Joseph J. Bookstein

The Complementary Roles of Chest Radiography, Lung Scanning, and Selective Pulmonary Angiography in the Diagnosis of Pulmonary Embolism

The chest X-ray, perfusion lung scan, and selective pulmonary arteriogram were independently reviewed in 104 patients with suspected pulmonary embolism. Thirteen patients also had 133Xe ventilation studies. Of the 45 patients with angiographically-documented pulmonary emboli, 37 had perfusion scans interpreted as high probability of pulmonary embolism (82% sensitivity). Fifty of 59 patients without angiographic evidence of pulmonary embolism had perfusion scans interpreted as low probability of pulmonary embolism, other, or normal (85% specificity).Of the 41 patients with acute pulmonary embolism, only three had normal chest X-rays. In 26 (63%) the abnormality on perfusion scan was more extensive than that on chest X-ray.When both the scan and chest X-ray pointed strongly in the same direction, a correct diagnosis could usually be made, and accuracy was greater than when diagnosis was based on the perfusion scan alone. The lung scan was of limited value in patients with cardiomegaly or left heart failure. The differential role of the 133Xe ventilation study remains unclear. On the basis of the present and other data, guidelines for the selection of patients for pulmonary arteriography are proposed.

Angiography of Massive Hemorrhage Secondary to Pancreatic Disease

Twenty patients with massive abdominal hemorrhage related to chronic pancreatitis, pancreatic neoplasms and arteriovenous malformations were studied angiographically. Abdominal hemorrhage drained most frequently into the gastrointestinal tract, but also flowed through cutaneous drain sites and fistulas, intraperitoneally, into pseudocysts and once into a large pancreatic tumor. The most common angiographic observation in pancreatitis was pseudoaneurysm formation. Both patients with arteriovenous malformation had dilated, racemose feeding arteries and early dense filling of the draining veins. Three patients had pancreatic carcinoma and documented bleeding from gastroesophageal varices related to portal or splenic vein occlusion by the tumor. Five patients were treated by vasopressin infusion, balloon tamponade, or therapeutic embolization.

Repair of acute traumatic rupture of the aorta without extracorporeal circulation.

n this era of rapid transportation, the increasing incidence of traumatic rupture of the thoracic aorta has almost paralleled the inI creasing number and speed of highway vehicles. Strassmann [231 found only a 1% incidence of aortic rupture in 7,000 autopsies in 1947. Recent reports from both the United States [8] and Europe [241 show that the incidence of traumatic rupture of the aorta is now between 10 and 15% in automobile fatalities. Traumatic rupture of the thoracic aorta carries a grave but not necessarily hopeless prognosis if it is managed adequately. Death by exsanguination is instantaneous in 80 to 90% of the patients who sustain aortic rupture [lo, 171. In the remaining 10 to 20% the aortic blood is contained by the adventitia, pleura, and surrounding tissue. A false aneurysm is formed, and the patient survives at least temporarily. Since most of these patients will die from lethal secondary hemorrhage within three weeks if they are not treated [lo, 171, it is imperative that the diagnosis be established quickly and that repair be carried out.

Protein-losing gastroenteropathy: Concepts derived from lymphangiography

SummaryLymphangiograms in 2 patients with protein-losing gastroenteropathy showed abnormalities of both abdominal and lower-extremity lymphatics.With the application of lymphangiography, the generalized nature of the lymphatic dysplasia in primary protein-losing gastroenteropathy has become evident.Striking lymphangiographic similarities between primary protein-losing gastroenteropathy and primary lymphedema suggest that both entities are part of a continuous spectrum of lymphatic dysplasias.

Acquired Pulmonic Stenosis Report of a Case Caused by Mediastinal Neoplasm

Acquired pulmonic stenosis is rare. A well-documented case of pulmonary infundibular stenosis due to mediastinal lymphoma has been described. Complete disappearance of the heart murmur followed therapy with nitrogen mustard. Other causes of acquired pulmonic stenosis have been discussed.

Saccular Aortic Aneurysm due to Aortic Valve Stenosis

A case of congenital aortic stenosis with an associated discrete saccular aortic aneurysm is presented. The few previously reported cases of this combination of lesions are reviewed and the nature and mechanisms of the aneurysmal changes are discussed. The apparent etiologic importance of the systolic jet striking a localized area of vessel wall is emphasized.

Pharmacoangiographic evaluation of the hemodynamic significance of coronary artery stenoses.

Acute stenoses of varying degree were produced in the circumflex arteries of 5 calves, and chronic stenoses which reduced blood flow by about 50% were effected in the left anterior descending coronary arteries of 14 dogs. Selective vasodilators or amyl nitrite increased blood flow more than 100% in nonstenotic arteries, but less in stenotic ones. Increased transstenotic blood flow was associated with an increased pressure gradient and increased frequency of collateral circulation. Collateral circulation was sometimes recognizable when the pre- and postvasodilatory angiograms were compared but not when the angiograms were examined individually. The altered flow patterns demonstrated by comparative studies may be a very sensitive index of collateral circulation.

POSSIBLE ASSOCIATION BETWEEN BENIGN HEPATOMAS AND ORAL CONTRACEPTIVES

n 7 case reports of women with benign hepatic adenoma suggest that, since all of the women were taking oral contraceptives (OCs), there may be an association between ingestion of exogenous hormones and development of benign hepatoma of the liver. The cases were rapidly diagnosed by using hepatic arteriography; prompt, precise diagnosis is emphasized because, though the tumors are benign, they may cause serious, if not fatal, hemorrhage if left unchecked. Case 1 was a 26-year-old woman who had taken Enovid for 2 years, who presented with acute abdomen and impending shock. Coliotomy was performed, in which a left-lobe hepatic tumor was found; she underwent left hepatectomy and cholecystectomy and no evidence of recurrence was found 1 year later. Case 2 had been taking Oracon for a unknown time. Case 3, on OCs for 6 years, had a pedunculated mobile tumor removed. Case 4, 25 years old, had been taking Ovral for 6 months before diagnosis and excision of a right lobe liver tumor. Case 5, 5 years on combined OCs, required surgical intervention for a hypervascular mass. Case 6, taking a total of 8 years of OC therapy, was operated on for an hepatic mass which was a white-to-yellow hemorrhagic mass. Case 7, taking Enovid for 7 years, yielded a surgical specimen that was hemorrhagic, partly necrotic, and yellow-tan, about 10 cm in diameter.n