Case Report: Radiographic Identification of Intrapleural Misplacement of Epidural Catheter in an Intubated Post-Lung Transplant Patient

Intrapleural misplacement of epidural catheter is a rare complication of thoracic epidural placement, which can be difficult to detect in intubated patients with unreliable pain reports and hemodynamic response to the test dose. We describe a case of intrapleural misplacement of thoracic epidural in a 50-year-old man status-post bilateral lung transplant and highlight the use of radiographic techniques to identify the misplacement.

[Characteristics and predictors of postoperative outcome of Crohn disease patients requiring abdominal surgery: a series of 1 048 cases from a single inflammatory bowel disease centre]

Objective: To examine the clinical characteristics, the potential relative factors for postoperative abdominal septic complications, and prognosis factors of surgical recurrence of Crohn disease (CD) patients after the first surgery. Methods: All the CD patients from Department of General Surgery, Jinling Hospital, Medical School of Nanjing University who had undergone at least one abdominal surgery from January 2007 to December 2017 were included for retrospective analysis. Hospital records were reviewed for information on clinical characteristics. Relative factors of postoperative abdominal septic complications were accessed by Logistic regression models, and prognosis factors of surgical recurrence were accessed by Cox proportional hazards regression models. Results: There were 1 048 patients included (733 males and 315 females), accounting for 1 513 operations. The age was 31(17) years and the length of resected small bowel was 30.0(40.0) cm at the first resection, 20.0(35.0) cm at the second resection, and 20.0(23.5) cm at the third resection. The length of resected small bowel was 25.0(40.0) cm at any resection. At the first abdominal surgery, 70.99%(744/1 048) patients were aged between 17 and 40 years, 66.98%(702/1 048) patients had ileocolonic disease, and 60.40%(633/1 048) patients had penetrating behavior. Penetrating behavior (OR=8.594, 95%CI: 3.397 to 21.740, P<0.01) and current smoking status (OR=2.671, 95%CI: 1.044 to 6.832, P=0.040) were significantly associated with an increased risk of postoperative septic complications, whereas staged operation (OR=0.360, 95%CI: 0.184 to 0.707, P=0.003) was associated with a decreased risk. Male gender (HR=1.500, 95%CI: 1.128 to 1.995, P=0.005), upper gastrointestinal disease (HR=1.526, 95%CI: 1.033 to 2.255, P=0.034), penetrating behavior (HR=1.506, 95%CI: 1.132 to 2.003, P=0.005) and emergency surgery (HR=1.812, 95%CI: 1.375 to 2.387, P<0.01) were significantly associated with an increased risk of postoperative surgical recurrence, whereas staged operation (HR=0.361, 95%CI: 0.227 to 0.574, P<0.01) was significantly associated with a decreased risk. Conclusions: In this cohort of CD patients receiving abdominal surgery from an inflammatory bowel disease center, the median age was 31 years and the median length of resected small bowel was 30 cm, at first resection. Patients who have risk factors of adverse postoperative outcome may be benefited from staged surgical approach.

Post-operative assessment in patients after liver transplantation: imaging parameters associated with 1-year graft failure

PURPOSE

To identify post-liver transplant CT findings which predict graft failure within 1 year.

MATERIALS AND METHODS

We evaluated the CT scans of 202 adult liver transplants performed in our institution who underwent CT within 3 months after transplantation. We recorded CT findings of liver perfusion defect (LPD), parenchymal homogeneity, and the diameters and attenuations of the hepatic vessels. Findings were correlated to 1-year graft failure, and interobserver variability was assessed.

RESULTS

Forty-one (20.3%) of the 202 liver grafts failed within 1 year. Graft failure was highly associated with LPD (n = 18/25, or 67%, versus 15/98, or 15%, p < 0.001), parenchymal hypoattenuation (n = 20/41, or 48.8% versus 17/161, or 10.6%, p < 0.001), and smaller diameter of portal veins (right portal vein [RPV], 10.7 ± 2.7 mm versus 14.7 ± 2.2 mm, and left portal vein [LPV], 9.8 ± 3.0 mm versus 12.4 ± 2.2 mm, p < 0.001, respectively). Of these findings, LPD (hazard ratio [HR], 5.43, p < 0.001) and small portal vein diameters (HR, RPV, 3.33, p < 0.001, and LPV, 3.13, p < 0.05) independently predicted graft failure. All the measurements showed fair to moderate interobserver agreement (0.233~0.597).

CONCLUSION

For patients who have CT scan within the first 3 months of liver transplantation, findings of LPD and small portal vein diameters predict 1-year graft failure.

KEY POINTS

•Failed grafts are highly associated with liver perfusion defect, hypoattenuation, and small portal vein. •Right portal vein < 11.5 mm and left portal vein < 10.0 mm were associated with poor graft outcome. •Liver perfusion defect and small portal vein diameter independently predicted graft failure.

CT findings of severe burn injuries after a motor vehicle collision: a case report

Severe burn injuries can complicate management of polytrauma. While CT is the primary imaging modality for evaluation of trauma injuries, CT findings of severe burn are rarely reported. A 31-year-old female was brought to the emergency department after motor vehicle collision in which she sustained a burn injury from contact with the vehicle muffler. Her initial trauma workup was notable for full-thickness burns to her left abdominal wall among other injuries. CT scan showed skin thickening and extensive stranding involving the whole layer of subcutaneous soft tissue. The deep fascia and underlying muscle layer were free from burn injuries. Identification of this finding on the CT scan helps establish appropriate care.

The Role of Noncontrast CT in the Evaluation of Surgical Abdomen Patients

Acute surgical abdomen is commonly encountered in the ED and CT is widely used as an informative diagnostic tool to evaluate potential surgical indications. However, the adverse effects of contrast material used in CT scanning have been documented. We sought to delineate the role of noncontrast CT in the evaluation of patients with acute surgical abdomen. Between August 2015 and December 2015, patients with nontraumatic surgical abdomen who underwent preoperative CT were enrolled in the current study. The patients for whom the CT results permitted surgical decision-making were the focus of this study. The disease entities included acute appendicitis, acute cholecystitis, hollow organ perforation, mechanical bowel obstruction, intra-abdominal abscess that could not be drained percutaneously, and ischemic bowel disease. The results of contrast-enhanced and noncontrast CT were compared and analyzed. The surgical conditions identifiable by noncontrast CT were recorded. In total, 227 patients were enrolled in the study. In 90.7 per cent of patients overall, the findings indicating the need for surgical treatment were visualized on both the noncontrast and contrast-enhanced images (acute appendicitis: 89.3%, acute cholecystitis: 89.7%, hollow organ perforation: 97.4%, bowel obstruction: 100%, intra-abdominal abscess: 100%, and ischemic bowel disease: 55.6%). Noncontrast CT provides benefit for critical decision-making. Body mass index may affect the accuracy of noncontrast imaging in the evaluation of patients with surgical abdomen. In some specific situations, contrast enhancement remains necessary.

The Role of Noncontrast CT in the Evaluation of Surgical Abdomen Patients

Acute surgical abdomen is commonly encountered in the ED and CT is widely used as an informative diagnostic tool to evaluate potential surgical indications. However, the adverse effects of contrast material used in CTscanning have been documented. We sought to delineate the role of noncontrast CT in the evaluation of patients with acute surgical abdomen. Between August 2015 and December 2015, patients with nontraumatic surgical abdomen who underwent preoperative CT were enrolled in the current study. The patients for whom the CT results permitted surgical decision-making were the focus of this study. The disease entities included acute appendicitis, acute cholecystitis, hollow organ perforation, mechanical bowel obstruction, intra-abdominal abscess that could not be drained percutaneously, and ischemic bowel disease. The results of contrast-enhanced and noncontrast CT were compared and analyzed. The surgical conditions identifiable by noncontrast CT were recorded. In total, 227 patients were enrolled in the study. In 90.7 per cent of patients overall, the findings indicating the need for surgical treatment were visualized on both the noncontrast and contrast-enhanced images (acute appendicitis: 89.3%, acute cholecystitis: 89.7%, hollow organ perforation: 97.4%, bowel obstruction: 100%, intra-abdominal abscess: 100%, and ischemic bowel disease: 55.6%). Noncontrast CT provides benefit for critical decision-making. Body mass index may affect the accuracy of noncontrast imaging in the evaluation of patients with surgical abdomen. In some specific situations, contrast enhancement remains necessary.

Comparison of hepatocellular carcinoma conspicuity on hepatobiliary phase images with gadoxetate disodium vs. delayed phase images with extracellular cellular contrast agent

OBJECTIVE

To compare the conspicuity of hepatocellular carcinoma (HCC) on hepatobiliary phase of gadoxetate disodium-enhanced vs. delayed phase of gadodiamide-enhanced MR images, relative to liver function.

METHODS AND MATERIALS

We retrospectively identified 86 patients with newly diagnosed HCC between 2010 and 2013 and recorded the severity of liver disease by Child-Pugh class (CPC). 38 patients had gadodiamide-enhanced 5-min delayed and 48 had gadoxetate disodium-enhanced 20-min delayed hepatobiliary MR images. The conspicuity of 86 HCCs (mean size, 2.7 cm) was graded visually on a 3-point scale and quantified by liver-to-tumor contrast ratios (LTC). The relative liver parenchymal enhancement (RPE) was measured. For different CPCs, we compared the conspicuity of HCC and RPE between gadodiamide and gadoxetate.

RESULTS

In patients with CPC A, the visual conspicuity and LTC of the 27 HCCs imaged with gadodiamide were significantly lower than those of the 38 HCCs with gadoxetate (P < 0.01, <0.01, respectively). RPE was lower in gadodiamide scans than gadoxetate scans (P < 0.01). Conversely, in patients with CPC B and C, HCCs appeared more frequently as definite hypointensity when imaged with gadodiamide (72.7%, 8/11) than gadoxetate (20%, 2/10, P = 0.03). LTC (mean 18.1 vs. 7.5, P = 0.04) and RPE (mean 75.5 vs. 45.4, P = 0.04) was significantly higher in the gadodiamide than gadoxetate scans.

CONCLUSION

In patients with compromised liver function, hypointensity of HCC is more conspicuous in the gadodiamide delayed phase than the gadoxetate hepatobiliary phase. This likely reflects the high extracellular accumulation of gadodiamide and poor hepatocyte uptake of gadoxetate in patients with compromised liver function.

Troubleshooting Arterial-Phase MR Images of Gadoxetate Disodium-Enhanced Liver

Gadoxetate disodium is a widely used magnetic resonance (MR) contrast agent for liver MR imaging, and it provides both dynamic and hepatobiliary phase images. However, acquiring optimal arterial phase images at liver MR using gadoxetate disodium is more challenging than using conventional extracellular MR contrast agent because of the small volume administered, the gadolinium content of the agent, and the common occurrence of transient severe motion. In this article, we identify the challenges in obtaining high-quality arterial-phase images of gadoxetate disodium-enhanced liver MR imaging and present strategies for optimizing arterial-phase imaging based on the thorough review of recent research in this field.

CT-guided core needle biopsy of deep suprahyoid head and neck lesions in untreated patients

This study aimed to evaluate the efficacy of CT-guided core needle biopsy (CNB) in the diagnosis of deep head and neck tumors in untreated patients. We retrospectively reviewed the records of ten consecutive CT-guided CNB procedures from ten patients without a related history from March 2004 to February 2012. The surgical results, treatment response and clinical follow-up were used as the diagnostic standards. All specimens were considered adequate. Nine out of ten cases matched the final diagnosis. Biopsy failed to diagnose the infratemporal meningioma en plaque in a particular case. Three cases were carcinomas. No complication was encountered. CT-guided core needle biopsy is an efficient and safe technique for histological diagnosis of skull base lesions in patients without a related history. This technique can offer a definite tissue diagnosis and avoid unnecessary surgical interventions for such patients.

CT-guided core needle biopsy of deep suprahyoid head and neck lesions

Objective

To evaluate the efficacy of computer tomography (CT)-guided core needle biopsy (CNB) in the diagnosis of deep suprahyoid lesions in patients with treated head and neck cancers.

Materials and Methods

Between December, 2003 and May, 2011, 28 CT-guided CNBs were performed in 28 patients with deep suprahyoid head and neck lesions. All patients had undergone treatment for head and neck cancers. Subzygomatic, paramaxillary, and retromandibular approaches were used. The surgical results, response to treatment, and clinical follow-up were used as the diagnostic reference standards.

Results

All biopsies yielded adequate specimens for definitive histological diagnoses. A specimen from a right parapharyngeal lesion showed atypia, which was deemed a false negative diagnosis. Diagnostic accuracy was 27/28 (96.4%). Two minor complications were encountered: a local hematoma and transient facial palsy. Between the 18 or 20 gauge biopsy needles, there was no statistical difference in the diagnostic results.

Conclusion

CT-guided core needle biopsy, with infrequent and minor complications, is an accurate and efficient method for the histological diagnosis of deep suprahyoid lesions in post-treated head and neck cancer patients. This procedure can preclude an unnecessary surgical intervention, especially in patients with head and neck cancers.

Diagnostic efficacy of ultrasonography-guided fine needle aspiration biopsy in evaluating salivary gland malignancy

BACKGROUND

Salivary gland masses constitute a diagnostic challenge in daily clinical practice and tissue sampling is required to establish a diagnosis. We aimed to evaluate the efficacy of ultrasonography-guided fine needle aspiration biopsy (UGFNAB) in the diagnosis of salivary gland lesions.

METHODS

From January 2007 to September 2010, a total of 158 patients who underwent both UGFNAB and surgical excision for salivary gland mass lesions were included in this study. Patients with insufficient sampling or inconclusive cytology diagnosis were excluded from the analysis of diagnostic accuracy of UGFNAB.

RESULTS

UGFNAB yielded sufficient sampling for analysis in 137 patients, leading to a diagnostic yield of 86.7%. Among these 137 patients, 24 patients were confirmed to have malignant tumors. The sensitivity, specificity and accuracy of UGFNAB for malignancy were 66.7%, 98.2%, and 92.7%, respectively. No UGFNAB-related complications were encountered.

CONCLUSIONS

UGFNAB of salivary gland masses is a safe technique that offers high specificity and accuracy but moderate diagnostic yield and sensitivity.

Aerosolized vancomycin therapy facilitating nursing home placement

OBJECTIVE

To demonstrate a novel method of eliminating nasopharyngeal colonization by methicillin-resistant Staphylococcus aureus (MRSA) in a debilitated, hospitalized patient.

DESIGN

Single-patient, nonblind, nonplacebo, case study.

SETTING

Community hospital, Brooklyn, NY.

PATIENT

Hospitalized patient with recalcitrant nasopharyngeal MRSA colonization that could not be eliminated by conventional therapeutic interventions.

INTERVENTIONS

Aerosolized vancomycin hydrochloride 120 mg q6h administered in room air via face mask together with vancomycin nasal drops, 2 drops to each nostril q6h.

MAIN OUTCOME MEASURE

Elimination of MRSA from the nasopharynx of the patient.

RESULTS

Successful elimination of MRSA colonization after four days of therapy.

CONCLUSIONS

Aerosolized vancomycin in combination with vancomycin nasal drops is beneficial in eliminating nasopharyngeal colonization by MRSA. Clinical trials are warranted to confirm this clinical observation.

Pulmonary artery involvement in aorto-arteritis. An analysis of DSA

Angiographic features of the pulmonary artery were studied in 24 patients with aortoarteritis (Takayasu's arteritis) by digital subtraction angiography. The pulmonary artery involvement was found in nine cases (37.5%). The right side was involved in eight and the left side in five cases. The right pulmonary artery was involved in two cases, the lobar artery in six, the segmental artery in six, and subsegmental as well as peripheral branches in four. The angiographic features were stenosis and/or occlusion as were the changes of the systemic arteries in aorto-arteritis. The aorta and its main branches were involved in all nine patients, but the severity of pulmonary vascular changes was not always related to the systemic vascular changes. Bronchial angiography demonstrated enlarged and tortuous bronchial arteries in four cases. Lung ECT revealed abnormalities in four cases.

Dynamic CT scan of intracranial tumors

Of ninety-eight patients with intracranial tumors examined by dynamic CT scanning, 66 were confirmed operatively and pathologically. Our study showed that: 1) Dynamic CT can be performed safely and easily in outpatients; 2) Acoustic neurinoma, meningioma, pituitary chromophobe adenoma, astrocytoma and metastatic tumor have varying levels of time-density curves; 3) The tissue-blood ratio (TBR) at peak time (TBRp) is a useful indicator of the vascularity of tumoral tissues, and analysis of the time-density curve combining with TBRp is helpful to the differential diagnosis of tumors; 4) Differential diagnosis between tumors and vascular abnormalities such as aneurysm and arteriovenous malformation could be made easily with dynamic CT.

[Preliminary investigation on dynamic CT scan of intracranial tumors]

74 patients with various intracranial tumors were studied by means of dynamic CT, among them 45 cases were confirmed by operation and pathology. In analyzing the time-density curve and the ratio of increase in CT number of the tumoral tissue to that in the arterial lumens (tissue-blood ratio, TBR), we found that: (1) Dynamic CT technique is safe and easy to perform suitable for out-patients; (2) The time-density curves in acoustic neurinoma, meningioma, glioma and metastatic tumors are different from each other because of difference in vascularity and the degree of B.B.B. breakdown. Meningioma curve shows a rapid rise to the peak followed by a subsequent plateau; (3) TBR at the peak time (TBRp) is useful as an index for tumor. Combined analysis of time-density curve and TBRp is helpful for tumor differentiation.

Osteoporosis--an early radiographic sign of endemic fluorosis

Radiological investigation of skeletal fluorosis was carried out among the inhabitants from two areas where the fluoride content of water was high, using both conventional radiography and radiographic measurements of bone mineral content (BMC). Of 139 cases in the first group, 68 presented bone abnormalities while 21 of 54 cases in the second group showed a similar change. Four essential types of bony lesion were classified. Osteoporosis, especially in the long bones, was the earliest change to be observed. The results of measurements at the distal end of the ulna indicated the presence of a low BMC even among inhabitants with a good nutritional status. It is concluded that osteoporosis towards the ends of long bones is an early radiographic sign of endemic fluorosis especially in an individual under the age of 40 years.

CT in diagnosis of acoustic neuromas

A detailed analysis of the CT findings in 75 cases of acoustic neuroma is presented. The method of examination included plain and enhanced CT, metrizamide CT cisternography (M-CTC), and gas CT cisternography (gas-CTC). The common CT appearances of acoustic neuromas were as follows: 93.6% appeared as isodense or hypodense on precontrast scan; homogeneous enhancement was observed in 53.8% on postcontrast scan; the tumor center, mostly located at the level of the internal acoustic canal, was spherical in shape with an acute angle between the lateral tumor border and petrous bone; and there was widening of the internal acoustic canal or destruction of petrous bone. However, the presence of an acoustic neuroma could not be excluded if widening of the internal acoustic canal was absent. It was not certain whether contrast filling of the internal acoustic canal occurred at M-CTC in the four cases so examined. One case of intracanalicular neuroma was diagnosed by gas-CTC, which is the most sensitive and reliable technique for detecting and excluding small tumors. The significance of various CT appearances, early diagnosis, and differential diagnosis of acoustic neuroma from other cerebellopontine-angle tumors, particularly meningioma, are discussed.