Evaluation of average amount of cerebral blood flow measured by brain perfusion index in patients with neuropsychiatric systemic lupus erythematosus

We used the brain perfusion index (BPI), an indicator of the average amount of cerebral blood flow (CBF), to evaluate the usefulness of the average amount of CBF for neuropsychiatric systemic lupus erythematosus (NPSLE). Of the seventy three SLE patients examined in this study (total 100 scans), 16 patients (23 scans) had already been diagnosed with NPSLE based on clinical symptoms indicative of central nervous system involvement. In addition, 12 patients (17 scans) exhibited the antiphospholipid antibody syndrome (APS). BPI is significantly influenced by age and we therefore used the BPI ratio (ratio of age predicted BPI to measured BPI value) for each assessment. The mean BPI value of 100 scans was 11.2 + 2.79, and the mean BPI ratio was 0.99 + 0.24 in all SLE patients. The mean BPI ratio among NPSLE (0.84 + 0.19) was significantly lower than that of the non-NPSLE patients (1.04 + 0.24) (P, 0.0005). However, there was no difference in the mean BPI ratio between APS patients (0.98 + 0.24) and non-APS patients (0.99 + 0.25). These results indicate that the mean CBF assessed by the BPI ratio using SPECT is of use in the evaluation of central nervous system involvement in SLE patients.

99mTc galactosyl human serum albumin liver dynamic SPET for pre-operative assessment of hepatectomy in relation to percutaneous transhepatic portal embolization

We have devised an original predictive residual index (PRI) using 99mTc diethylenetriaminepentaacetic acid galactosyl human serum albumin (99mTc-GSA) liver dynamic SPET for the pre-operative assessment of hepatectomy, including the prediction of residual liver function before hepatectomy. The aim of this study was to evaluate the usefulness of the PRI by using 99mTc-GSA liver dynamic SPET before and after percutaneous transhepatic portal embolization (PTPE) to induce compensatory hypertrophy of the remnant lobe, and to compare the results with the prognosis after hepatectomy. The subjects included eight patients with cholangiocellular carcinoma, five with gallbladder cancer, four with hepatocellular carcinoma and three with metastatic liver cancer. 99mTc-GSA liver dynamic SPET was performed immediately before and 2 weeks after PTPE. Dynamic SPET with 35 continuous rotations was performed to obtain the k-value according to the accumulation curve in each voxel (0.54 cm x 0.54 cm x 1.08 cm) of the liver immediately after a bolus injection of 185 MBq 99mTc-GSA. Each rotation consisted of 180 degrees turn in 64 steps in a 64 x 64 matrix. The acquisition time of each rotation was 35 s. We devised an original PRI by combining the k-value with functional liver volume which were measured by liver dynamic SPET. Hepatectomy was performed following the second SPET. The correlation between the PRI and post-operative patient prognosis was investigated retrospectively. The functional liver volume of the remnant lobe and the PRI significantly increased after PTPE compared with respective values before PTPE (P<0.005 and P<0.0001, respectively). Regarding the relationship between the PRI and the clinical course following surgery, post-operative complications were observed in only two patients. The PRI values of these two patients were 0.323 and 0.394. When the PRI was above 0.400, no patient had symptoms of hepatic failure. The results of this study suggest that, when the PRI value is above 0.400, there is a low probability of hepatic failure after hepatectomy. We conclude that the PRI devised in this study is useful in the pre-operative assessment of hepatectomy after PTPE.

Pharmacologically stimulated portal flow measurement by magnetic resonance imaging for assessment of liver function

PURPOSE

To evaluate pharmacologically stimulated portal flow measured by magnetic resonance (MR) imaging for assessment of liver function.

MATERIALS AND METHODS

Pharmacologically stimulated portal flow was measured by phase contrast MR imaging in 27 patients when they were undergoing abdominal angiography for liver tumors or gall bladder cancer. The patients included 11 cases of liver cirrhosis and eight of chronic hepatitis. Pharmacological stimulation was done by infusion of 10 microg/Kg of nicardipine hydrochloride into the superior mesenteric artery through an angiographic catheter. We examined the correlation between stimulated or non-stimulated portal flow and biochemical liver function tests.

RESULTS

Correlation coefficients and their corresponding p values between non-stimulated portal flow and the indocyanine green residual rate at 15 min after injection (ICG R15), serum albumin (ALB), total bilirubin (TB), cholinesterase (CHE), and hepaplastin test (HP) were--0.414 (0.056), 0.296 (0.134), -0.570 (0.002), 0.289 (0.153), and 0.321 (0.126), respectively, whereas those between stimulated portal flow and ICG R15, ALB, TB, CHE, and HP were--0.561 (0.007), 0.411 (0.033), -0.509 (0.007), 0.445 (0.023), and 0.494 (0.014), respectively.

CONCLUSION

Stimulated portal flow showed better correlations with biochemical liver function tests than non-stimulated portal flow. It is suggested that stimulated portal flow measurement is more useful for the evaluation of liver function than non-stimulated portal flow measurement.

[MRI phase contrast flow measurement of portal vein: influence and compensation of respiratory motion and propriety of phase correction using background]

The purposes of this study were to (1) determine which condition, breath holding (BH) or quiet breathing (QB), is better for phase contrast (PC) measurement of the portal flow (PF); (2) assess the usefulness of respiratory compensation (RC), a technique that diminishes motion artifacts due to breathing, on PC flow measurement; and (3) evaluate the propriety of phase correction (PhC) using background for PC flow measurement. For purposes (1) and (2) respiratory simulation phantom (RSP) was measured, and PF measurements were performed in 6 healthy subjects (HS) and 53 patients. Thirty of the patients had liver cirrhosis (LC) and 23 did not. For purpose (3), flow measurements were carried out in the phantom and 6 HS. (1) In 6 HS, intra-subjective coefficients of variation (CV) were smaller under QB than under BH (p < 0.05). And PF in patients with LC was less than in those not under QB (p < 0.01). This difference was not statistically significant under BH. (2) In the RSP study PC flow measurement with high sort RC showed good reliability. (3) Intraobserver variation was smaller without PhC than with PhC (p < 0.05) in the HS study. It may be more useful to perform portal flow measurements under QB with RC and without PhC than with PhC or under BH.

Index for predicting post-operative residual liver function by pre-operative dynamic liver SPET

To predict residual liver function before hepatic resection, we devised a predictive index by combining clearance values with functional liver volume measured by liver dynamic single photon emission tomography (SPET). Forty-seven patients with liver disease underwent liver dynamic SPET with 99Tcm-Sn colloid before hepatic resection. There were no operation-related deaths. Three patients died from hepatic failure more than 1 month following the operation. Their predictive indices were 0.24, 0.33 and 0.34. When the predictive index was above 0.35, no patient had symptoms of hepatic failure or died. Our data suggest that when the predictive index is above 0.35, there is a low probability of hepatic failure after hepatectomy.

Use of fluid-attenuated inversion recovery (FLAIR) pulse sequences for differential diagnosis of hepatic hemangiomas and hepatic cysts

Fluid-attenuated inversion recovery (FLAIR) imaging of hepatic hemangiomas (10 patients, 16 lesions) and hepatic cysts (8 patients, 10 lesions) was performed. All hemangiomas were hypointense on T1-weighted images and hyperintense on T2-weighted images. With Gd-DTPA (0.1 mmol/kg), all hemangiomas were enhanced but not all cysts. It was necessary to perform contrast enhanced imaging to differentiate hepatic hemangiomas from hepatic cysts. However, on FLAIR imaging, hepatic hemangiomas were strongly hyperintense and 9 of the 10 hepatic cysts were isointense. One of the hepatic cysts was slightly hyperintense. FLAIR images were useful in differential diagnosis of hepatic hemangiomas and hepatic cysts without using Gd-DTPA.

Transvenous embolization of high flow carotid cavernous fistula: a case report

We treated a patient with a high flow traumatic carotid-cavernous fistula (CCF) by embolization using detachable balloons and metallic coils, by transarterial and transvenous approaches. The patient was a 20-year-old woman who had fractures in the skull base from a traffic accident. She was admitted to our hospital one month after the accident due to exophthalmos, chemosis, and periorbital bruit. Cerebral angiograms demonstrated left traumatic CCF and steal phenomenon of blood flow. Balloon embolization by transarterial approach performed three times was unsuccessful, probably because of balloon puncture due to bone fragments. Embolization using metalic coils via the superior ophthalmic vein route was then attempted. As a result of this approach, complete obliteration of CCF was obtained, and clinical symptoms subsided within a few days. Treatment of CCF by transvenous approach is one alternative when transarterial occlusion is difficult.

[Portal embolization using lipiodol-gelatin sponge]

Gelatin sponge moistened with lipiodol was prepared for use in portal embolization to improve percutaneous transhepatic portal embolization as preoperative management of patients undergoing extensive liver resection. For one sheet of gelatin sponge (20 x 60 x 7mm)0.5ml of lipiodol was used. Five sheets cut to 2mm square pieces and mixed with physiological saline solution were injected into the right portal vein. This embolic material proved safer and more reliable than gelatin sponge mixed with water-soluble contrast medium, because it provided sufficient opacification to grasp the extent of embolization and prevented back flow.

[A basic study on gastric emptying test using barium grains and effect of drugs on gastric emptying in rats]

We reported an experimental study on a new non-invasive method for evaluation of gastric emptying by abdominal X-ray after administration of radiopaque barium grains. Adult male Wistar rats weighing around 200 g were used. After they were fasted for 24 hours, 1 ml of gruel mixed with 10 barium grains (1 mm diameter) was introduced into the rat stomach with a catheter. The rats were sacrificed at 30, 60, 90, 120 and 150 minutes after the introduction of the gruel. X-rays were taken at each time point and grains in the stomach were counted in the X-ray photographs. All barium grains were emptied from the stomach in 150 minutes. After incision of the abdomen, the residual gastric contents were weighed. A positive correlation was found between the grains in the stomach and the weight of the contents. We studied the effects of cisapride, scopolamine buthylbromide and enprostil on the gastric emptying time by this method. Cisapride accelerated gastric emptying, whereas scopolamine buthylbromide delayed it. A prostaglandin E2 analog, enprostil delayed the gastric emptying. This method was found to be a simple procedure which is outstanding for quantitative determination and useful in evaluating gastric emptying functions.

[Results of radiotherapy for stage III uterine cervical carcinomas and preliminary study of combined radiotherapy and transarterial infusion chemotherapy]

This is a retrospective analysis of 55 patients with stage III carcinoma of the uterine cervix treated with radiation from November 1984 through December 1991. Eleven of the patients were treated with radiation and transarterial infusion chemotherapy (TAI), using cis-platinum and pepleomycin. The 3- and 5-year cumulative survival rates for all patients were 61% and 58%, respectively, and the 3-year cumulative survival rate for the group with combined radiation and TAI was 47%. According to initial failure site, the locoregional recurrence rate was 36.8%, and that for para-aortic lymph node metastasis and distant metastasis was 31.6%. The failure pattern was similar between the irradiation only group and the group with combined radiation and TAI. The incidence of intestinal complications of grades 1 and 2 was 20%. Irradiation combined with TAI did not increase the incidence of complications.

[Evaluation of liver function in carbon tetrachloride-damaged rabbits by dynamic SPECT: comparison of 99mTc-GSA and 99mTc-Sn colloid]

Technetium-99m-DTPA-galactosyl human serum albumin (99mTc-GSA) is a new ligand that binds specifically to asialoglycoprotein receptors in hepatocytes. We performed liver dynamic SPECT using 99mTc-GSA and 99mTc-Sn colloid in nine normal control rabbits and 17 chronically CCI4-damaged rabbits (total 29 examinations), and also performed liver function tests (ICGR15, Alb, etc). Using the obtained dynamic SPECT data, we analyzed the liver kinetics of 99mTc-Sn colloid using a one-compartment model (hepatic blood flow [K]) and 99mTc-GSA using a two-compartment model (hepatic blood flow and receptor binding [K1], catabolism [K2]). As the CCl4-treated period increased, K1 decreased most significantly. K1 showed the most significant statistical correlation with the results of liver function tests, ICGR15 (p < 0.0001), Alb, PT, HP, Bil and GPT. Further, only K1 showed a correlation with the hepatic fibrosis of the HAI score. From the present results, liver dynamic SPECT using 99mTc-GSA may be said to provide a novel method for the evaluation of hepatic functional reserve.

[Clinical trial of IVC filter to temporary placement]

We developed a new inferior vena caval filter to prevent pulmonary embolism for a patient with IVC thrombus. This filter made by covering top half of Dotter Intravascular Retriever catheter with Dacron mesh sheet, was placed in IVC through a 10 F sheath from right jugular vein. In one case, after anticoagulant therapy and thrombectomy using balloon catheter, many free-floating thrombus were trapped in this filter and were taken out from the IVC. This filter was useful for preventing pulmonary embolism when removing thrombus in IVC, iliac and lower extremity veins. We propose to call this device "Hino's filter".

[An efficient method for quantification of Helicobacter pylori in biopsy specimen using PCR]

A procedure for the detection and quantification of Helicobacter pylori in gastrointestinal tissue biopsy specimens by polymerase chain reaction (PCR) is presented. This method provides an accurate quantitative and sensitive measurement of the amount of H. pylori in the gastrointestinal tract without cultivation of this microorganism. We have used 30 cycles of PCR in the presence of 3.5mM Mg++ and demonstrated that the DNA content of one H. pylori cell is 0.0076pg. Using this approach, we analyzed samples of gastrointestinal tissue biopsies from 10 patients with various gastrointestinal disorder. Each of these patients had detectable H. pylori at levels ranging from 0.10 to 60.61 cells for each tissue cell. This new technique thus provides a useful way to detect H. pylori in gastrointestinal tissue biopsy specimens.

[A case of pseudoinfarct of the liver (Zahn's infarct)]

We reported a case of pseudoinfarct (Zahn's infarct) of the liver caused by the inflammatory pseudotumor. A dense segmental staining in the area of Zahn's infarct, which was thought to be characteristic finding, was found on the hepatic angiography. This finding was supposed to be consistent with sinusoidal hyperemia according to the pathological finding.

A kinetic study on secretion and elimination of endogenous thyrotropin in the thyrotropin-releasing hormone test

Serum thyrotropin (TSH) concentrations in normal young men were measured by a high-sensitivity immunoradiometric assay before and after intravenous administration of 500 micrograms of TSH-releasing hormone (TRH). A kinetic model was applied to evaluate the secretion rate both before (V0) and after (V0 + V* at maximum rate) the administration of TRH, the elimination constant (K), the latent time (L) between TRH administration and start of the stimulated secretion, and the total amount of TSH (T) released in response to TRH. V0, V* and T varied widely from individual to individual, but correlated well with TSH before TRH administration (r = 0.93, 0.80 and 0.87, respectively). A few minutes (1.89 +/- 1.30 min) after the administration of TRH, the secretion of TSH (0.025 +/- 0.016 microU/min ml) was stimulated, and the total release over about 1 h was 12.5 +/- 5.6 microU/ml. Serum TSH was maximum at 31.5 +/- 5.7 min. The half-time of disappearance of TSH was 42 +/- 9 min. These data confirm that the stimulated secretion continues for more than 30 min, and that the pituitary releases 43.2 +/- 22.9 mU of TSH (assuming the distribution volume of TSH is 5.8% of body weight) in response to TRH, an amount which correlates closely (r = 0.91) with TSH before TRH administration.

[Scintigraphic estimation of dearterialization after transcatheter hepatic arterial embolization therapy]

Radionuclide angiography was performed by bolus injection of 99mTc-phytate in 10 patients with liver neoplasms before and after the transcatheter hepatic arterial embolization therapy. The ratio of the slopes of the upstrokes for the hepatic arterial and abdominal aortic first transit curves constitutes the regional hepatic arterial to aortic blood flow ratio (RHA/A ratio), which represents quantitatively the arterial blood flow of hepatic region of interest as a fraction of aortic blood flow. The degree of embolic dearterialization was estimated by the change of this ratio derives from the same region of interest for each patient before and after the embolization. The values and post-embolic reduction of the ratio correlated well individually with the angiographic features and other patients' data. The arterial blood supply to the tumor could not be reducted using Lipiodol alone as the embolic material in only 1 case. The finding that the splenic arterial to aortic blood flow ratio (S/A ratio), calculated in the same way, was practically unchanged after the hepatic arterial embolization indicates the good reproducibility of these measurements. This noninvasive method may be helpful to evaluate the therapeutic effect of hepatic arterial embolization.

[Ultrasonographic diagnosis of mild fatty infiltration of the liver with the difference between liver and kidney echolevels]

At the same dynamic range (DR) a constant difference of echolevels was found between two materials with different acoustic impedance in any gain-setting by the phantom study. Our retrospective study in which we compared the difference between liver-kidney echolevels with the US-findings of fatty liver indicated that the difference over 10 in echoleveled by our equipment with 3.5 MHz phased array sector scan and 42 dB DR had a possibility of the fatty infiltration of the live. In our prospective study of 1452 abdominal US-studies we found 93 cases (6.5%) with the difference over 10 in echolevel. In all these patients the difference of liver-spleen CT-numbers and liver-kidney echolevels was compared. Although the liver CT-number is normally higher than the spleen, 75 of 93 patients showed the lower liver CT-number than that of the spleen, indicating fatty infiltration of the liver. The abnormal difference of echolevels were independent from the severity of fatty infiltration. Concerning the US-findings, "bright liver" (77.4%) and "masking sign" (66.7%) were more sensitive than "vascular blurring" (44.1%) and "deep attenuation" (44.1%). But for the severe fatty infiltration with the difference over -20 H.U. between liver-spleen CT numbers, the last two findings seemed very credible. The abnormal difference between liver-kidney echolevels was most sensitive (80.7%), especially in mild cases with 0 to -19 H.U. (53 in 75 cases), and very objective than the other US-findings.

[An evaluation of predicting postoperative residual liver function using 99mTc tin colloid]

The rate of clearance (K value) of 99mTc tin colloid in the liver differentiates normal subjects from liver cirrhosis patients; so 99mTc tin colloid is as useful as 198Au colloid as a marker of liver function. There are several reports concerning volume estimation using liver scintigraphy. Our original method was devised to measure the effective liver volume by scintigraphy. By combining the K value with effective liver volume, a predictive index was obtained in order to predict the residual liver function before hepatic resection. The index in 24 patients with liver diseases was investigated before hepatic resection. Three of them died due to hepatic failure after hepatic resection. The indices were between 0.40 and 0.45 in two of these three patients and 0.338 in one. Among the patients without hepatic failure, the indices showed more than 0.45 in 19 patients and between 0.40 and 0.45 in two. These results indicate that the limitation of hepatic resection is between 0.40 and 0.45 of the predictive index.

[Evaluation of pN factors in patients with primary lung cancer by using perfusion, inhalation and ventilation studies]

The interpretation of scintigraphic patterns and the role of pathophysiological mechanisms in patients with primary lung cancer were investigated. To determine the relative roles of perfusion, inhalation and ventilation scintigraphy, the relationship between the count ratio of the affected side to the healthy side and the post-surgical histological lymph nodes factors were observed in this study. These scintigraphic count ratio's in patients with primary lung cancer did not reflect the pN factors except in the perfusion study in patients with hilar primary lung cancer.

[Evaluation and comparison of high-sensitivity immunoradiometric assay kits for thyroid stimulating hormone]

Fundamental and clinical characteristics of 3 kinds of high-sensitivity immunoradiometric assay (IRMA) kits for thyroid stimulating hormone (TSH). i.e., RIA BEADS II (kit A), TSH kit Daiichi II (kit B) and Ab tube TSH 'Eiken' (kit C) and one conventional radioimmunoassay (RIA) kit, i.e., TSH kit Daiichi (kit D), were studied. In the recovery test and the reproducibility test, there was no significant difference between the 4 kits. The sensitivities of kits A, B and C were much higher than that of kit D, and those IRMA kits were sensitive enough to distinguish hyperthyroidism from normal samples. For low concentrations of TSH (less than 5 microU/ml), the data from kits D, B, C and A tended to show higher values in that order. The correlation between the data measured by kits B and D, and the tendency of kit A toward lower values agreed well with other reports.

[Intraarterial Adriamycin for patients with hepatocellular carcinoma and metastatic liver carcinoma]

Six patients with hepatocellular carcinoma (HCC) and 9 patients with metastatic liver carcinoma (MLC) (4 with stomach cancer, 4 with pancreas cancer and 1 with colon cancer) were treated with rapid hepatic artery infusion of adriamycin. Partial response was obtained in 3 patients (44%) with HCC and 2 patients (22%) with MLC. The median survival time was 6 months in HCC patients and 8 months in MLC patients. Patients with elevated serum alkaline phosphatase or those with ascites were poorly prognostic. Myelosuppressive toxicity was seen frequently, but, no life-threatening complications occurred. Other toxicities were generally mild and well tolerated. These results indicated that hepatic artery infusion of adriamycin is a useful treatment modality in the management of both HCC and MLC.

[An evaluation of radioactive colloid for measuring the volume of effective liver]

A methods for liver scintigraphy for finding the effective liver volume were developed. Matrix ROI (region of interest) was set on the anterior liver scintigram with 99mTc tin colloid and 198Au colloid, respectively. The various depths of liver under matrix ROI were calculated from the count rate noting the absorption coefficient. The effective liver volume was the sum total of the areas of matrix ROI to the various depths. In order to check the accuracy of this method, the effective liver volume was calculated using the liver phantom and the patient's liver scintigraphy. The volume obtained for the liver phantom was nearly equal to the real volume. The liver volume in 19 patients using 99mTc tin colloid and 198Au colloid showed good correlation with the volume as measured by computed tomography (CT) scan (r = 0.841, r = 0.749).

Perfusion, inhalation, and ventilation studies in patients with primary lung carcinoma

To determine the relative roles of perfusion, inhalation, and ventilation lung scintigraphy, studies were done respectively in 48, 50, and 34 of 54 primary lung carcinoma patients (prior to thoracotomy and subsequent radical tumor resection). We observed the relationships between both the size of perfusion, inhalation, and ventilation defects observed scintigraphically, and the size of the mass lesion seen radiologically. We also estimated the correlation between those scintigraphic classifications and pTN. Although inhalation and perfusion images exhibited similar patterns, in hilar type lung carcinoma patients, the inhalation study showed superior mass lesion delineation. In peripheral type lung carcinoma, however, the incidence of negative inhalation defect (52%) differed significantly from that of negative perfusion defect (21%) (p less than 0.05). Xe-133 gas ventilation has limitations but is occasionally helpful in detecting obstructive airway disease. The coexistence ratio of COPD in lung carcinoma patients showed no significant difference from that of COPD in the controls. Perfusion and inhalation classification did not correlate with pTN factor.

Double aortic arch with aneurysm-a surgical case report

An unusual case of double aortic arch with aneurysm is described. A 61-year-old, hypertensive and syphilitic male patient complained of increasing difficulty in swallowing of approximately five months duration. Barium swallow and subsequent aortography showed the presence of an aneurysm of the ascending aorta involving the left (anterior) arch of the double aortic arch. The tightening of the vascular ring by aneurysmal dilatation of the left aortic arch appeared to be responsible for the delayed onset of the symptom. Surgical correction was made by removing the aneurysmal ascending aorta and left aortic arch and a Dacron graft was inserted between the ascending aorta and the right (posterior) aortic arch. The patient died of cerebral complication about forty hours postoperatively. Surgical problems associated with this unusual condition were discussed retrospectively from the operative and autopsy findings. In reviewing the pertinent literatures this case appeared to be the first operated case of double aortic arch associated with aneurysm.