From: Michael R. Schuster, MD, and Kathleen A. Scanlan, MD Department of Diagnostic Radiology, University of Wisconsin Hospitals and Clinics 600 Highland Avenue, Madison, WI 53792 Editor:
We have read with interest issue of Radiology by Im el
an associated entity by Walkey (2) in the March 1991 issue. Both Im et al and Walkey describe enhancing pulmonary yessels
on dynamic computed tomographic (CT) scans of the as the “CT angiogram sign.” Examples of bronchioboalveolar cell carcinoma and pneumococcal and tuberculous pneumonia were illustrated. We have recently observed a similar appearance in a patient with bymphoma.
Dr Im and colleagues (1) have eloquently described the CT angiogram sign in bronchioloalveolan carcinoma while illustrating several other conditions in which the sign is present. Dr Wabkey (2) has submitted another condition in which it is seen. Our example of pulmonary necrosis, probably secondary to bymphomatous involvement, serves to reinforce the point that radiologic signs and findings are rarely diagnostic of a single condition but produce a list of possible diagnoses. The more specific the sign, the shorter the differential diagnosis. The finding of totally consolidated lung, without air bronchognaphy, and with continued perfusion is uncommon and should lead to a limited differential diagnosis.
References 1. 2.
Im J-G, Han MC, Yu EJ, et at. Lobar bronchioloalveolar carcinoma: “angiogram sign” on CT scans. Radiology 1990; 176:749-753. Watkey MM. And what is your sign (letter)? Radiology 1991; 178: 894.
From: George G. Hamtnell, FRCR Department of Radiology, 185 Pilgrim Road, Boston,
New England MA 02215
Editor: In the March 1991 issue of Radiology, Dr Yedlicka and cobleagues (1) report on use of a nitinob gooseneck snare (Microvena, Vadnais Heights, Minn) and describe a high-tech solution to a still relatively uncommon problem. One wonders if the majority of interventional radiologists will find it necessary or cost-effective to keep a full range of these snares in stock or whether they would be better served by making their own snares, depending on the clinical situation with which they are
Contrast-enhanced sign of enhanced
lung. This portion cavitation.
vessels within necrotic (liquid), noncavitated of the right lower lobe ultimately underwent
phoma was referred for dynamic contrast material-enhanced CT of the chest to evaluate a right pleural effusion. The patient did indeed have a right effusion, but, in addition, the right lower
gram sign (Figure). Much of the lobe underwent cavitation, and the patient died soon after. Postmortem examination showed fibrosis and scarring in the area of cavitation as well as liquefactive necrosis of much of the remainder of the lobe. Although large cell lymphoma was not recovered from the necrotic lobe, multiple lymph nodes showed similar necrosis and were thought to represent lymphomatous foci that responded to chemotherapy.
for a long
of the to
In addition, it may be difficult to retrieve an eccentrically positioned intravascular fragment with these devices. This is one situation in which the nitinol gooseneck snare may be advantageous. It is, however, possible to produce a homemade snare that will also grasp eccentrically positioned fragments and that can be modified to fit the contours of the vessel in which a fragment has become lodged. Such a snare can be assembled from an appropriately shaped diagnostic angiographic catheter and guide wire. The catheter shape should be chosen to allow cannulation of the vessel where the intravascular fragment has lodged. In this respect, a cobra or Judkins right coronary-shaped catheter will often be most appropriate. With a small-diameter (ie, 0.015-inch), fixedcore guide wire, even diagnostic catheters with small diameters can
bowing case. During attempted antegrade cannulation of a common femonal artery before superficial femoral artery dilation, a Radiofocus guide wire (manufactured by Temumo, Piscataway, NJ; distributed by Medi-tech/Boston Scientific, Watertown, Mass), commonly referred to as the “Glidewire,” was used through a one-piece thin-wall needle. During manipulation, a fragment of hydrophffic coating from the guide wire
became detached from the wire, although no resistance was felt, and was seen to pass distally into a branch of the deep femoral artery. It was believed that the fragment of coating should
a 5-F cobra
used or the introducer ter or dilator. Variations both foreign
0.015-inch fixed-cone guide wire bent loop. To prevent an excessively tight
to provide an eccentric angle forming at the apex of the snare-which could weaken the wire-the two ends of the guide wire were introduced into the patient-end tip of the diagnostic catheter and advanced until approximately 2 inches
of the looped end
of the catheter.
dures are frequently structed from readily
catheter. The snare and catheter were introduced via a 6-F anterial sheath with a hemostatic valve. The snare was advanced to the level of the fragment of guide wire coating (Figure). The
a homemade materials used
snare confor diagnostic
GH, eds. Interventional radiology. Philadelphia: 384. Curry JL. Retrieval of detached intravascular
platz K. Nitinot gooseneck snare for removal of foreign bodies: experimental study and clinical evaluation. Radiology 1991; 178: 691-693. Kadir S, Athanasoulis CA. Percutaneous retrieval of intravascular foreign bodies. In: Athanasoulis CA, Pfister RC, Green RE, Robenson
of wire should
References 1. Yedlicka
intact via the sheath, and angioplasty was completed without further complications. The Glidewime seems to be used frequently through cutting needles in spite of the manufacturer’s specific warnings against doing this. Apparently no resistance to manipulation was felt
use of this
were projecting from the hub end of the catheter, allowing withdrawal of the snare. The snare was withdrawn into the catheter until only ‘/2 inch of loop projected from the tip of the wire
of this form of steerable snare have body retrieval and also for grasping wires used during antegrade transeptab
advantage that the components are readily available in the majority of angiography departments, and the size and curve of the snare can be modified to take account of the anatomy involved in a particular situation.
from the patient ends
extraction of catheter vessels. AJR 1971;
111:467-472. Crook R, Weston M, Wilde RPH, Hantnell GG. Aortic comparison of the techniques and results of transeptal grade methods. Clix Radiol 1990; 42:110-113.
Dotter CT, Rosch J, Bilbao MK Transluminal and guide fragments from the heart and great
valvoplasty: and retro-
From: Clinton Department
B. Sayler, MD of Radiology,
Medical Center 1015 Northwest
Editor: I am responding to the article by Sickles (1) in the May 1991 issue of Radiology. Congratulations to Dr Sickles on his tenacity in the follow-up of “low-suspicion” lesions. He has answered some
Of particular interest are the 1,853 cases of tiny calcifications that made up approximately 58% of the lesions. My question whether calcifications too small to be seen on regular screenfilm mammograms
The percentage of mammograms Dr Siddes designated as showing “probably benign” lesions (11.2%) is higher than that found in other studies he cited (ie, Helvie et al , 5.4%; Wolfe, et a! , 6.4%). I believe that some of the higher percentages were due to tiny calcifications, which most of us do not follow up. There were two malignancies in the 1,853 cases of tiny calcifications, so they were indeed very low in suspicion. An analysis of these calcifications because it would contribute to our
if there into
a pattern, category
would be of great benefit knowledge of benign calcifi-
to be fob-
mammographers have considered malignant to look like grains of sand or small irregular spicubated or branching calcifications. The size of these “sand particles” as resolved with traditional mammography is beHistorically,
just proximal the
the fragment. stationary
to the detached enabled
to be snared.
is improved solving
and microfocus specks
0.24 mm with
of magnification, imthe resolution (as determined by re-
x-ray tubes, American
ton, Wis]). December