Ron Khazan

MR cholangiography in biliary obstruction using Half-Fourier acquisition

PURPOSE Our goal was to evaluate biliary obstruction using a T2-weighted, turbo, SE MR sequence with half-Fourier acquisition (HASTE). METHOD A prospective evaluation of 21 consecutive patients with clinical evidence of obstructive jaundice was carried out comparing HASTE MR cholangiography (MRC) to endoscopic retrograde cholangiopancreatography and percutaneous transhepatic cholangiography. A control group of five normal volunteers was also evaluated. The study group was imaged with a 1.5 T MR scanner using a body coil. The HASTE sequence was applied in axial, coronal, and oblique sagittal planes. Ultrafast acquisition scanning times allowed the use of a single breath hold. Bile duct dilatation, level of obstruction, and cause of obstruction were assessed on both imaging modalities by two radiologists blinded to the clinical diagnosis and to each others results. RESULTS All studies were interpretable with anatomy well seen in 82% of the cases. MRCs of a normal control group were correctly interpreted. The presence of biliary dilatation was accurately depicted by HASTE MRC in 100% of patients with complete interobserver agreement. The level of obstruction was depicted correctly in 87% of patients with 93% interobserver agreement. The right main duct was seen by MRC in 80% of obstructed systems. The left main duct was seen in all obstructed patients. The gallbladder was identified in 88% of patients by MRC. Common bile duct stricture and stones could be differentiated as a cause of obstruction in all cases. CONCLUSION MRC using the HASTE imaging sequence can safely and accurately depict the presence and level of biliary obstruction. The fast acquisition time of 13 s/scan makes the technique suitable for uncooperative and ill patients. HASTE MRC should be considered an alternative procedure to direct cholangiography in selected patients.

Renal cell carcinoma with situs inversus totalis

A case of renal cell carcinoma in a patient with situs inversus totalis is reported. Only 8 cases of malignant neoplasms have been reported in situs inversus totalis, and our case represents the second case report of renal cell carcinoma in a patient with situs inversus totalis. The frequency of situs inversus totalis is between 1 in 8,000 and 1 in 20,000. Cardiac and pulmonary anomalies are common in patients with situs inversus totalis. Renal anomalies, including agenesis, dysplasia, hypoplasia, ectopia, polycystic kidney, and horseshoe kidney, have been reported. Because of the association between situs inversus and cardiac, pulmonary, renal, and vascular anomalies, management of the patient with situs inversus and urologic disease requires careful preoperative evaluation.

Clinical Decision Making Using Teleradiology in Urology

OBJECTIVE Using a personal computer-based teleradiology system, we compared accuracy, confidence, and diagnostic ability in the interpretation of digitized radiographs to determine if teleradiology-imported studies convey sufficient information to make relevant clinical decisions involving urology. Variables of diagnostic accuracy, confidence, image quality, interpretation, and the impact of clinical decisions made after viewing digitized radiographs were compared with those of original radiographs. MATERIALS AND METHODS We evaluated 956 radiographs that included 94 IV pyelograms, four voiding cystourethrograms, and two nephrostograms. The radiographs were digitized and transferred over an Ethernet network to a remote personal computer-based viewing station. The digitized images were viewed by urologists and graded according to confidence in making a diagnosis, image quality, diagnostic difficulty, clinical management based on the image itself, and brief patient history. The hard-copy radiographs were then interpreted immediately afterward, and diagnostic decisions were reassessed. All analog radiographs were reviewed by an attending radiologist. RESULTS Ninety-seven percent of the decisions made from the digitized radiographs did not change after reviewing conventional radiographs of the same case. When comparing the variables of clinical confidence, quality of the film on the teleradiology system versus analog films, and diagnostic difficulty, we found no statistical difference (p > .05) between the two techniques. Overall accuracy in interpreting the digitized images on the teleradiology system was 88% by urologists compared with that of the attending radiologists interpretation of the analog radiographs. However, urologists detected findings on five (5%) analog radiographs that had been previously unreported by the radiologist. CONCLUSION Viewing radiographs transmitted to a personal computer-based viewing station is an appropriate means of reviewing films with sufficient quality on which to base clinical decisions. Our focus was whether decisions made after viewing the transmitted radiographs would change after viewing the hard-copy images of the same case. In 97% of the cases, the decision did not change. In those cases in which management was altered, recommendation of further imaging studies was the most common factor.

Rapid nephrostomy tube placement using a CT guided single stick system

ous iliac vein stents, 2/7 (28.5%) Wallstents and 5/7 (71.5%) wi th Palmaz stents. The etiologies included 5 multiple dialysis catheter placements, I venous obstruct ion secondary to prostrate carcinoma, and 1 Mays Thurner Syndrome. The location of the stentts were 2/7 (28.5%) right c o m m o n iliac vein, 2/7 (28.5%) left c o m m o n iliac vein, 2/7 (28.5%) right external iliac vein, and 1/7 (14.5%) left external iliac vein. Resul ts : All patients did well wi th no complications. One patient presented 8 mon ths later with a deep venous thrombosis due to iliac vein stenosis in a different location and needed the procedure repeated again. The patency of the iliac veins was evaluated by either contrast venography or ultrasound. Four patients had follow up studies for stent patency: 3 patients had contrast venography and I with ultrasound. Two patients were lost to follow up. Conclusions: Consideration of an iliac vein s tenoses should be made particularly in a patient wi th a history of multiple catheter placements . Iliac vein s tenoses can be treated safely wi th a percutaneous endovascular stent. Take H om e Points: See conclusions.