Plain Film Studies Research Articles

Unenhanced dynamic mediastinal computed tomography in the selection of patients requiring thoracic aortography for the detection of acute traumatic aortic injury

In our institution, the selection of patients who require thoracic aortography to evaluate for acute traumatic aortic injury (ATAI) is based upon an appropriate mechanism of injury and radiologic demonstration of a mediastinal hematoma. When plain chest or chest and/or mediastinal radiographs demonstrate a mediastinal hematoma, the patient undergoes thoracic aortography as promptly as is clinically feasible. If the plain film studies are negative for mediastinal hematoma, thoracic aortography is not performed because the patient is presumed not to have an ATAI.

The role of previous radiographs and reports in the interpretation of current radiographs.

The authors studied radiologists' patterns of using old reports and previous radiographs in the interpretation of current radiographic studies. Supplying information from previous studies is considered necessary for accurate interpretation; however, it is not clear how this information is used. Eighteen radiologists interpreted 305 plain-film studies in a general radiologic interpretation area. Radiologists described their perceptions of the use of previous radiographs and reports in film interpretation. Overall, old films were used for 99% of interpretations and previous reports were used for 65%. Prior information increased confidence in 89% of cases, influenced diagnosis in 56% of cases, and assisted in detecting new pathology in 6% of interpretations. Old radiographs were judged most valuable in documenting the progression, regression, or stability of disease in 89% of cases. Previous reports were principally used to obtain patient history (43%). In no cases did the radiologist perceive that the old reports assisted in locating new pathology. Old films are judged more valuable than reports for documenting disease progress, and radiologists are unlikely to accept written reports as a substitute. Previous reports are used principally to improve clinical histories, a function that might be eliminated if adequate clinical data could be captured by other means.

AIDS: Radiologic findings in the thorax and abdomen

Thoracic manifestation of AIDS are initially diagnosed on plain film studies. Pneumocystis carinii infections are characterised by bi-hilar streaky, interstitial and diffuse micronodular infiltrations. These findings are best seen on thoracic CT examinations.

Diagnostic imaging of the temporomandibular joint: recommendations for use of the various techniques.

The indications for an imaging study of the TMJ are the same for MR, CT, and arthrognaphy; only those for a plain film study differ. In general, an examination is warranted (1) when the diagnosis of an internal derangement is in doubt and must be established before therapy can be instituted; (2) if the diagnosis is not in doubt but confirmation or documentation is required, such as for third-party payers and in medicolegal cases; (3) pneoperatively for disk surgery; and (4) when therapy for a presumed internal derangement has failed and doubt about the diagnosis arises. Note that this set of indications excludes many patients with clicking, painful joints who will have conservative treatment. We believe it is impontant to emphasize that not every patient with an internal derangement needs to have an imaging study. An internal derangement of the TMJ is basically an anterionly displaced disk. Although joint dynamics, capsular tears, adhesions, and disk perforations also can be imaged, they are usually incidental findings that are not treated differently from the accompanying displaced disk. Only when it is decided that an imaging study should be performed is it necessary to decide which type of study is appropriate. Choosing the type of study that is appropriate will depend on what is available and what information the referring clinician desires. Each imaging technique has its strengths and weaknesses (Table 1); however, in most cases the only information required is the disk position.

Radiology in the diagnosis of splenic abscess.

Radiologic findings in 20 patients with splenic abscesses were reviewed. Chest roentgenograms frequently showed abnormalities which were nonspecific and nondiagnostic. Results of barium sulfate studies were normal in 66.7% of patients tested. Gas beneath the left side of the diaphragm or within the splenic shadow was revealed by abdominal plain film or barium sulfate study in three patients. Focal splenic abnormalities were present in 50% of the patients who underwent 99mTc sulfur colloid scans; in 71.4% of patients who underwent 67Ga scans, increased uptake of isotope was seen in the left upper quadrant of the abdomen. In only one of six patients who underwent both 99mTc and 67Ga scans did results show corresponding abnormalities. Pathologic findings in the left upper quadrant of the abdomen were detected by ultrasonography in three of five patients. Angiography confirmed splenic abscess in one patient. Abnormal splenic lucencies were seen on computed tomography in four patients, although one repeat scan was interpreted as normal. Although no one technique consistently detected splenic abscesses and data from several studies are combined, computed tomography appears the best modality. The diagnosis of splenic abscess and the decision for surgical intervention should be based on clinical impressions, even in the absence of unequivocal radiologic findings.

CT of Maxillofacial Trauma

Failure to recognize facial fractures is an important cause for later cosmetic and functional complications. Using limited preliminary plain film study in the Water's projection can usually predict the need for more sophisticated imaging and can serve as a basis for proper planning of CT examination, the procedure of choice when more sophisticated imaging is indicated. This article describes how and when to use CT, with an emphasis on which projection(s) to use for which injury.

The Radiology of Osteomyelitis

In the early stages of acute osteomyelitis, bone scanning is especially helpful. It is important to correlate the bone scan with clinical findings because the scan is nonspecific. Radiograms reveal the extent of disease, but may lag behind clinical findings; however, plain film studies may reveal sequestra not seen by other means. Gallium scanning may be of value in osteomyelitis, as may be computerized tomography.

RADIOGRAPHIC EVALUATION OF THE GASTRIC STAPLING PROCEDURE FOR OBESITY IN 100 PATIENTS

Gastric surgical procedures for therapy of obesity have gained renewed Interest following problems due to complications of small bowel bypass approaches. One such procedure is isolation of the gastric fundus using surgical stapling instruments. Evaluation of 100 patients receiving this procedure included routine radiographic approaches with plain film and oral contrast studies with water-soluble contrast and barium; ultrasonic and computerized tomography of the abdomen as well as nuclear medicine scanning techniques for abscess detection in patients with suspected anastomotic leaks; as well as study of the physiology of the fundic remnant with oral isotopic methods using labeled solid and liquid phase emptying rates as compared with normals. Results indicate a complication rate of approximately 5%. The spectrum of complications include early post-surgical problems due to obstruction of the remnant outlet and anastomotic leak with and without abscess formation; delayed problems include failure of therapy due to alteration of the remnant from overeating and development of esophageal reflux not present prior to surgery. This procedure appears to be a successful approach to therapy of morbid obesity and with increased usage will require radiologic evaluation in a broad spectrum of clinical settings.

THE EFFECT OF CHANGES IN LIVER VOLUME ON THE ADJACENT VISCERA

A complex interrelationship exists between the liver and several intraperitoneal and extraperitoneal structures. Recognition of the radiographic effects of changes in liver size, hepatic displacement of other organs and tissues, variations in body build, and changes in the position of the patient can be most important in the differential diagnosis of many diseases.

Roentgenological observation in the disease of biliary tract by plain film study of abdomen

Roentgenological observation in the disease of biliary tract by plain film study of abdomen

Computed tomography in the diagnosis of an atlas fracture

New uses of computed tomography are being discovered and reported daily. We report yet another application in a case of a fracture of the atlas. While the fracture was suspected on the plain film study and on the linear tomograms, it could be demonstrated only by computed tomography. CT is ideally suited for cross-sectional visualization of the spinal canal and is recommended when fractures of the cervical spine are suspected by history on clinical findings.

Cholelithiasis in children.

Review of 367 cases of cholelithiasis in children from the literature and our experience showed that 81% of these patients has no evidence of hemolytic anemia. Oral cholecystograms were diagnostic of cholelithiasis in approximately 70% of these cases. Plain film studies were found to be of diagnostic value as a high percentage of gallstones were visible on plain radiographs of the abdomen.

The pre-operative diagnosis of renal hamartoma

The characteristic angiographic findings in renal hamartoma consist of: a large dilated feeding vessel passing through the mass, multiple multisacculated aneurvsmal dilatations (bunch of grapes), a delicate discrete discrete neovascularity without A-V shunting, and 'onion peeling' on the venous phase. In addition radiolucent areas within the renal mass indicate a high fat content. When these findings are present renal hamartoma can be diagnosed confidently. Racial nephrectomy and needless sacrifice of a whole kidney for a benign lesion can be avoided. Heminephrectomy may be sufficient, thus saving the patient valuable renal tissue. Four cases of renal hamartoma are presented. Plain film and angiographic studies are shown. All four showed the characteristic angiographic findings of renal hamartoma and were diagnosed pre-operatively.

The value of tomography of the sterno-clavicular region

Nine patients out of a series of 20 are presented illustrating some of the conditions which may affect the sterno-clavicular region (SCR). The value of tomography as a routine procedure in the study of the SCR is stressed, as in many cases the plain film studies fail to reveal clear-cut evidence of pathological changes. Establishing the exact aetiological nature of the lesion is not always possible by means of radiology alone. However, the radiological demonstration of disease in the SCR is invaluable as a guide to the further management of the patient.

Alimentary Tract Roentgenology.

In the six years since Margulis and Burhenne's Alimentary Tract Roentgenology was first printed, it has established itself as a basic reference for all practicing radiologists, radiology residents and other physicians involved in the diseases of the gastrointestinal tract. During this interval new techniques and new concepts have been developed, new insights into the pathophysiology of gastrointestinal disease have been formed, and the role of the radiologist in the diagnosis and overall management of gastrointestinal disease has substantially expanded. These changes are reflected in the second edition of Alimentary Tract Roentgenology which became available in the fall of 1973. The new text is approximately 500 pages longer, the number of illustrations is more than double while avoiding duplication of content, and the index has been expanded from 15 to 42 pages, greatly enhancing the usefulness of the text as a rapid reference source. Two new chapters on physiology provide clear, concise, and up-to-date information on the normal mechanisms involved in digestion and absorption. Emphasis on the radiographic correlation with pathophysiology is initiated here and continued throughout much of the new material. Sections dealing with pathology have now been integrated into each separate anatomical division, thereby increasing its exposure and utilization, while serving to emphasize the close relationship that must exist between the two diagnostic methods. New chapters dealing with abdominal trauma and motility disorders of the esophagus fill a void which had detracted from the overall value of the first edition. The chapter on colonic polyps has been brought up-to-date with a concise discussion of the polyposis syndromes. A major addition to the section on the liver and biliary tract is Arthur Clemett's new chapter, in which he uniquely combines cholangiography, arteriography and portography, isotope scanning, barium contrast and plain film studies to clearly portray a host of congenital, inflammatory, vascular, and neoplastic abnormalities of the liver and biliary tree. Burhenne's chapter on the biliary tract includes a discussion on the removal of retained common duct stones, a technique of immense clinical value. Its recognition and inclusion in this text will assist greatly in the widespread application of this exciting technique. The increased use of arteriography in the abdomen is reflected in the expanded chapter devoted to this topic. The illustrations are excellent and the bibliography is current. In summary, this new edition of Alimentary Tract Roentgenology has substantially increased in value over the original text as an inclusive reference work on the radiology of gastrointestinal disease. It belongs in every radiologist's library.

The preoperative identification of the abnormal parathyroid--current status.

Physicians more alert to the subtle systemic manifestations of hyperparathyroidism are diagnosing the disease with increased frequency. Coincident with the increase in diagnosis is a renewed interest in the preoperative identification of the abnormal parathyroid by radiologic means. Radiologic localization should aid the surgeon in his operative search for these elusive organs. Thyrocervical arteriography, pneumomediastinography, esophageal cineroentgenography, and plain film studies have been advocated to identify the abnormal parathyroid. Arteriography occasionally demonstrates a tumor stain or vascular deflection by a mass. When positive, the arteriogram can be of considerable help; however, the false negative rate is high in the few small series which have been published (1–4). The initial enthusiasm for routine esophageal fluoroscopy (5) has not withstood the test of time (6), but recent reports of esophageal cineroentgenography are encouraging (7). Radioisotopic labeling of the parathyroid may permit a functional evaluation in addition to the anatomic localization of abnormal tissue. Sisson and Beierwaltes (8), using cobalt-57-labeled cyanocobalamine, demonstrated increased parathyroid concentration of this compound over surrounding thyroid tissue and neck muscles, but the label was not" sufficiently selective to be detected externally. Workman (9), with intraoperative probe counting, identified hyperactive parathyroids with this compound. Abnormal parathyroids have been located by external scintiscanning with Se75 se1enomethionine (10–15). The clinical results to date have been encouraging albeit frustrating. The basic premise, that neck tissues which most actively synthesize protein would pick up more labeled amino acid than surrounding structures, was initially substantiated in the rat (16). In these experiments, autoradiography demonstrated that a stimulated parathyroid would accrete more tritiated methionine than the neighboring suppressed thyroid gland. A low calcium diet stimulated the uptake by normal parathyroid, and thyroid hormone pretreatment suppressed the thyroid uptake. Methionine was selected because it is the only amino acid with an available gammaemitting analogue for external detection. Se75 selenomethionine, in which there is an isomorphous substitution of Se75 for sulfur, had been used for pancreatic scanning. Se75 selenomethionine behaves similarly to methionine in protein synthesis. Subsequent experiments have confirmed the affinity of the hyperactive parathyroid gland for this amino acid analogue. Following the initial rat experiments a patient with overt hyperparathyroidism was given 200 μc of Se75 selenomethionine one hour prior to the surgical excision of a large parathyroid adenoma (17). The patient had been treated with triiodothyronine (100 μg/day) for three days.

LEFT-SIDED ANGIOCARDIOGRAPHY IN INFANTS: METHODS AND INDICATIONS.

Of the many technics for left-sided angiocardiography that have been employed in the past (3, 9–11, 13, 16–18), in our experience the retrograde approach to selective aortic and left ventricular angiocardiography (left-sided angiography) has proved safe and invaluable. Details of the percutaneous technic of left-sided angiography in various acquired and congenital cardiac malformations seen at our institution, the University of Minnesota Hospitals, Minneapolis, were recently described by Amplatz (2). His report, however, was confined to adults and children over two years of age. As the technics concerned with infants are specific and differ from those for older children and adults, it seemed appropriate to describe the method of selective left-sided angiography as performed in 120 infants with congenital cardiac disease. The patients comprising the material for this report were observed during the period from July 1962 through December 1963. Several representative cases serve as specific examples in portraying the indications and the clinical value of these studies. Of the 120 infants undergoing left-sided angiography, 40 were six weeks of age or less, 32 were between the ages of six weeks and six months, 18 were between six months and one year, and the remaining 30 were between one and two years of age. Method It is important to point out that selective left-sided angiography may be employed to good advantage in two situations. The first, and less frequent, is as an isolated procedure. The second is as an adjunct to right- and left-sided cardiac catheterization. Retrograde arterial catheterization in infants is performed usually in the surgically isolated right brachial artery at the antecubital fossa. It is important to rule out aberrant right subclavian artery by plain film studies. A generous incision is made over the medial aspect of the right antecubital fossa, the exact site being determined by palpation of the artery. The brachial artery and accompanying vein are isolated by blunt dissection. One of the important keys to a successful study is avoidance of arterial spasm, generally the result of excess trauma to the brachial artery. The artery is separated from the accompanying vein, and #00 silk or 1/4 in. umbilical tape is passed under the artery distally and proximally to facilitate isolation of the vessel. A loose "granny" knot, placed proximally, acts as an emergency ligature. Next, a Teflon catheter needle (inner needle ranging in size from #22 to #18 gauge), identical to that described by Amplatz, is inserted into the artery (Fig. 1). Insertion is facilitated by slight traction upon the distal silk ligature in a direction opposite that of the advancing needle. The inner needle is then removed, and the Teflon sheath is advanced, left in place, and connected to a saline drip by a 3-way stopcock.

Roentgen Diagnosis of Abdominal Tumors in Childhood.

The thesis is simple and not new. A mass in the child's abdomen can be accurately located by radiologic examination. Conventional, plain film study is used first. Barium gastrointestinal study and enemas, excretory and retrograde urography, and intravenous cholangiography follow if needed. These examinations, affording observations of the size of the mass, its contour, variation with change in position, presence of calcification, or other internal characteristics, can then be correlated with the clinical and laboratory findings and the sex and age of the patient to give an accurate diagnosis in the light of statistical probability. The more complicated less readily available radiographic techniques, such as presacral gas inflation and aortography, are only rarely needed. Simple and as obviously worthy as this thesis of Drs. Nice, Margulis, and Rigler may be, it needs reiteration. They have written a book limited in scope, yet their coverage of their subject is complete. Necessary

Plain film diagnosis of fulminating ulcerative colitis.

Fulminating ulcerative colitis is a grave form of idiopathic ulcerative colitis, and its management is invariably an extremely difficult problem, demanding skillful application of medical and surgical technics. We have recently examined 26 cases of colitis of this type in which a striking and frequently specific appearance of the colon was observed on plain radiographs of the abdomen. The value of the plain film in this condition, apart from its demonstration of colonic distention, has received virtually no attention in the literature, despite the other gross alterations which may be visible in the gas-filled bowel. Because the severity of the illness and the likelihood of perforation often preclude any more elaborate radiological procedures, it seems pertinent to discuss these radiographic changes and relate them to the clinical and pathological aspects of the disease. Large series at this hospital and elsewhere have shown that about one in twenty cases of ulcerative colitis will be of the fulminating variety, either initially or as an exacerbation of pre-existing chronic colonic disease. In our group of 26 cases, more than one-third appeared with the fulminating episode as the initial manifestation. The term fulminating is used by Bockus (1) to describe those cases of acute ulcerative colitis in which “the onset is relatively abrupt and the severity of the attack may reach its peak in two or three weeks. The attack may continue for weeks or months and terminate fatally, pass into a chronic stage, or into a remission.” The clinical picture is striking, with cardinal symptoms of abdominal pain, bloody diarrhea, vomiting, high fever, and prostration, which may develop within a few weeks or occasionally in a few days. Abdominal distention with localized or diffuse tenderness is present, and peristalsis is diminished. Proctoscopy and sigmoidoscopy almost invariably reveal an active ulcerating disease process. The diagnosis, therefore, is usually established on the basis of clinical findings. However, the presence of abdominal pain and distention usually prompts a plain film study and this affords the radiologist an opportunity to make the definitive diagnosis. In any case, it enables him to give valuable confirmatory information. The plain film may also uncover possible complications and additional disease processes, and occasionally, when diarrhea has not been a feature of the illness, clinically unsuspected colitis may be recognized. Pathology Following total colectomy in cases of fulminating colitis, a striking feature frequently found on examination of surgical specimens is irregular thickening of the bowel wall throughout its entire length, or width, or both. The wall is friable and the thickening is due to inflammatory infiltration, primarily of the mucosa, often also of the muscular layer, and even of the serosa.