Thomas F. Meaney

Natural history of renal arterial disease.

Information about the natural history of renal arterial disease is important for the approach to a precise selection of hypertensive patients for medical or surgical therapy. Surgery carries a high risk of myocardial infarction and stroke in patients with renal atherosclerosis and associated coronary and cerebrovascular disease. Moreover, technical problems arise when the arterial disease affects branches of the renal artery, is bilateral, or affects the renal artery supplying a solitary kidney. Although antihypertensive drug therapy has proved effective in controlling blood pressure in patients with renal vascular hypertension (1), concern may arise that renal function deteriorate because of progression of the arterial disease. This report presents the information obtained in 91 patients studied by serial renal arteriography for periods ranging from six months to ten years. Clinical Material, Method, and Criteria of Study The 91 patients (32 males and 59 females) in the study were admitted to the Clevela...

A pathologic-arteriographic correlation of renal arterial disease

Abstract A study of the microscopic features of occlusive renal arterial lesions in 97 patients has shown the advantage of classifying these diseases according to their primary locations in the arterial wall and the types of tissue they comprise. Two lesions were primarily intimal, atherosclerosis and intimal fibroplasia, and three were predominantly medial, medial fibroplasia, fibromuscular hyperplasia, and subadventitial fibroplasia. This classification permitted a close correlation with renal arteriographic features. Atherosclerotic lesions were either circumferential or eccentric plaques, sometimes complicated by thrombosis or dissecting aneurysm. They occurred predominantly in men. Arteriograms showed stenosis of the orifice, with poststenotic dilatation; the presence of thrombosis or dissecting aneurysm was usually indicated by complete obliteration. Intimal fibroplasia was characterized by fibrous intimal hyperplasia associated, at times, with disruption of the internal elastic membrane. Arteriographic features depended on the condition of this membrane; when it was disrupted, an aneurysm formed, producing an irregularly dilated artery. Medial fibroplasia with aneurysms produced the “string-of-beads” arteriogram previously attributed to fibromuscular hyperplasia. The “beads” were aneurysms that developed because segments of the arterial wall were absent, permitting focal dilatations. These thin segments alternated with areas in which the media had been largely replaced by collagen. Muscular hyperplasia was not present. Fibromuscular hyperplasia was an uncommon lesion resulting from increased amounts of fibrous and muscular tissue; it was sometimes accompanied by disruption of the internal elastic membrane. Arteriograms showed either symmetrical stenosis or, when the internal elastic membrane was disrupted, an irregularly dilated artery. We could find no arteriographic features that would differentiate this lesion from intimal fibroplasia. Subadventitial fibroplasia was characterized by dense collagenous thickening of the outer media irregularly replacing the muscular layer; it affected long segments of the renal artery. The arteriographic appearance was that of a severely stenosing lesion with regions of intense stenosis alternating with regions of lesser narrowing. This lesion has also been called “fibromuscular hyperplasia” because the variably severe stenosis produces an irregular arterial outline that suggests “beading.” This study shows subadventitial fibroplasia to be distinct from fibromuscular hyperplasia, as well as from medial fibroplasia, which produces the “string-of-beads” arteriogram.

Computed tomography of the thorax and abdomen; a preliminary report

The utility of computed tomography (CT) in the study of the anatomy, physiology, and pathology of the human body has been the subject of considerable interest since the introduction of CT scanning. The advent of a new prototype scanning device has made it possible to examine a variety of abnormalities in the abdomen and thorax in a manner not previously possible. This development permits a remarkable insight into the study of human disease in vivo.

Renal trauma and hypertension

Eleven cases of hypertension after renal trauma were reviewed. The average age of the patients was 22 years on first examination at the Cleveland Clinic. Ten patients were asymptomatic; 4 were not aware that they had suffered specific renal trauma. The onset of hypertension occurred at very different intervals after the traumatic event, sometimes after several years, thus making imperative long-term observation of patients suspected of having sustained renal trauma. Nephrectomy ameliorated hypertension in 7 of 8 patients, 6 of whom became normotensive; more conservative operations failed to relieve hypertension in 2 of 3 patients. Mechanisms of post-traumatic renal hypertension include parenchymal compression from hematomas (analogous to the cellophane-wrapped kidney of Page) and renal artery stenosis or occlusion (analogous to the Goldblatt kidney).

Definitive role of CT scanning of the pancreas. The second year's experience.

In a group of 188 patients, 192 computed tomographic (CT) scans of the pancreas were done, and the diagnostic accuracy of CT determined relative to other modalities. CT was the most effective method of detecting neoplastic and inflammatory diseases. The full extent of the disease process, including involvement of the retroperitoneum and metastasis to the liver, was visualized with one examination. Calcification and cystic collections associated with pancreatitis were also clearly seen.

Computed Tomography in the Detection of Juxtasellar Lesions

One thousand consecutive computed tomograms were reviewed to determine the accuracy of the procedure in the detection of juxtasellar lesions. The detection rate was compared to those of plain skull films, radionuclide studies, angiography, and pneumoencephalography. Computed tomography was slightly superior to angiography and was surpassed only by pneumoencephalography, both of which are invasive procedures which carry a definite risk. The data indicate that computed tomography is the screening method of choice in the detection of juxtasellar masses.

Errors in angiographic diagnosis of renal masses.

THE PLACE of renal arteriography in theT diagnosis and management of patients with suspected renal masses has been the subject of controversy since dos Santos introduced translumbar aortography in 1929 (1). Errors were made, however, in differentiating renal cysts from neoplasms (2–4). The kidney might be overlapped by extrarenal arteries, and the contrast medium diluted to such an extent as to limit vascular details. Many physicians believed that all patients with urographic evidence suggesting neoplasm should undergo surgical exploration and that renal angiography was unnecessary. The advent of the selective technic of renal angiography prompted a reappraisal of the role of arteriography in the diagnosis of renal lesions. As experience with this new method increased, however, it became evident that the angiographic appearances of renal adenomas, hamartomas, and inflammatory processes might be confused with those of cysts and malignant tumors, and that renal-cell carcinoma might be mistakenly diagnosed a...

Response of a non-Hodgkin lymphoma to 60Co therapy monitored by 31P MRS in situ☆

High quality 31P MR spectra (signal to noise ratio (S/N) approximately 18, 15 min acquisition for each spectrum) were consistently obtained with surface coils over a period of 6-week RT. Both transient and steady state alterations in metabolites in response to RT were found in this case. The transient changes occurred during the first 3 hr immediately after the 3rd fractionated RT, these changes include the transient elevation of the PCr resonance, a decrease in PDE and an increase in intracellular pH. The monitoring showed that the metabolites approached steady state approximately 2 hr after the fractionated radiation intervention, suggesting that in vivo MRS can be useful for studying the dynamics of tumor response to RT such as repair of potential lethal damage, growth delay, and reoxygenation etc. The steady-state MR spectra showed the net response to each intervention and can clinically be useful for predicting and measuring the result of the fractionated RT. In this case study, the PDE peak which contains the phospholipid metabolites GPC and GPE, is the most sensitive resonance in response to RT. After the 3rd RT, prior to tumor size reduction, the PDE to ATP ratio decreased 33% and intracellular pH increased to 7.34 +/- 0.05 from 7.27 +/- 0.05. In the subsequent RT interventions, both the tumor size and PDE/ATP ratio continually decreased whereas the pH values remained alkaline and fluctuated around 7.34 to 7.65. The data suggest that the phospholipid metabolite PDE may signal important alterations in membrane metabolism that eventually lead to cell death.

Radiologic Approach to the Patient with Suspected Pheochromocytoma

Thirty-four patients with 37 pheochromocytomas were studied by catheter angiography and results of these studies were reviewed. The radiographic approach to the patient with suspected pheochromocytoma is discussed. Following clinical and laboratory work-up and general radiographic procedures (urography with adrenal laminagraphy), arteriography with careful monitoring is indicated. Selective catheterization is recommended before aortography. Adrenal venography is necessary if all arterial studies are negative. This protocol permits safe and accurate evaluation of patients suspected of having pheochromocytoma.

Differential renal venous renin activity in diagnosis of renovascular hypertension. Review of 29 cases.

Bilateral renal venous renin activity determinations were performed preoperatively in 29 patients with unilateral renal artery disease. After the operations, 19 patients had relief of hypertension and 10 did not. Analysis of the renal venous renin activity data indicated that a value for renin activity (stenotic side) greater or less than 4 ng/ml per 4 hours or renin activity ratio stenotic(S)/nonstenotic(N) greater or less than 1.5 yielded a correct prediction of surgical results in 79 percent and 72 percent of the cases, respectively. The renin activity (stenotic side) greater than 4 ng/ml per 4 hour and renin activity ratio S/N greater than 1.5 combined, as an index of surgical success, yielded a correct prediction in 69 percent of the cases. However, when the renin activity (stenotic side) and renin activity ratio S/N were both increased (indicative of success in 12 of 14 patients) or were both normal (indicative of failure in all 5 patients with this finding) the prognostic index was high (89 percent). When there was a disparity in the two values (as in 10 patients), the prognostic accuracy was uncertain and results unpredictable. The criteria of other investigators for a positive renal venous renin study were reviewed. Reanalysis of these data indicated that the criteria of success as denoted by renin activity ratio S/N greater than 1.5 and elevated renal venous renin activity (stenotic side) compare favorably with those obtained with a ratio of 2.0 or more and elevated renal venous renin activity (stenotic side) in the series reviewed.