Late Venous Phase Research Articles

Melanocytoma of the Choroid: Angiographic and Histopathologic Findings

A juxtapapillary choroidal melanocytoma that was clinically confused with a choroidal melanoma is described. The clinical examination of a 40-year-old female patient included ultrasonography, fluorescein, and indocyanine green angiography. Histopathologic and immunohistochemical study of the enucleated eye resulted in the identification of a markedly pigmented, 3.8 mm elevated choroidal melanocytic tumor observed nasally to the disk. A-scan ultrasonography showed a high initial spike with a low to medium internal reflectivity with decreasing amplitude. On fluorescein angiography, the tumor was surrounded by a rim of retinal pigment epithelium depigmentation with a well-defined comet-tail. The lesion was hypofluorescent in the early phases of the indocyanine green angiogram, but from the late venous phase appeared ill-defined hyperfluorescence. Histopathologic study revealed a juxtapapillary choroidal melanocytoma The pigmented tumor cells stained positive for HMB45 and vimentin but negative for S100, GFAP, NSE, and MNF116. No tumor cells stained positive for the proliferation marker Ki67. These findings conclude that choroidal melanocytoma may mimick choroidal melanoma. Abnormalities on fluorescein angiography may be a clinical hint to suspect a pigmented tumor different from a choroidal melanoma.

Hold up of dye in the arm during fluorescein angiography: a quantitative demonstration

PURPOSE: To demonstrate a hold-up of part of the fluorescein bolus in the arm as a result of arm position. METHOD: Case report. We obtained a fluorescein angiogram with a calibrated confocal scanning laser ophthalmoscope in a 20-year-old healthy subject. During and after injection, the upper arm was held in approximately 60 degrees abduction, 65 degrees exorotation, and slight anteflexion. In the late venous phase, the subject moved the upper arm on the injected side to a more neutral, downward position. RESULTS: We measured a distinct rise in fluorescence level about 10 seconds after movement of the arm. The most likely explanation is relief of a partial obstruction of the venous drainage, which had been caused by the position of the upper arm described above. CONCLUSION: Impaired venous drainage of the injected arm caused by exorotation and abduction of the upper arm is a potentially common cause of delayed dye arrival or unexpectedly reduced contrast level during fluorescein angiography. Therefore, arm position needs attention in fluorescein angiography.

Hepatic lesions: morphologic and functional characterization with multiphase breath-hold 3D gadolinium-enhanced MR angiography--initial results.

To investigate multiphase (arterial, portal venous, and late venous phases) breath-hold three-dimensional (3D) gadolinium-enhanced magnetic resonance (MR) angiography for the detection and functional characterization of hepatic lesions. Breath-hold fast spoiled gradient-echo 3D gadolinium-enhanced MR angiography was performed in 18 patients with 35 hepatic lesions. Measurements of signal intensity were obtained for 27 seconds in each phase, with 23-second delays between the three phases. Lesion-liver visibilities at each phase on the MR angiographic, precontrast T1-weighted, T2-weighted, and postcontrast T1-weighted images were compared. The MR angiographic functional lesion characterization was based on the combined assessment of spatial variations and the evolution of contrast material enhancement in all three phases. All 35 lesions were correctly characterized on the MR angiographic images, which is significantly (P < .01) better than the precontrast T1-weighted (n = 14 [40%]), T2-weighted (n = 23 [66%]), and postcontrast T1-weighted (n = 25 [71%]) imaging results. Analysis of the spatial variations and the evolution of contrast material enhancement significantly (P < .01) improved lesion characterization in 66% (23 of 35) of all lesions. Multiphase breath-hold 3D gadolinium-enhanced MR angiography is feasible and robust and significantly improves the morphologic detection of benign or malignant lesions during the early arterial phase. It further improves the functional characterization of hepatic lesions, combining an arterial, portal-venous, and late MR angiographic phase of contrast enhancement.

Aneurysmal bone cyst: its pathogenesis based on angiographic, immunohistochemical and electron microscopic studies.

Based on angiographic, immunohistochemical as well as electron microscopic findings, authors outline a hypothesis for the etiopathogenesis of aneurysmal bone cysts. No changes were found at the arterial site in 16 studied aneurysmal bone cysts, with no signs of an arteriovenous shunt. In certain cases, however, dilated and tortous efferent veins became visible in the late venous phase. Due to the impedance of venous flow, the intracystic pressure increases and the small veins become dilated causing formation of aneurysmal slits. This is supported by the immunohistochemical finding that S-actin shows concentric arrangement around the aneurysmal cavities. Endothelial lining and basal membrane remnants were detectable in places, though the aneurysmal slits were devoid of continuous endothelial lining and basal membrane. We suggested that the aneurysmal bone cyst corresponds to a hemodynamic disturbance and is due to primary or secondary venous malformation of the bones.

The distribution of angioarchitectural changes within the vicinity of the arteriovenous crossing in branch retinal vein occlusion

Objective Branch retinal vein occlusions (BRVOs) are known to occur most commonly in the vicinity of arteriovenous (A/V) crossings. The authors aimed to identify types of venous wall abnormalities in BRVO and document their position in relation to the A/V crossing. Design A retrospective review of the color photographs and fluorescein angiograms from the most recent 110 patients with first- or second-order BRVO was performed. Main outcome measures The films were examined for the presence of angioarchitectural changes of specified type within one-quarter—disk diameter of the A/V crossing involved in the BRVO. The specific changes noted were fluorescein leakage, presumed thrombi, and flow abnormalities, which were recorded along with their position in relation to the A/V crossing. Results Of the 110 patients diagnosed with BRVO, 59 had photography of satisfactory quality. Forty-one (70%) of these 59 patients had venous lesions, of which significantly more (chi-square = 5.74, P < 0.02) were downstream (56%) than upstream (12%) from the A/V crossing. Thirty-two percent were upstream and downstream. Of the hemodynamic changes seen, 49% had late venous phase leakage of fluorescein, 85% had abnormal flow, and 7% had presumed thrombi. All thrombi seen were downstream. Conclusions Venous lesions in the vicinity of the A/V crossing commonly are seen in BRVO, most of which occur downstream. This suggests that the venous narrowing at the crossing may induce downstream hemodynamic changes predisposing to endothelial damage and thrombus generation.

A CASE OF NEURILEMMOMA ORGINATED FROM THE INTERCOSTAL NERVE WHICH MADE A RETRACTION OT THE LIVER

A case of neurilemmoma originated from the intercostal nerve which made a retraction to the liver in a 63-year-old woman is reported. The patient was seen at the hospital because of right hypochondralgia. Physically, her right chest wall was distended. Ultrasonography and CT scan visualized a tumor about 5cm in diameter which looked like liver tumor in S2. This tumor had a low intensity capsule was enhanced by gadolinium in T1 weighted view, and was high intensity in T5 weighted view by MRI. Right 9th intercostal angiogram revealed tumor vessel at the early arterial phase and tumor stain at the late venous phase. Laparotomy was performed with a diagnosis of primary tumor of the abdominal wall. The tumor arising from the right lateral abdominal wall projected into the abdominal cavity in a shape of hemisphere and buried in the liver S5, forming a retraction. No adhesion to the liver was confirmed. The tumor surrounding peritoneum was resected. The resected specimen was macroscopically white smooth elastic hard mass, 6.0×4.5×4.0cm in size. Microscopically it was neurilemmoma comprized of Antoni type A and type B concomitantory. These has been no sign of recurrence of 4 years after the operation but the patient is strictly followed up on an ambulant basis.

脈絡膜循環障害に関する臨床的研究

In order to know frequency of choroidal circulatory disturbance, 126 eyes with central serous chorioretinopathy followed-up between Jan. 1985 and Dec. 1990 were retrospectively investigated by fundus fluorescein angiography. Appearance of choroidal circulatory disturbance was divided into two types. The type 1 showed choroidal filling delay at late retinal venous phase. The type 2 showed mosaic pattern of choroidal background at late retinal venous phase. Among the 126 eyes, 3 eyes were type 1 (2.4%) and 57 eyes were type 2 (45.2%), totaling 60 eyes (47.6%). Sixty-three eyes with normal part of branch retinal vein occlusion matching in sex and age were selected as controls. In the controls, no eye was type 1 (0%) and 8 eyes were type 2 (12.7%), totaling 8 eyes (12.7%). Distinctly, proportion of the type 2 was higher in central serous chorioretinopathy than in branch retinal vein occlusion. In conclusion, the pathogenesis of central serous chorioretinopathy is related to choroidal circulatory disturbance and especially mosaic pattern (type 2) was found to be a new type of circulatory disturbance.

Transverse sinus dural fistula: Combined surgical and endovascular approach: A case report

The treatment of a large dural sinus fistula can be very difficult and complicated. The very extensive and complex nature of these malformations may require a combination therapy in the form of surgery and multistaged embolization. The transverse sinus fistula in our patient was fed by multiple large high-flow feeders and was draining retrograde into the superior sagittal sinus (SSS) and the cortical veins. The SSS did not fill in the late venous phase of the carotid angiogram, suggesting increased venous pressure. A case of transverse sinus dural fistula is described that was managed by a combination of surgery and embolization. The complex nature of this malformation encouraged us to adopt a combination of multistaged embolization and surgery for the management and clinical control. The patient underwent embolization of multiple feeders from the branches of the external carotid artery. After this procedure, the patient underwent endovascular occlusion of the transverse sinus via the SSS. Throughout the endovascular treatment, the patient had concomitant intracranial pressure monitoring and SSS pressure monitoring, along with transcranial cerebral oximetry (TCCO). Despite this aggressive endovascular intervention, the fistula could not be completely closed. The patient then underwent surgical excision of the transverse sinus along with duraplasty and cranioplasty. The patient had a good recovery and posttreatment angiogram revealed normal antegrade flow in the SSS with no evidence of the fistula. The combined surgical and endovascular techniques are described and their use in clinical practice is discussed. The complexity of certain large dural sinus fistulae should not be underestimated. They may require a prolonged multistaged treatment for their total obliteration. Also, despite the large size and complexity of the disease, complete cure can be achieved.

Stereotactic linear radiosurgery for cavernous angiomas.

Optimal management of symptomatic cavernous angiomas (CA) located in the thalamus and the brainstem is problematic. Clinical and radiological (MRI) follow-up series suggest that having hemorrhaged once, recurrent hemorrhage with progressive neurologic dysfunction may commonly occur. We have therefore chosen to treat these lesions when first symptomatic with stereotactic linear radiosurgery (SLR). We now report, after a median follow-up of 27 months, 12 patients with CAs (9 women, 3 men, mean age 40 years) treated in this fashion. Ten patients presented with hemorrhage (3 had more than one hemorrhage): two patients had new onset seizures. All patients had enhanced MRI/MRAs characteristic of CA. There were five brainstem and five thalamic CAs, and one each in the temporal lobe and insula. Cerebral angiograms were done in 8 patients for comparison with their respective MRAs. Only one CA was visualized in the late venous phase on cerebral angiogram and identical vascular features were appreciated on the MRA. The diameter of the CAs ranged from 1.0 to 3.0 cm with a mean of 1.6 cm. Dosimetry planning was based on MRI/CT features and the mean dose at the isocenter was 2.167 cGy (range = 2,000-2,500 cGy) delivered with a mean collimation diameter of 1.46 cm (range = 1.0-2.0 cm). All 12 patients continued to improve neurologically after SLR and had MRI-documented changes in their lesions: in general, the lesions became smaller and signal characteristics converted to methemaglobin. However, 1 patient had an early post-SLR hemorrhage, documented by MRI, at 4.5 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Angiographic Findings of Vertebral Dissecting Aneurysm

The authors report two cases of vertebral dissecting aneurysm. The first case, a 49-year-old female, developed severe headache and computed tomography scan showed subarachnoid hemorrhage (SAH), but 4-vessel cerebral angiography failed to show an aneurysm. The second angiograms obtained 2 weeks later showed possible aneurysmal dilatation on the right vertebral artery. The third angiograms, 2.5 months after SAH, disclosed a right vertebral fusiform aneurysm on the arterial phase and it was diagnosed as a dissecting aneurysm since the contrast medium remained until the very late venous phase. The previous angiograms were reviewed using the subtraction technique, which revealed retention of the contrast medium. The second case, a 42-year-old female, suffered from SAH. Left vertebral angiography revealed a fusiform aneurysmal tapered narrowing just distal to the aneurysm, which was a typical "pearl and string sign." The subtraction film of the venous phase also showed retention of the contrast medium in the aneurysmal portion. These findings accurately diagnosed dissecting aneurysm of the vertebral artery. Since the classical true diagnostic "double lumen sign" was rarely observed in the angiograms, it was not easy to diagnose dissecting aneurysm of the vertebral artery. The authors emphasize the angiographic findings of retention of the contrast medium in the venous phase as a "true diagnostic sign" for correct diagnosis of dissecting aneurysm.

Optic pit syndrome.

In a study of 15 eyes with optic pits fluorescein angiography revealed that only pits associated with serous detachment of the macular retina showed fluorescence in the late venous phase, while the pits uncomplicated by detachment remained hypofluorescent throughout the test. This finding strongly supports the hypothesis that the subretinal fluid producing the macular detachment originates from leakage of vessels located in the floor of the pit. In addition a high incidence of anomalies was found to be associated with optic pits. Therefore the author suggests to call the association between optic pit and large optic disc, parapapillary chorioretinal changes, cilioretinal vessels, situs inversus and eventual other vessel abnormalities, the 'optic pit syndrome'.

Radiographic findings in 32 cases of primary CNS lymphoma.

Computed tomographic (CT) or angiographic (or both) findings were analyzed in 32 cases of pathologically proved primary non-Hodgkin lymphoma of the central nervous system. CT scans were available in 28 of the 32 cases. Thirty lesions were found in the 28 cases. In comparison with previous literature, the frequency of involvement of deep central structures (30%), multiple lesions (11%), and subependymal lesions (4%) was lower and that of lesions in the periphery of the supratentorial compartment was higher (46%). In agreement with previous literature, most of the lesions were of increased density (63%), enhanced (100%), and enhanced homogeneously (71%). Twenty-nine of the 32 patients underwent cerebral angiography. In 12 patients, a homogeneous vascular stain was found that appeared in the late arterial or early venous phase and had a meningiomalike pattern. This staining pattern has not been emphasized sufficiently in previous literature. It was believed that such an angiographic pattern in a dense, homogeneously enhancing parenchymal lesion is suggestive of a primary lymphoma of the central nervous system. Magnetic resonance imaging was performed in one patient with two lesions, and both lesions demonstrated prolonged T2 relaxation times.

Digital celiac arteriography.

Sixty patients underwent intraarterial DSA with injection into the celiac artery for evaluation of various hepatic, pancreatic, and splenic lesions. Twenty of these patients also underwent conventional arteriography for comparison. Excellent images during the early arterial phase (free of bone superimposition and artifacts) were obtained with DSA. The late arterial and parenchymal phases of the examination were less definitive when compared with conventional angiography. The venous phases of the liver studies were good and compared favorably in contrast and resolution to conventional methods. In the late venous phase, good images of the portal system were obtained using a small amount of contrast medium. Respiratory movements and artifacts were overcome with postprocessing. Most of the studies were performed using the 12-inch mode of the image intensifier, which represents the best choice between the size of the field examined and the spatial resolution of the system. We believe that DSA is a suitable substitute for conventional angiography in most patients in whom celiac trunk angiography would be used.

Early postoperative angiographic control of the Warren procedure in 40 patients.

AbstractBetween December 1975 and December 1980, a total of 43 patients with portal hypertension due to intrahepatic block underwent the Warren procedure for distal splenorenal anastomosis. Forty of them were submitted to celiomesenteric arteriography between the 10th and 90th postoperative days to assess the efficacy of the procedure and to estimate its effects on the portal flow to the liver. On the late venous phase of the celiac angiogram, the patency of the shunt was demonstrated in 37 patients (92.5%), along with a consistent reduction of splenic volume; there was a clear flattening of esophageal varices at esophagoscopy. The shunt was not patent in the other 3 patients (7.5%), all of whom had anatomic venous abnormalities (diameter of the splenic vein smaller than 10 mm and/or abnormal renal vein). Two of these patients rebled soon after the operation, while the third subject underwent a prophylactic renoportal shunt.The effects of the procedure on the mesentericoportal flow were studied on the late phase of the superior mesenteric arteriogram. Venous flow to the liver was unaltered in 28 patients, substantially reduced by a latent partial portal thrombosis in 10 (25%), and totally suppressed in 2. Of these 2 complete portal thromboses, one resulted in early recurrent bleeding, while the other has remained asymptomatic. In spite of the portogastric disconnection, reverse flow in large veins from the portal vein to the cardial varices was observed in 14 patients (35%). Thus, after the Warren procedure, esophageal varices are efficiently decompressed by a patent shunt but portal flow is not always preserved.

Angiographic Diagnosis of Teleangiectases with Cavernous Angioma of the Posterior Fossa

Two cases of pontine vascular malformation with a characteristic venous angiographic appearance are reported. Both patients had a slowly progressive clinical course, normal spinal fluid, and evidence of a pontine mass. In the late venous phase, large abnormal vessels were seen to coverage towards the midline from each cerebellar hemisphere. The abnormal vessels were microscopically identified as teleangiectases in one of the cases. Both cases had pontine hematomas, originating from a cavernous angioma in one of them; in the other the exact origin of the bleeding could not be determined. It is concluded that in cases with a progressive pontine syndrome the characteristic appearance of the venous phase of angiography may indicate a bleeding pontine vascular malformation.

Radiographic anatomy of normal cerebral deep medullary veins: criteria for distinguishing them from their abnormal counterparts.

The angiographic demonstration per se of cerebral deep medullary veins does not necessarily indicate abnormality. Their visualization, under normal conditions, depends on the selectivity of injection, the quality of radiographic imaging, and the quantity of contrast material injected. Normal deep medullary veins were recognized in the late venous phase of two-thirds of normal selective internal carotid angiographies; their location most often was adjacent to the atrium and posterior body of the lateral ventricle. Normal and abnormal deep medullary veins can be differentiated in terms of appearance-time, caliber, length and regional distribution.

Choroidal neovascularization in multifocal (presumed histoplasmin) choroiditis.

Fifteen patients with multifocal choroiditis and greenish discoloration associated with typical macular lesions were studied by rapid sequence fluorescein angiography. In all cases new vessels could be identified at these sites during fluorescein angiography, particularly during the late arterial and early retinal venous phases. Chronic serous fluid formation frequently results in new vessel proliferation, and this in turn alters the overlying pigment epithelium, causing a greenishgray appearance on ophthalmoscopic evaluation. Photocoagulation is a logical form of treatment once new vessels can be identified, particularly if hemorrhage has occurred.

Operative technic of removal of epidural hematoma of the vertex depressing the superior sagittal sinus

An operative technic is depicted utilizing an air craniotome for the removal of an epidural hematoma of the vertex [5]. Salient points which have proved helpful in the management of these hematomas include: 1. 1. The knowledge of their location in sites other than the “classical” site underlying a fracture of the temporal bone. 2. 2. Definitive diagnosis by the late venous phase of the carotid angiogram. 3. 3. The value of the sigmoid incision of the scalp in affording wide bilateral exposure. 4. 4. The rapidity and ease with which these hematomas may be visualized and removed using a compressed air perforator, craniotome, and drill. 5. 5. The value of sewing back the dura to the vertex of the skull and the transient postoperative use of the Snyder Hemovac to obliterate the epidural dead space.

Intracerebral Vascular Rupture

In the past several years, most patients with severe head trauma at our hospital have been studied with emergency cerebral angiography. Recently, we have seen two cases of intracerebral vascular rupture associated with severe head trauma. Because of the rare nature of this occurrence, it was thought that a brief report was indicated. Case Histories Case I: T. B., a 60-year-old male, was admitted to the Boston City Hospital in coma. Multiple bruises about the head and neck suggested that he had sustained recent trauma. Neurological examination disclosed flaccid paralysis of all four extremities and a dilated fixed left pupil. Plain skull films were normal. Radiologic Findings: An emergency left common carotid angiogram (Fig. 1) taken two hours after admission showed cerebral herniation underneath the falx. The middle cerebral artery was medially displaced, and a crescentic avascular extracerebral collection, measuring 2 cm in width, was apparent over the convexity. Over the frontal operculum, above the midportion of the insula, a 7-mm round collection of contrast material was noted. This persisted for six seconds and disappeared in the late venous phase. Surgery: A large acute subdural hematoma was found. In the area of the angiographically noted “pseudoaneurysm” there was a tear in the arachnoidal meninges and a rupture of a medium-sized branch of the ascending frontoparietal group. A clot was adherent to the tear of the vessel. As the clot was removed, active bleeding was noted. Comment: This is an example of severe head trauma with rupture of one of the branches of the middle cerebral artery as well as a tear of the meninges. The blood in the subdural space in this case was felt to originate predominantly from the torn vessel with extravasation through the arachnoidal tear. Case II: P. C., an unidentified middle-aged male was brought to the emergency room in coma. No history was obtainable, but it appeared that he had recently been severely beaten about the head and neck. There were multiple fractures of the ribs and both lower extremities. The head was swollen, and the patient was bleeding into the soft tissues of the neck and scalp. Several units of blood replacement were required for profuse hemorrhage from the nasopharynx. Neurological examination disclosed the patient to be completely unresponsive, with fixed pupils and no localizing signs. Skull roentgenograms disclosed multiple linear fractures. Radiologic Findings: An emergency right brachial angiogram (Fig. 2) taken eight hours after admission showed normal vertebral and extracranial carotid vessels. There was marked herniation underneath the falx. The middle meningeal artery was markedly displaced inward in its low convexity at the level of the floor and lateral boundary of the middle cranial fossa. The middle cerebral artery was markedly elevated. The anterior choroidal artery approximated the midline, indicating severe uncal herniation.

THE POSTVERTEBRAL NECK VEINS IN CEREBRAL ANGIOGRAPHY.

Many radiologists are aware of the opacification of large veins in the back of the neck during cerebral angiography, the nature of which, however, is undefined. Because of their appearance, these “postvertebral” veins might readily be mistaken for a vascular malformation. The present study was undertaken to determine their nature and the incidence and significance of their opacification. Materials and Methods The 329 cerebral angiographic studies from 220 patients, which comprise the basis for this work, are about 60 per cent retrospective and 40 per cent current material. In most cases local anesthesia was used without premedication. In each, at least 3 lateral and 2 anteroposterior views were obtained on a radiographic skull unit with a manual film-changer. Injections employed were 7 ml. of 50 per cent Hypaque into the common carotid artery, 5 ml. into the internal carotid artery, or 4 ml. into the vertebral artery. In the following instances a deliberate attempt was made to demonstrate the postvcrtebral veins: a. In 15 cases of opacification of postvertebral veins on the routine lateral phlebogram, an additional injection was made into the artery with exposure of 2 anteroposterior films of the neck during the venous phase. b. In 3 cases in which a catheter hadalready been placed in the internal carotid artery and the vertebral veins were opacified, the patients were turned to the prone position, and an additional injection was made with exposure of 3 lateral films during the venous phase. In 19 examinations, patients were instructed to continue normal rate and depth of respiration during the injection so as to avoid a Valsalva maneuver. Opacification was graded as slight, moderate, or marked, according to the density of opacification and the number and size of opacified veins which ranged from a few small ones to large leashes of veins or venous trunks. Radiologic Appearances The postvertebral neck veins are commonly observed on routine lateral views during the intermediate or late venous phase after carotid or vertebral artery injection. Opacification is occasionally pronounced, as in Figure 1 (Case I) which demonstrates numerous suboccipital veins and a large venous trunk following right common carotid artery injection. Similar veins were opacified in this case subsequent to left vertebral artery injection. Such an appearance might readily be mistaken for a vascular malformation. The anatomic variety of these veins is illustrated in a second case (Fig. 2, A) in which opacification of two large trunks extended from the occiput to the lower cervical region after contrast injection into the right internal carotid artery. These large vessels are thought to be ascending rami of the transverse cervical veins (13). Because of their posterior position, the various veins are collectively called postvertebral (4).