John G. Murray

Arterial occlusion in the management of pain from metastatic renal carcinoma.

Arterial embolization was performed in nine patients with metastases from renal carcinoma who had severe pain resistant to conventional therapy. Patients with metastases in the ilium (four), the lumbosacral spine (one), and the base of the skull (one) experienced pain relief lasting from one to six months. The other three patients, who had metastases in the proximal femur, underwent preoperative embolization to facilitate tumor curettage and internal hip fixation. No significant complications were seen with this therapeutic approach.

MR Venography with True Fast Imaging with Steady-state Precession for Suspected Lowerlimb Deep Vein Thrombosis

PURPOSE To compare true fast imaging with steady-state precession (FISP) magnetic resonance (MR) venography for suspected deep vein thrombosis (DVT) with contrast agent-enhanced venography. MATERIALS AND METHODS This was a prospective study of randomly selected patients with a clinical suspicion of DVT of the lower limb. Standard contrast venography was performed and compared with MR venography from the inferior vena cava to the feet in 24 patients with use of true FISP sequences (repetition time, 3.74 msec; echo time, 1.8 msec). Two radiologists independently read the MR venography and contrast venography studies. Segment visibility, secondary signs of DVT, and additional diagnoses were noted. RESULTS MR venography demonstrated all venous segments in the pelvis and thigh. When results were analyzed on a per-patient basis, there was good agreement between contrast venography and MR venography (kappa = 0.64; 95% CI, 0.33-0.94; P = .0001). When the venous system was analyzed on a segmental basis, there was very good agreement between contrast venography and MR venography (kappa = 0.81; 95% CI, 0.68-0.94; P = .0001). The sensitivity and specificity for DVT detection were 100% for the iliac and popliteal segments and 100% and 98%, 68% and 94%, and 87% and 98%, respectively, for the femoral, below-knee, and all veins. Eleven of 14 patients without DVT had an alternative diagnosis suggested by MR venography. CONCLUSIONS MR venography with axial true FISP allows noninvasive rapid diagnosis of acute DVT in the iliac, femoral, popliteal, and calf muscle veins. MR venography is much less reliable in the tibial or peroneal veins. It may demonstrate a nonvenous cause of a patients symptoms.

Multiple Myeloma: A Review of Imaging Features and Radiological Techniques

The recently updated Durie/Salmon PLUS staging system published in 2006 highlights the many advances that have been made in the imaging of multiple myeloma, a common malignancy of plasma cells. In this article, we shall focus primarily on the more sensitive and specific whole-body imaging techniques, including whole-body computed tomography, whole-body magnetic resonance imaging, and positron emission computed tomography. We shall also discuss new and emerging imaging techniques and future developments in the radiological assessment of multiple myeloma.

Transjugular liver biopsy: assessment of safety and efficacy of the Quick-Core biopsy needle

AbstractBackground: We assessed the safety and efficacy of transjugular liver biopsy with the Quick-Core biopsy needle. Methods: Fifty consecutive patients with liver failure and contraindications to percutaneous liver biopsy were referred for transjugular liver biopsy. Eighteen (36%) patients had thrombocytopenia (platelet range = 44–92/μL, mean = 66/μL), 31 (62%) patients had elevated prothrombin times (international normalized ratio range = 1.3–3, mean = 1.6), and 19 (38%) patients had ascites. The Cook Quick-Core biopsy needle was used. Results: Average procedure time was 30 min. Transjugular access to the hepatic veins was successful in 49 of 50 cases. A transfemoral approach was used in one patient. Tissue specimens were satisfactory for histologic diagnosis in all cases. Established cirrhosis was present in 37 (74%) patients. The mean number of cores was 2.2 (range = 1–3). The mean number of portal triads per core was 10.4 (range = 6–20). There were no procedure-related complications. Conclusion: Transjugular liver biopsy with the Quick-Core biopsy needle is safe and effective in patients in whom the percutaneous route is contraindicated by coagulopathy or ascites.

Steady-state free-precession (SSFP) cine MRI in distinguishing normal and bicuspid aortic valves.

To assess the diagnostic sensitivity and specificity of double‐oblique true fast imaging with steady‐state precession (SSFP) cine MRI in distinguishing normal and bicuspid aortic valves.

Bile duct hamartomas (von Meyenburg complexes): value of MR imaging in diagnosis.

Abstract. We present a case of a patient initially believed to have multiple liver metastases based on ultrasound and computed tomography findings in whom a diagnosis of multiple bile duct hamartomas (von Meyenburg complexes) was indicated after ultrasound-guided liver biopsy. Magnetic resonance imaging aided greatly in confirming the diagnosis of von Meyenburg complexes, thereby avoiding laparotomy and open liver biopsy.

The application of a clinical risk stratification score may reduce unnecessary investigations for pulmonary embolism in pregnancy

Objective: To examine the use of the modified Wells score in pregnancy as a risk stratification tool in the diagnosis of pulmonary embolism (PE). Methods: All pregnant or post-partum patients who were referred for CT Pulmonary Angiography (CTPA) to evaluate suspected PE over a 5-year period were included in the study. Patient records were used to apply the modified Wells score (MWS) and analyze their risk of PE. Results: A total of 125 women were referred for CTPA over 5 years. A MWS of 6 or greater (“High Risk”) was 100% sensitive and 90% specific with a positive predictive value of 36% for PE on CTPA. No patients with a low MWS (less than 6) had a PE, giving a negative predictive value of 100%. p ≤ 0.001. D-dimers, chest X-ray, blood gases and EKG were significantly less effective than the MWS in aiding the diagnosis of PE. Conclusion: Current methods employed for the diagnosis of PE are inadequate. Risk stratification using the MWS may allow safe exclusion of PE before resorting to CTPA. To the best of our knowledge this is the first study to have used the MWS in a pregnant patient group.

Transrectal ultrasound-guided biopsy of the prostate gland: value of 12 versus 6 cores

Abstract We investigated the effect on prostate carcinoma detection of 12 versus 6 core biopsies at transrectal ultrasound (TRUS), when all biopsies are taken from the lateral peripheral zone. This was a prospective study of 202 consecutive men, ages 51 to 81 years, referred for TRUS-guided biopsy of the prostate gland. All patients had prostate serum antigen levels higher than 4.0 ng/mL and/or abnormal digital rectal examination. In each case three biopsies were taken from the peripheral zones of the right and left lobes of the prostate. Biopsies were taken at the apex, midway between the apex and the base, and at the base. A second set of biopsies was taken from the same regions and analyzed separately. In total, twelve biopsies were taken. Note was subsequently made of additional carcinoma diagnosis increase in Gleason grade, and new diagnoses of carcinoma in the opposite side of the gland diagnosed on the second set of biopsies alone. Seventy-eight of the 202 men (38.6%) had prostatic carcinoma diagnosed on TRUS-guided biopsy. Of these 78 patients, six were diagnosed with malignancy based on the second set of biopsies alone, a 2.9% increase in the 202 patients, representing an increased yield of 8.3% (95% confidence interval, 5.3–28.6%). In nine cases (12.5%; 95% confidence interval, 6.2–22.9%), the Gleason tumor grade was increased on the second set of sextant biopsies; in an additional nine cases, carcinoma was detected in the opposite side of the gland. There were two complications (1%). A 12- versus six-core biopsy strategy for TRUS-guided biopsy of the prostate gland improves detection and histologic grading of prostate carcinoma. The added benefit of additional biopsies was lower in this series than in some prior studies using extensive biopsy protocols.

Giant distal humeral geode.

Abstract We describe the imaging features of a giant geode of the distal humerus in a patient with rheumatoid arthritis, which presented initially as a pathological fracture. The value of magnetic resonance imaging in establishing this diagnosis is emphasized.

Digital subtraction in Gd-DTPA enhanced imaging of the breast.

PURPOSE This study examines the role of digital subtraction magnetic resonance imaging (MRI) of the breast in the interpretation of the morphology and characteristics of breast disease. METHODS Thirty-one patients with an abnormal mammogram or clinically palpable abnormality underwent MRI of the breast prior to surgical excision of the lesion. FLASH 3-D images of the breast were acquired before and after IV contrast injection of Gd-DTPA. Digital subtraction was performed on selected images. The images were independently assessed by two radiologists experienced in both mammography and MRI. RESULTS Accurate diagnosis was possible in 29 out of 31 patients using the subtraction technique compared to 23 cases using the pre-subtraction images alone. The actual extent of disease and multicentricity were also better appreciated on the subtracted image. Subtraction also provided better identification of tumour recurrence in the post-operative and post-radiotherapy breast. Chest wall and lymph node involvement were more easily appreciated on the subtraction images. CONCLUSION Digital subtraction is a simple, effective and relatively cheap technique which can aid in the interpretation of magnetic resonance imaging of the breast.