An on-line digital image management system

The continuing increase in diagnostic examinations using digitally formatted image instrumentation imposes new requirements on the acquisition, display, transmission, recording, and archiving of all diagnostic data. The fabrication decisions and initial clinical testing of a prototype on-line, decentralized digital image management system are described. With this system, raw digital data can be viewed by multiple users as soon as it is acquired by an acquisition node and transmitted to a display node. Radiologists and clinicians have given this system a favorable reception.

Computer graphics for digitally formatted images

The increasing use of digitally formatted imaging systems requires high-quality interactive gray-scale computer raster graphics systems for the management, display, and analog film recording of digital image and alphanumeric information. These systems are a combination of computer hardware and software and implement a set of graphics protocols. This paper describes a set of interactive graphics protocols that has been developed for clinical use.

CT findings of suprapatellar synovial cysts

The computed tomographic (CT) findings of two suprapatellar (SP) synovial cysts are presented, and the correlated anatomicopathologic changes are discussed. The cysts show characteristically semilunar shapes and anteromedial locations in the SP regions with superolateral extension. The cyst walls vary in thickness, and the cyst contents also vary from a transudate to a thick mucoid fluid, which may show a high attenuation value on CT. Differential diagnoses include liposarcoma, hematoma, xanthoma, fibrosarcoma, or other soft tissue tumors.

Renal cell carcinoma--angioinfarction

In our experience the mortality rate in 46 patients who underwent angioinfarction for renal cell carcinoma was 4 per cent. Fever, ileus and leukocytosis were noted in 86 to 90 per cent of our patients. The use of absolute ethanol as a medium for renal infarction was associated with a significant incidence of damage to other organs. A 30 per cent decrease in tumor volume following angioinfarction using absorbable gelatin sponge and Gianturco coils was noted in 75 per cent of the patients. There was no evidence of metastatic tumor reduction and we could not document any significant decrease in operative time or blood loss. It would appear that there is some increased survival rate in patients with metastasis who are given adjuvant immune ribonucleic acid therapy. However, the numbers in our series are not significant to draw any definite conclusion. It is apparent that patients treated with infarction, delayed nephrectomy and medroxyprogesterone acetate did not have any significant survival over those treated with palliative nephrectomy or chemotherapy. The macrophage maturation assay may be useful during clinical followup.

Takayasu's arteritis: reversal of pulse deficit after early treatment with corticosteroids

Takayasu's arteritis is a rare disease characterized by inflammation and stenosis of large arteries. The aortic arch and its branches are most often affected. Initial symptoms are nonspecific and the diagnosis may be delayed until signs of vascular insufficiency appear. Results of medical treatment have been conflicting. We report a case of a young woman with a short history of pulse deficits, high erythrocyte sedimentation rate, narrowing of the subclavian arteries on arteriography, and a complete return of pulses after high dose corticosteroids. Takayasu's arteritis is a treatable disease in its early phase, but treatment response may be disappointing after irreversible vascular lesions develop.

The computed tomographic findings of popliteal cysts

The computed tomographic (CT) findings of two popliteal cysts are presented, and the correlated anatomico-pathologic changes are discussed. The characteristic findings include thin, well-defined cyst wall, fluid density contents, central septum or septi, and medial popliteal location with mediocaudal extension. These findings, however, may vary due to herniation or rupture of the synovial membrane, gelatinous cyst contents, or metaplastic change of the cyst wall. Differential diagnoses include liposarcoma, popliteal aneurysm or hematoma, thrombophlebitis, xanthoma, fibrosarcoma, or other soft tissue tumors.

A peripheralized digital image management system: prospectus

The number of diagnostic radiology examinations being performed on digitally formatted imaging equipment is continually increasing. However, most digital data are recorded as analogue images and the films stored in a central file. The dynamic range of raw digital data is lost. Currently, the space and cost requirements for storage of all digital data have discouraged most users from attempting it. This article presents the concepts and describes the requirements and initial fabrication of a system that will capture and retain all digital data using a network of peripheralized image acquisition, display, and storage devices. Any piece of digitally formatted equipment can be interfaced into the system. A real-time computer capability provides that any digital examination can be reviewed at any display station for up to 10 days.

The cost of managing digital diagnostic images

A study of the cost of recording and archiving digitally formatted diagnostic images is presented for an academic radiology department serving a 614-bed university hospital and a large outpatient population. The radiological examinations include computed tomography, nuclear medicine, ultrasound, and digital radiography. The archiving management strategies studied include the combined use of computer magnetic tapes, computer disc storage, and multiformat video film recordings. The estimated cost per patient for the archiving of digital diagnostic images is presented.

Three-dimensional computer reconstructions of brain lesions from surface contours provided by computed tomography: a prospectus

We present a prospectus on the use of computer graphics for the three-dimensional reconstruction and visualization of brain lesions from computed tomographic head examinations, including an algorithm that utilizes surface contour information to reconstruct and display three-dimensional anatomical sites. We provide examples of the use of this algorithm. We offer an algorithm for estimation of the volume and surface area of anatomical sites. The advantages and disadvantages for the clinical use of these algorithms are discussed.

Diagnosis of pericardial effusion by computed tomography

We assessed the diagnostic utility of computed tomography (CT) in the detection of pericardial effusion by using a dog model in which the amount and type of pericardial fluid were controlled and by obtaining CT scans on patients with suspected pericardial effusion prior to pericardiocentesis. The experimental studies showed that CT was capable of detecting pericardial effusion composed of serous fluid or saline in amounts as small as 50 ml. However, the hemopericardium was radiographically isodense with the heart and difficult to detect by CT unless the epicardial fat pad was identified or intravenous contrast enhancement of the heart was used. CT clearly demonstrated the presence of pericardial effusion in all six patients studied prior to successful pericardiocentesis or pericardiectomy. We conclude that CT is a sensitive noninvasive method which can be used for the diagnosis of pericardial effusion.

Abdominal pseudocysts as a complication of ventriculoperitoneal shunt. A report of two cases

The preoperative diagnosis of abdominal cerebrospinal fluid pseudocyst, in association with ventriculoperitoneal shunts, was made in two patients. Computed tomography and/or ultrasound and radiologicol procedures of choice to demonstrate and localize these cysts.

Continuous image recording using gray-tone, dry-process silver paper

A method of recording continuous gray-tone images on dry-process silver paper from raster-scan video signals is described. The Tektronix 4634 image-forming module uses a fiber-optic faceplate cathode-ray tube to couple the light output onto the recording paper. The latent image is heat developed and presented in sheet form. An initial comparison between dry silver paper and conventional film for video-generated computed tomography and nuclear medicine examinations, shows little apparent difference in image quality. Considerable cost savings are possible when using dry silver paper. Additional cost savings are possible if multiple images can be recorded on each dry silver sheet.

Subcutaneous implantation of percutaneous ureteral stents

The authors describe their experience with subcutaneous implantation of percutaneous ureteral stents. Three of the five procedures were complicated by infection, urine leak and/or chronic drainage at some time during their course. One patient developed pressure changes of the skin overlying the implanted tube. The problems encountered in this initial experience are avoidable. Subcutaneous implantation of percutaneous ureteral stents can be useful in the management of appropriate patients.

CT for intracavitary radiotherapy planning

Twenty-two patients with malignant uterine tumors were examined with computed tomography (CT) for treatment planning after insertion of an afterloading Fletcher applicator. The CT findings maximized the individualization of treatment planning, including the number, dosage, and loading arrangement of radioactive sources. Artifacts were produced by the metal; but in most cases the scans accurately portrayed the three-dimensional anatomic relationship of the applicator, uterus, and neighboring vital structures. The CT information made it possible to calculate dose distribution more rapidly and accurately for both intracavitary therapy and combined intracavitary and external therapy. Unsuspected uterine perforation was detected by CT in one case.

Comparison of computed tomography and ultrasound in abdominal staging of renal cancer

The relative accuracy of computed tomography (CT) and ultrasound in abdominal staging of renal cancer was determined in 22 patients. CT is capable of detecting tumor invasion of perinephric fat and adjacent muscles, which cannot usually be shown by ultrasound. While both CT and ultrasound demonstrate venous and retroperitoneal tumor extension, CT is more reliable since bowel gas not infrequently obscures the retroperitoneum on ultrasonic scanning. However, ultrasound will often provide valuable information; and whenever a solid renal mass is detected by echography using prone scans, abdominal scans should be obtained for staging pruposes.

Conversion of percutaneous ureteral stent to indwelling pigtail stent over guidewire

A ureteral stent placed percutaneously through a nephrostomy can be readily exchanged endoscopically for a ureteral indwelling pigtail stent over a percutaneous guide wire. Percutaneous antegrade stent placement can sometimes be accomplished when retrograde placement cannot. We report 10 successful conversions to indwelling stent in 11 cases. In 1 case the percutaneous guide wire could not be retrieved endoscopically because of a bleeding tumor in the bladder. No serious difficulties or complications were encountered. The percutaneous approach offers an alternative method of providing internal urinary diversion if retrograde ureteral indwelling stent placement has failed.

Chronic gastrointestinal bleeding from ileal varices after total proctocolectomy for ulcerative colitis: correction by mesocaval shunt

This report describes a 48-yr-old woman who had undergone proctocolectomy and ileostomy for ulcerative colitis. Subsequently, numerous episodes of bleeding via the ileostomy occurred during a 24-mo period. Despite numerous procedures, including upper gastrointestinal endoscopy, ileoscopy. celiac and superior mesenteric arteriography, and exploratory laparatomy, a bleeding site was not identified. However, a detailed arteriographic examination with special venous phase studies clearly demonstrated ileal varices. A mesocaval shunt resulted in a marked reduction in portal pressure, and the patient had experienced no recurrent bleeding over a 24-mo period. The importance of obtaining appropriate venous phase studies during arteriography is emphasized because it is critical in establishing the correct diagnosis.

Percutaneous ureteral stent placement for stricture management and internal urinary drainage

Percutaneous ureteral stent placement was attempted in nine patients with 14 ureteral lesions. Eight strictures in six patients were successfully stented. Three were subsequently converted to indwelling ureteral stents. The technique is described. No significant complications occurred. The procedure should be attempted as part of percutaneous nephrostomy for benign ureteral strictures, ureteral fistulae, or when ever long term nonoperative diversion can be useful.

Computed tomographic staging of malignant gastric neoplasms

Eight patients with proved gastric carcinoma and 3 with gastric lymphoma were studied preoperatively with computed tomography. CT accurately identified abnormal stomach wall thickening and intra-abdominal tumor extension. Mural thickening was seen on the CT scan when a moderately distended stomach had a wall more than 10 mm thick. CT was useful for assessing surgical resectability, evaluating tumor response to chemotherapy or radiotherapy, and detecting postoperative recurrence. Fourteen patients with an abnormal barium study suggesting gastric malignancy were also studied with CT, which correctly demonstrated a normal stomach or identified the reason for the abnormal barium study, such as an unusual placed spleen or a pancreatic carcinoma invading the stomach.

Preoperative determination of abdominal extent of renal cell carcinoma by computed tomography

CT scans were assessed for ability to detect abdominal extent of tumor in 17 patients with renal cell carcinoma. Computed tomography has a unique advantage over other imaging modalities in that it can distinguish between tumors confined to Gerota's fascia and those which show contiguous spread, invading adjacent structures such as muscles, liver and the periaortic and pericaval regions. CT can also detect regional lymph node metastases and tumor extension into the renal vein and inferior vena cava. Preoperative assessment of tumor extent helps to determine patient prognosis, surgical approach and whether transcatheter tumor embolization should be used.

Comparison of computed tomography and other imaging modalities in the evaluation of musculoskeletal tumors

An algorithmic approach for the evaluation of musculoskeletal tumors is proposed on the basis of a prospective comparison of different imaging techniques in 50 unselected patients. Conventional radiography was superior to other techniques in predicting the nature of primary bone tumors. Computed tomography proved the most effective method for assessing the extent of musculoskeletal tumors and therefore had a significant influence on management in 66% of patients studied. CT was more informative than angiography and also provided more anatomical detail than ultrasound. Radionuclide scanning was mainly of value in detecting unsuspected skeletal metastases in patients with apparently solitary skeletal lesions.

Computed tomographic and ultrasonic appearances of primary carcinoma of the common bile duct

Two patients with obstructive jaundice due to surgically proved primary carcinoma of the common bile duct were examined by CT and ultrasound. The combination of the two modalities showed dilatation of the extrahepatic biliary system and the main pancreatic duct. The diagnosis of primary bile duct carcinoma is suggested by these findings in the presence of a normal pancreatic head, although similar findings may occur with a small pancreatic or ampullary carcinoma.

Computed tomography in the diagnosis of renal carcinoma complicating Hippel-Lindau syndrome

Four patients on long-term follow-up for Hippel-Lindau syndrome (HLS) are presented. All had undergone nephrectomy for renal carcinoma; in 2, carcinoma subsequently developed in the remaining kidney. Because of the tendency of these tumors to develop bilaterally, wide local resection is preferable to radical nephrectomy if the tumors can be diagnosed when small and noninvasive. CT is currently the most accurate method of regularly screening patients with HLS for asymptomatic renal carcinoma.

Computed tomography in diagnosis of pelvic lipomatosis

Pelvic lipomatosis is a rare condition which may be associated with obstructive uropathy. The radiologic features may be stimulated by pelvic malignancy and, in the past, surgery has often had to be performed for confirmation of the diagnosis. A case is described in which computed tomography (CT) provided definite proof that the pelvic organ displacement was due to excessive fat. It is considered that CT may obviate the need for further workup or surgery in these patients unless exploration is required for the relief of ureteric obstruction.

Supratentorial leptomeningeal hemangioblastoma

A familial case of von Hippel-Lindau syndrome with a supratentorial leptomeningeal hemangioblastoma is reported. This is the first case in which the meningeal origin of a supratentorial hemangioblastoma has been histologically verified in von Hippel-Lindau syndrome.

Esophageal infarction complicating spontaneous rupture of the thoracic aorta

An 81-year-old man suffered a spontaneous rupture of the thoracic aorta through an atheromatous plaque, leading to total dysphagia and eventual esophageal infarction.

Some important radiological aspects of the kidney in Hippel-Lindau syndrome: the value of prospective study in an affected family

Eighty-three per cent of the affected members of a family with Hippel-Lindau syndrome had hypernephromas and cortical cysts of the kidney. Two of the asymptomatic members proved to have multiple hypernephromas by a prospective study. The carcinomas are frequently multifocal or bilateral. The cortical cysts are usually multiple, bilateral and small, and often contain carcinoma in the wall. The association of multifocal or bilateral hypernephromas with renal cortical cysts represents an important aspect of the Hippel-Lindau syndrome. The value of prospective renal studies in affected families is stressed.

Angiographic documentation of systemic-portal venous shunting as a cause of a liver scan ""hot spot'' in superior vena caval obstruction

Four patients with superior vena caval obstruction were evaluated with contrast venography and radiocolloid liver scans to investigate systemic-portal venous shunting as a cause of a liver scan "hot spot". In two of the cases a hot spot due to systemic-portal venous shunting was documented by angiography. The venous anatomy and pathophysiology related to hot spot formation on the liver scan is discussed. To develop a liver scan hot spot it appears necessary to have considerable systemic-portal venous flow through anterior parietal and periumbilical venous channels.

A practical approach to the diagnosis of abdominal aortic aneurysms

In this study 217 patients with proved abdominal aortic aneurysm were reviewed and the diagnostic accuracy of ultrasonography was assessed in comparison with physical examination, plain abdominal roentgenography, and aortography for the evaluation of patients with a suspected abdominal aortic aneurysm. Ultrasonography is most accurate in detecting an aneurysm and in defining the size of the aneurysm. Routine aortography to evaluate the renal and iliac artery is not justified in the preoperative evaluation of patients with an abdominal aneurysm since the renal artery infrequently is involved by the aneurysmal process (3.7 percent) and the surgical results are consistently successful in those patients with renal and/or iliac artery involvement. If preoperatively needed, the renal status can be evaluated accurately with an isotope renogram combined with photoscan of the kidney. A practical approach to the diagnosis of pulsatile abdominal masses is proposed.

Familial neuroblastoma presenting as multiple tumors

Multiple primary tumors are a common mode of presentation in familial neuroblastoma but must be differentiated from metastatic disease. The cases of 2 siblings with multiple neuroblastomas are presented and 44 additional cases of neuroblastoma reviewed. It was found that primary tumors localize to the posterior mediastinum, the adrenals, and the paravertebral ganglia whereas metastatic disease is found in the anterior and middle mediastinum, bones and para-aortic nodes. Based on these observations, the diagnosis of multiple primary tumors can be made and should lead to early consideration of familial neuroblastoma.

The Radiology Corner. Gastrointestinal histoplasmosis, roentgenographic, clinical and pathological correlation

Five cases with gastrointestinal histoplasmosis are presented. Gastrointestinal involvement is moderately frequent during the hematogenous dissemination of histoplasmosis. Depending on the underlying pathological changes, six roentgenographic patterns can be identified: 1. malabsorptive; 2. ulcerative; 3. polypoid; 4. granulomatous; 5. tumefactive and 6. compressive. Perforation, hemorrhage, obstruction and erroneous diagnosis for ulcerative colitis, Crohn's disease or carcinoma are the major complications. Histoplasmosis should be included in the differential diagnosis of diseases presenting with a malabsorption pattern, gastrointestinal polyposis, ulcerative and granulomatous gastrointestinal diseases and carcinoma, particularly if pulmonary lesions co-exist.