuation Aspergillosis
Mani
JR, Norman
D. lntraspinal
synovial
Values
in Paranasal
A i 4-year-old boy complained that his nose was blocked on the left side. He had a history of aspergillosis of the right paranasal sinuses and had had surgery for this about 8 months earlier. CT showed a soft-tissue mass in the left nasal cavity extending into the left maxillary antrum, ethmoid air cells complex, and frontal and sphenoid sinuses (Fig. i ).These mass lesions were patchy, with a
zone of lower attenuation in the periphery. Mucoperiosteal was
present
attenuation
some places. No bony destruction values of these masses on unenhanced
Fig. 1.-coronal scan
of
thickening
was seen. The CT scans were
in
CT Fig. 1.-Intraspinal synovial cyst A, Axial Ti-weighted MR image at L4-L5 level shows a heterogeneous dorsolateral mass on right Intimately related to ligamentum flavum and facet joint. Signal intensity of central area of mass Is lower than that of peripheral aspects. B, Gadolinium-enhanced axial Ti-weighted MR image at same level as A shows diffuse rim enhancement of synovial cyst
cysts:
1989;170:527-530
unenhanced
paranasal
sinuses
shows a heterogeneous soft-tissue mass with areas of high attenuation (about 90 H) in left nasal cavfty and maxillary antrum. Pcripheral rim of low attenuation represents thick mucoperiosteum.
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AJR:157,
August
LETTERS
1991
90-i 00 H. No significant enhancement was seen after administration of contrast material. The diagnosis of recurrence of aspergillosis was confirmed histologically after surgery. Limited studies have been done on the CT features of paranasal aspergillosis. Centeno et al. [i ] have described various CT features of fungal sinus disease, but the high attenuation values seen in our case have not been mentioned before. This finding probably is due to the presence of calcium salts in the Aspergillus mycelia, which was reported by Stammberger et al. [2]. The high attenuation value is an important feature that can be used to differentiate a fungal mass from neoplasm. No neoplasms have such high attenuation values on unenhanced CT scans. Tumors of bone and cartilage can have a high attenuation value, but their appearance is different. Kamlesh C. Khandelwal Rajul J. Udani Nikhil
4i7
A
B
Fig. 1.-Guard for prevention of finger-stick injuries. A, Guard protects finger from puncture when stylet is replaced. B, Device can be positioned at predetermined depth on needle accurate placement of needle into a particular body space.
stick
injuries
H. Merchant
during
1 . Centeno
RS, Benston JR, Macuso AA. cT scanning in rhinocerebral mucoromycosis and aspergillosis. Radiology 1981;140:383-389 2. Stammberger H, Jakse A, Beaufort F. Aspergillosis of the paranasal histopathology
and
clinical
aspect.
Ann
during
replacement
of
the
stylet
Oto!
1984;93:251 -256
replacement
of the
stylet
into
the
needle
(Fig.
Harvard
1 A). The
Medical
Boston,
Guard for Prevention Caused by Stylets Because
Ii], I wish
needle-stick to describe
of Finger-Stick injuries
a device
are potentially
Injuries life-threatening
that can be used to prevent
1 . Jagger J, Hunt EH, Brand-Elnaggar injury caused by various devices 1988;319 : 284-288
events needle-
J, Pearson RD. Rates in a university hospital.
are published at the discretion of the Editor and are subject to editing. to the Editor must not be more than two double-spaced, typewritten pages. One or two figures may be included. Abbreviations should not be used. See Author Guidelines, page A5. Material being submitted or published elsewhere should not be duplicated in letters, and authors Letters
must
disclose
concerning
financial a paper
associations published
device
School
MA 02215
REFERENCE
Letters Letters
of letters
in stylet
can be positioned at a desired depth on the needle to ensure accurate placement of the needle into a body space (Fig. 1 B). After use, the needle and the guard are discarded. Commercial availability in the fall is anticipated. Andrew M. Singer Beth Israel Hospital
REFERENCES
diagnosis,
occur
needles. The device is made of sterilizable, puncture-proof plastic. It is cone shaped, about 3 cm in diameter, and made so that it can be positioned at the hub end of the needle. The user’s fingers are placed beneath the device and are protected from inadvertent needle-stick injuries
Omprakash Sharma Tata Memorial Hospital Bombay 400 012, India
sinuses: X-ray Rhino! Laryngo!
that
for
or other in the AJR
reply to be published in the same issue. Opinions necessarily reflect the opinions of the Editor.
possible will
be sent
expressed
conflicts to the
of interest. authors
in the Letters
of the
paper
to the Editor
for
a
do not
of needle-stick N Eng! J Med
