William N. Hanafee

Transjugular portal venography and radiologic portacaval shunt: an experimental study.

Conventional methods of opacifying the portal system are splenic portography (1) and intra-arterial contrast injections into the visceral arteries with delayed films (6). More exotic means reported include translumbar portal vein puncture (4), umbilical vein catheterization (2), hemorrhoidal vein cannulization under spinal anesthesia (7), or laparotomy with cannulization of a mesenteric vein branch (5). All methods produce good to fair opacification of the portal venous system but allow no selectivity of contrast injections or opportunities for manipulative procedures in the venous system. For two years we have performed cholangiography (3) by passing a modified Ross needle and catheter system down the internal jugular vein and superior vena cava, across the right atrium into the inferior vena cava, and then into the hepatic veins in order to puncture the biliary duct system from inside the liver. With this same approach, one of the major branches of the portal vein can be punctured and the catheter inser...

Transjugular Percutaneous Cholangiography

A method of performing percutaneous cholangiography is suggested that may substantially reduce the incidence of bile peritonitis and also alleviate the necessity of immediate operation when an obstructive biliary lesion is encountered. By passing a catheter percutaneously via the right internal jugular vein, a direct line approach is made available to the hepatic vein via the superior vena cava, right atrium, and the inferior vena cava. Through this catheter a needle may be inserted for percutaneous cholangiography by puncturing the bile ducts from inside the liver. Technic Under sterile conditions, an area of skin and subcutaneous tissue is anesthetized with local anesthesia about 3 cm below the angle of the mandible and immediately medial to the sternocleidomastoid muscle. A 3 mm stab wound of the skin and subcutaneous tissues is made to prevent later hang-up of the catheter. An 18-gauge thin-walled needle approximately 8 cm long is attached to a 10 cc plain tip syringe containing 7 cc of 1 per cent X y...

INTRACRANIAL COLLATERAL CIRCULATION VIA LEPTOMENINGEAL AND RETE MIRABILE ANASTOMOSES.

EMBOLIC OR THROMBOTIC occlusions of intracranial arteries are followed by adjustments in the distribution of blood through the circle of Willis, external-internal carotid communication by way of the opthalmic artery, leptomeningeal arterial anastomosis, and, occasionally, the rete mirable. Angiographic analyses of changes in flow through the circle of Willis as a result of intracranial arterial occlusive disease are well known. The purpose of this report is to discuss our technique of angiographic demonstration of leptomeningeal and rete mirabile arterial anastomosis with illustrative cases. Angiographic criteria for the diagnosis of intracranial arterial occlusion will be illustrated and discussed. The demonstration of these occlusions requires special radiological equipment, and the technique of selective carotid angiography simplifies the procedure. Selective internal carotid angiography by the catheter technique offers certain advantages in the diagnosis of intracranial arterial occlusions in the visualization of collateral circulation. Occlusions of large intracranial arteries rarely present any diagnostic problems, but, when a small branch is occluded, the diagnosis may be difficult. In these cases, overlapping branches of the external carotid may be very confusing, and, if complete filling of the peripheral branches of the intracranial arteries is not obtained, collateral circulation via leptomeningeal arteries may not be seen. Leptomeningeal arteries. There is an extensive arteriolar network over the surface of the cerebral cortex which is, in effect, a mantle in the pia mater supplied by the internal carotid and vertebral arteries. The conducting arteries connect with one another through this extensive arteriolar network via anastomotic vessels called leptomeningeal arteries. Heubner,l in 1874, first demonstrated these anastomotic vessels. Fay,z in 1925, injected metallic mercury via a cannula in the middle cerebral artery at autopsy and demonstrated anastoniotic arteries on stereoscopic roentgenograms. Cobb,3 in 1931, reported his studies of the anatomy of the cerebral circulation and stated that there are no end arteries in the brain. Vander Eecken and A d a r n ~ , ~ in 1935, described the anatomy of the meningeal arterial anastomoses in adults and children and discussed their functional significance. The leptomeningeal arteries lie in the depths of the sulci of the brain and vary from 180 to 610 p in diameter. Some of the arteries form loops to anastomose with others, while some may have oblique or branched configurations.4 Collateral circulation via these vessels has been demonstrated angiographically by a number of authors.5-7 Rete mirahle. The rete mirabile, or “wonderful net,” refers to anastomotic vessels joining the meningeal arteries from the external carotid artery with the leptomeningeal arteries on the surface of the brain.s-lo

Electrocardiographic Changes During Selective Coronary Cineangiography

Examination was made of standard lead III of the electrocardiogram recorded during selective right and left coronary artery injections of Hypaque-M 75% in 107 patients. Left coronary artery injection caused the mean frontal plane QRS vector to shift transiently to the left and T wave vector to shift toward the right. Right coronary artery injection caused shifts of the QRS and T wave vectors in the opposite directions. Occlusion of one main coronary artery caused these ECG changes to be minimal or absent. Transient sinus bradycardia was common with injection of either coronary artery. Serious arrhythmias were rare. The electrocardiogram recorded during selective coronary arteriography can give information useful to the angiographer during the procedure itself as well as during the subsequent interpretation of the angiogram.

Axillary Artery Approach to Carotid, Vertebral, Abdominal Aorta, and Coronary Angiography

Considerable attention has been directed recently to the angiographic demonstration of occlusive disease in the arteries to the brain and in the coronary arteries. These patients have generalized arterial disease so that frequently severe involvement of the iliac makes transfemoral catheterization technically difficult or even prohibitively dangerous. The axillary artery is a convenient alternative approach because it is part of the brachiocephalic trunk. In addition, on the right side, beyond the subclavian and distal innominate, the proximal innominate artery and ascending aorta form a straight line approach to the root of the aorta and coronary arteries. Others (1, 5, 11) have chosen the upper extremity as a site of entrance into the arterial tree. Peirce (7) tried and abandoned the axillary artery approach. He had one case of thrombosis, one of neuritis, and two unsuccessful studies out of five examinations. Because of frequent severe hemorrhages at the puncture site and unsuccessful examination, Sutt...

Venography of the Cavernous Sinus, Orbital Veins, and Basal Venous Plexus

The dural sinuses about the base of the skull have received little attention in radiological literature. When opacified, the cavernous sinus together with the intercavernous sinuses offer intimate information about the configuration of the pituitary gland. In addition, free communication with the ophthalmic veins allows investigation for orbital mass lesions. The purpose of this report is to outline a technic for passing a catheter percutaneously via the internal jugular vein into the inferior petrosal sinus to visualize the cavernous sinus and orbital veins. Anatomy Free communication exists between the many rich venous plexuses about the base of the skull. Relatively large channels, the superior and inferior petrosal sinuses, unite the sigmoid sinus with the cavernous sinus. The superior ophthalmic vein drains directly into the cavernous sinus through the superior orbital fissure. The inferior ophthalmic vein may drain posteriorly directly into the cavernous sinus or to the pterygoid plexus. The pterygo...

The role of computed tomography in the management of cancer of the larynx.

Computed tomography (CT) offers a unique method of displaying the anatomy of laryngeal cancer. Asymmetrical contours of the thyroid cartilages have been found as a normal variant. Marked asymmetry may indicate buckling of the cartilage which could contribute to acute airway obstruction following radiation therapy. A low-density, soft-tissue plane medial to the thyroid cartilages may prove valuable in evaluating cartilaginous involvement with tumor. Computed tomography should make a significant contribution to more accurate planning of radiation therapy portals by showing the relationship of lymphatic spread to the primary tumors.

A Comparative Evaluation of Computed Tomography and Laryngography

A prospective study of 66 patients was conducted to evaluate the relative merits of computed tomography (CT) and laryngography in the assessment of laryngeal disorders. CT complemented direct laryngoscopy and biopsy for treatment planning and was superior to both modalities for showing deep infiltration, invasion of cartilage, and extension to the soft tissues of the neck. The subglottic space can be studied adequately by CT, which could also be useful in diagnosis of lymph node metastases. Distortion of the thyroid cartilage can be shown by CT. CT was equal to or better than laryngography in approximately 90% of cases.

The Anterior Inferior Cerebellar Artery: Its Radiographic Anatomy and Significance in the Diagnosis of Extra-axial Tumors of the Posterior Fossa

The anterior inferior cerebellar artery traverses the cerebellopontine angle cistern in close association with the seventh and eighth cranial nerves and supplies the lower pons, medulla, and anterior portion of the cerebellum. In spite of the known anatomic relationships of this artery, angiographic diagnosis of cerebellopontine angle tumors has depended upon presence of tumor vessels (4, 7, 11, 14, 18), superior displacement of the superior cerebellar artery (5, 8, 11, 13), and displacement or obliteration of the petrosal veins (5, 15). This is in part due to the fact that lateral and half-axial projections routinely obtained during vertebral angiography are not suitable for visualization of the anterior inferior cerebellar artery. It has been our practice to obtain straight anteroposterior roentgenograms which permit visualization of the anterior inferior cerebellar artery with the use of the subtraction technic (6). In a review of 250 catheter vertebral angiograms on 227 patients there were 9 cases wit...

Computed tomography of the injured larynx.

Computed tomography (CT) permitted a much more detailed appraisal of laryngeal dysfunction in patients with blunt laryngeal trauma (8 cases) and iatrogenic injury caused by radiation therapy (7 cases), surgery (2 cases), or intubation (1 case). In thyroid cartilage fractures, the fragments may be widely displaced. The cricoid ring breaks in two places, frequently involving the signet. CT facilitates diagnosis of the mechanism of injury based on the site and extent of fractures. The patterns of distortion and fibrosis of the laryngeal cartilage following radiation therapy may be manifested as encroachment on the airway, easily mistaken for recurrent tumor or localized edema. Minor distortion probably escapes detection on clinical examination. The authors consider CT the examination of choice in laryngeal injury.