Penetrating trauma to the abdominal aorta: CT demonstration of active bleeding

Contrast-enhanced helical computed tomography (CT) is the imaging study of choice for evaluating the abdomen in hemodynamically stable patients following blunt trauma. Surviving victims of penetrating trauma, in contrast, are often hemodynamically unstable and may require urgent celiotomy with or without diagnostic peritoneal lavage (DPL) or ultrasonography. Abdominal CT is not routinely performed in this patient population, but may be done if the patient with penetrating abdominal trauma is stable on admission or becomes so with resuscitation. CT in this context can address questions regarding the location and extent of injury and help decide appropriate management. We present a case of a stabilized blunt and penetrating trauma patient with negative DPL and active retroperitoneal aortic extravasation demonstrated by CT. To our knowledge, penetrating injury to the aorta with active bleeding has not been previously seen on CT.     

CT evaluation of appendicitis and diverticulitis. Part II: Diverticulitis

CT has become the primary imaging modality for evaluation of possible diverticulitis. In studies of patients taken to surgery for suspected diverticulitis without first undergoing CT, 25–33 % of resected specimens show no inflammation. The overall accuracy of CT in establishing or excluding the diagnosis is between 84 and 99 %. In patients without diverticulitis, an alternative diagnosis is seen in 50–58 % of cases. The appearance of carcinoma with perforation and diverticulitis may be the same, and, as a result, the degree of certainty in the diagnosis should be stated. Techniques include use of either oral and intravenous contrast or rectally administered contrast. No case of colonic perforation due to rectally administered water-soluble contrast for CT has been reported, although there have been cases of perforation using barium and fluoroscopy. All techniques scan the entire abdomen and pelvis since there are frequent alternative diagnoses seen beyond the area of initial pain.     

Blueberry juice used per os in upper abdominal MR imaging: composition and initial clinical data

The aim of this study was to evaluate the use of a commercially available blueberry juice (BJ) both as a positive and negative oral contrast agent and to present the exact contents of paramagnetic ions. The concentration of Mn and Fe were determined in tinned myrtilles in syrup (atomic absorption). Nine healthy volunteers and 12 patients (age range 20–65 years) were examined using a 1-T MR scanner before and after per os administration of 430 ml of BJ. A qualitative analysis of signal alterations in the stomach, duodenum, and proximal small intestine was performed. In addition, a quantitative analysis was assessed in terms of signal-to-noise ratio calculation. The mean concentration ( ×± SD) of the ions found in the content of the three cans were 3.3 ± 0.4 μg/g for iron and 20.6 ± 2.6 μg/g for manganese. Based on the qualitative evaluation, signal alteration on T1-weighted images after administration of BJ was statistically significant in the stomach and duodenum, but not in the proximal small bowel. Signal alteration on T2-weighted images was not statistically significant in any part of the gastrointestinal tract. The quantitative analysis of the T1- and T2 shortening showed that BJ is efficient with only T1-weighted sequences, and this applied to the stomach, duodenum, and proximal small bowel. Blueberry juice can be used as an oral contrast agent in upper abdominal MR for T1-weighted imaging. Received: 7 September 1999; Revised: 29 November 1999; Accepted: 16 February 2000     

MRI of bone marrow disorders

Four factors can be used in MR of bone marrow: fat–water distribution, artifacts induced by bone trabeculae, diffusion, and uptake of contrast media. Fat–water is imaged using T1-weighted spin-echo, short tau inversion recovery (STIR), and fast STIR, in- and out-of-phase gradient echo, and fat pre-saturation sequences; bone trabeculae by gradient echo with long TE; diffusion by single-shot spin-echo. The injection of contrast media is a more easy and efficient way to improve the specificity. The value and limitations of those sequences are discussed in marrow replacements (metastases, lymphoma, leukemia) and in myeloid hyperplasia or depletion.     

CT evaluation of appendicitis and diverticulitis. Part I: Appendicitis

CT has become the primary imaging modality for evaluation of possible appendicitis. About 20 % of patients taken to surgery for appendicitis without CT have had a normal appendix removed. CT has demonstrated overall accuracy of between 93 % and 98 %. Alternative diagnoses are seen in 34–80 % of patients without appendicitis but who were suspected of having appendicitis. For evaluation of appendicitis different techniques have been successful, including the use of no contrast, use of oral and intravenous contrast, and use of rectally administered contrast. Scanning of the entire abdomen and pelvis and scanning of an area limited to the right lower quadrant are also options. Ultrasonography has been shown to have a role in pediatric patients. If ultrasonography is positive, CT is not necessary. If ultrasonography is negative, CT should follow.     

Diagnostic imaging of suspected appendicitis in pregnant women: comparison of CT to ultrasonography

Purpose: To compare the sensitivity and specificity of CT versus ultrasonography for the diagnosis of appendicitis in a population of pregnant women. Materials and methods: Radiology records (1988–1999) were searched for results of examinations performed on pregnant patients with suspected appendicitis. Subjects included only women with known intrauterine pregnancies. Thirty-two pregnant women were identified who had been studied by CT, ultrasound, or both. Ten patients had undergone focused abdominal CT with colon contrast, while 29 had undergone abdominal or pelvic ultrasonography with attention to the appendix. Results were compared to surgical pathology or follow-up findings. Results: CT sensitivity was 100 %, specificity 100 %, positive predictive value (PPV) 100 %, negative predictive value (NPV) 100 % and accuracy was 100 %. Ultrasound sensitivity was 100 %, specificity 83 %, PPV 50 %, NPV 100 %, and accuracy 21 %. Conclusion: In this small cohort of gravid females with suspected appendicitis, the sensitivity of focused abdominal CT with colon contrast was equal to that in the nonpregnant patient. In contradistinction to this, abdominal ultrasonography was frequently indeterminate. We hypothesize that ultrasonography is less accurate due to body habitus and the variable location of the appendix during pregnancy.     

T1-relaxation kinetics of extracellular, intracellular and intravascular MR contrast agents in normal and acutely reperfused infarcted myocardium using echo-planar MR imaging

The objective of this study was to determine and compare if MR contrast agents distributed into various compartments can provide estimation of fractional distribution volume (FDV) in normal and infarcted myocardium using inversion recovery echo-planar MR imaging (IR EPI). Three different types of MR agents were investigated: (a) an extracellular agent, GdDTPA-BMA (0.1 mmol/kg); (b) an intravascular agent, GdDTPA-albumin (0.025 mmol/kg); and (c) an intracellular agent, manganese chloride (0.025 mmol/kg). The null point was determined from a series of IR EPI images in which TI was varied. Temporal changes in ΔR1 (ΔR1 = 1/T1_post-1/T1_pre) were measured during the initial 29–59 min after administration. Rats (n = 24) were subjected to 1-h coronary artery occlusion/reperfusion. Histochemical staining confirmed the presence and location of infarction. GdDTPA-BMA caused increase in ΔR1 of infarction < blood < < normal myocardium. ΔR1 ratios were 1.55 ± 0.08 for infarction and 0.33 ± 0.03 for normal myocardium, consistent with FDV of 0.82 ± 0.04 and 0.18 ± 0.01. The fractional distribution of this agent in normal myocardium approximated the extracellular space of myocardium. GdDTPA-albumin caused increase in ΔR1 of blood < < infarction < < normal myocardium. ΔR1 ratio in normal, but not infarcted, myocardium was constant at 0.10 ± 0.02 and approximated fractional blood volume. MnCl₂ caused equivalent increase in ΔR1 of normal and infarcted myocardium. ΔR1 of normal myocardium did not change overtime, whereas ΔR1 of blood rapidly decreased, leading to overestimation of FDV in normal and infarcted myocardium. In conclusion, extracellular, intravascular and intracellular MR contrast agents exhibited different T1-relaxation kinetics in both normal and infarcted myocardium. Constant ΔR1 ratio (myocardium/blood) after administration of MR contrast agent is a prerequisite for estimation of FDV of MR contrast agent in myocardium. Received: 22 December 1998; Revised: 7 April 1999; Accepted: 18 May 1999     

Delayed allergy-like reactions to X-ray contrast media: mechanistic considerations

Iodinated X-ray contrast media are among the most frequently used pharmaceuticals for intravascular administration. Although the newer low osmolality, nonionic contrast media, are generally well tolerated, it is well known that they, like the ionic contrast media, give rise to immediate or delayed adverse reactions in susceptible individuals. In the present review, the delayed allergy-like reactions, which by definition occur more than 1 h after contrast medium administration, are described, and the possible pathophysiological mechanisms discussed. Delayed allergy-like reactions to contrast media, which have been reported to occur in 0.5–2 % of recipients, are mainly mild to moderate skin reactions of the maculopapular exanthematous and urticarial/angioedematous types. Most of the reactions become apparent after a latency of 3 h to 2 days and disappear within 1 week. The incidence of more severe reactions is extremely low. Main risk factors for delayed allergy-like reactions appear to be a previous contrast medium reaction, a history of allergy, IL-2 treatment and being of Japanese descent. At present, the exact pathogenesis of these delayed reactions is still unclear. There is, however, increasing evidence that a significant proportion of the reactions are T-cell mediated. Received: 27 December 1999; Revised: 23 March 2000; Accepted: 26 May 2000     

A prospective comparative study of non-contrast helical computed tomography and intravenous urogram for the assessment of renal colic

Objective: To compare noncontrast helical computed tomography (NCHCT) and intravenous urography (IVU) for diagnosis of urinary calculi in evaluation of renal colic. Materials and methods: A 4-month prospective paired study compared NCHCT and IVU in patients being evaluated for renal colic. Each patient was studied with NCHCT followed by an IVU. An IVU was regarded as positive if any of the following were identified: delayed filling, hydronephrosis, hydroureter, ureteral calculus, or extravasation of contrast. A NCHCT was regarded as positive if any of the following were identified: hydronephrosis, hydroureter, ureteral calculus, or perinephric or ureteral inflammatory change. The sensitivity (Se), specificity (Sp), positive predictive value (PPV), and negative predictive value (NPV) were reported using the clinical outcome as the gold standard, by either observation of passage or retrieval of calculus. Bladder distention was noted on NCHCT relative to the level of the acetabulum. The charts were also reviewed retrospectively for the results of urinalysis. Results: One hundred sixty-eight patients had both examinations interpreted. Nineteen positive NCHCT and IVU studies were eliminated due to lack of observation or retrieval of calculus, leaving 149 studies for interpretation. NCHCT had Se 0.98, Sp 0.95, PPV 0.98, and NPV 0.95. IVU had Se 0.83, Sp 0.95, PPV 0.97, and NPV 0.67. In 13/168 (8 %) cases, and in 9/37 (24 %) negative cases, NCHCT offered an alternative diagnosis. Ureterovesical junction (UVJ) calculus was identified on 84 NCHCT scans, with near-even distribution between well, partially, and poorly distended bladder. No UVJ calculus was identified on IVU that was not present on NCHCT. Absence of hematuria was found in 26 % of patients with proven urolithiasis. Conclusion: NCHCT is superior to IVU for the evaluation of renal colic. NCHCT identifies significant pathology in 24 % of cases negative for ureteral obstruction/calculus. Bladder distention does not play an important role in detection of UVJ calculus. Hematuria is not universally present in patients with painful urolithiasis.     

Safety of colon contrast material in (helical) CT examination of patients with suspected diverticulitis

Purpose: Today patients with suspected diverticulitis are commonly imaged with a CT scan utilizing a variety of methods of contrast medium administration. Although CT with rectally administered colon contrast has demonstrated a high diagnostic accuracy, concerns have been raised over its safety in patients with diverticulitis. The following retrospective investigation was undertaken to answer this concern. Materials and methods: Between January, 1997, and July, 1999, 308 patients with suspected diverticulitis were examined in the Emergency Radiology Division of the Massachusetts General Hospital by means of a helical CT scan performed with rectally administered colon contrast material. The patients' CT findings were correlated with their clinical courses and/or surgical findings. Results: Of the 308 CT scans, 115 (37.3 %) were positive for diverticulitis. Of 193 patients without diverticulitis, 91 (47.1 % of patients without diverticulitis) had alternative diagnoses made by CT, such as small bowel obstruction, epiploic appendagitis, and urinary tract calculi. No complications due to colon contrast material were noted. Even in cases where there was free extraluminal air, no extravasated contrast material was seen. Rectally administered colon contrast was well tolerated by patients and provided excellent large bowel opacification. This method saved imaging time in an emergency setting, as there was no need to wait for oral contrast to reach the colon. Conclusion: Out of 308 CT scans, there were no complications from the use of rectally administered colon contrast material. No case of traumatic bowel perforation secondary to colon contrast material was observed. Rectally administered colon contrast material is safe in the CT examination of patients with suspected diverticulitis.     

Pancreatitis: computed tomography and magnetic resonance imaging

The value of CT in management of severe acute pancreatitis is well established. Some, but not all, experimental studies suggest a detrimental effect of intravenous iodinated contrast agents in acute pancreatitis, but although initial clinical data tends to support this, the positive advantages of enhanced CT outweigh the possible risks. Magnetic resonance imaging has been shown to be as effective as CT in demonstrating the presence and extent of pancreatic necrosis and fluid collections, and probably superior in indicating the suitability of such collections for percutaneous drainage. Image-guided intervention remains a key approach in the management of severely ill patients, and the indications, techniques and results of radiological intervention are reviewed herein. Both CT and MRI can be used to diagnose advanced chronic pancreatitis, with the recent addition of MRCP as a viable alternative to diagnostic endoscopic retrograde cholangiopancreatography (ERCP). Both MRCP and CT/MR imaging of the pancreatic parenchyma still have limitations in the recognition of the earliest changes of chronic pancreatitis – for which ERCP and tests of pancreatic function remain more sensitive – but the clinical significance of these minor changes remains contentious. Received: 12 February 1998; Revision received: 17 June 1998; Accepted: 22 June 1998     

Prognostic value of perfusion- and diffusion-weighted MR imaging in first 3 days of stroke

The aim of this study was to evaluate the differences in cerebral perfusion seen on mean transit time (MTT) and cerebral blood volume (CBV) maps and to assess the subsequent prognostic value of the MTT–DWI (diffusion-weighted MRI) and CBV–DWI mismatch in the first three days of stroke on lesion enlargement and clinical outcome. In 38 patients, imaged 1–46 h after onset of symptoms, lesion volumes on proton-density (PD)-weighted MRI, DWI and PWI (both MTT and CBV maps) were compared with lesion volumes on follow-up PD-weighted scans, and to clinical outcome (National Institutes of Health Stroke Scale, Barthel index, and Rankin scale). The MTT-CBV, MTT–DWI and CBV–DWI mismatches were compared with change in lesion volume between initial and follow-up PD-weighted scans. Lesion volume on both DWI and PWI correlated significantly with clinical outcome parameters (p < 0.001) with strongest correlation for lesion volume on CBV. Perfusion–diffusion mismatches were found for both CBV and MTT and correlated significantly with lesion enlargement on PD-weighted imaging with strongest correlation for the CBV–DWI mismatch. The CBV–DWI mismatch has the highest accuracy in predicting lesion size on follow-up imaging and in predicting clinical outcome. Lesion volume measurements on CBV maps have a higher specificity than on PD-weighted, MTT or DWI images in predicting clinical follow-up imaging and in predicting clinical outcome. Received: 21 January 2000; Revised: 18 April 2000; Accepted: 20 April 2000     

Focal airtrapping at expiratory high-resolution CT: comparison with pulmonary function tests

This study was undertaken to determine prevalence, extent, and severity of focal airtrapping at expiratory high-resolution CT, and to compare focal airtrapping with age, gender, pulmonary function tests, and blood gas analysis. Two-hundred seventeen patients with and without pulmonary disease underwent paired inspiratory/expiratory high-resolution CT. Six scan pairs with corresponding scan levels were visually assessed for focal – not diffuse – airtrapping using a four-point scale. Pulmonary function tests and blood gas analysis were available for correlation in all patients (mean interval 5 days). Focal airtrapping with lower lung predominance was observed in 80 % of patients. Twenty-six of 26 patients with restrictive lung function impairment exhibited focal airtrapping (mean score 2.4), whereas only 72 of 98 (74 %) patients with obstruction did (mean score 1.5; p < 0.05). Fifty-eight of 70 (83 %) patients with normal lung function (mean score 1.8) and 19 of 23 (83 %) patients with mixed impairment (mean score 1.8) had focal airtrapping. Focal airtrapping showed negative correlations with static lung volumes (–0.27 to –0.37; p < 0.001) in all patients and moderate positive correlations with dynamic parameters (0.3–0.4; p < 0.001) in patients with obstruction. No significant correlations were found with age, gender, and blood gas analysis. Visual assessment of focal – not diffuse – airtrapping at expiratory high-resolution CT does not correlate with physiological evidence of obstruction as derived from pulmonary function tests since the perception of focal airtrapping requires an adequate expiratory increase in lung density. Received: 11 February 2000; Revised: 8 June 2000; Accepted: 9 June 2000     

Anterior subluxation of the cervical spine

Anterior subluxation (AS), or hyperflexion sprain, generates a disproportionate level of concern in emergency medicine. Anxiety related to this injury arises from the fact that AS may produce delayed mechanical instability of the cervical spine, with resultant pain and neurological impairment. Furthermore, its radiographic presentation may be very subtle, and it may be impossible to reliably diagnose or exclude this injury using standard screening radiographs. Additional studies, such as flexion–extension (FE) radiography and magnetic resonance (MR) imaging, are often used in the acute setting to assess injury status and radiographically exclude AS injury. There are a number of reasons to discourage this latter practice, which can represent an impossible attempt to “radiographically clear the cervical spine” of blunt trauma patients with “100 % certainty.” This is because AS is an uncommon lesion, and the neurological deficits secondary to delayed instability are almost always minor and transient. Furthermore, AS is usually not entirely occult on screening plain films (which are typically “abnormal” even if in nonspecific ways). Finally, FE imaging, done acutely in the presence of spasm, is probably unable to exclude this diagnosis reliably, even when plain films are normal, and emergent MR, probably the most accurate technique, is not widely available. Risk stratification provides a rational alternative approach for assessing injury status. Low-risk patients may be spared further imaging provided they are given appropriate precautionary return instructions. High-risk patients require emergent evaluation by an experienced spine specialist, and may benefit from advanced imaging. Patients at moderate risk may be best managed with symptomatic treatment, warnings to avoid significant physical activity, and delayed FE imaging and evaluation by a spinal specialist. They should also be instructed to seek immediate medical attention if they develop any indications of delayed instability, including severe pain and /or neurological signs. This stratified approach not only increases the likelihood that delayed subluxation will be recognized before it leads to chronic instability, but frees clinicians and radiologists from the quixotic burden of trying to “clear” the cervical spine with 100 % certainty in the acute setting.     

Clinical relevance of gallium-67 scintigraphy in lymphoma before and after therapy

The clinical impact of gallium-67 scintigraphy before and after therapy for lymphoma remains controversial. The aims of this study were: (1) to compare the staging of lymphoma by ⁶⁷Ga scintigraphy only with staging by clinical examination and conventional imaging (CI), and (2) to analyse the clinical relevance of both ⁶⁷Ga imaging and CI after treatment. From March 1995 to November 1998, 86 ⁶⁷Ga scintigraphy studies were performed in 62 patients with Hodgkin’s disease (n=52) or non-Hodgkin’s lymphoma (n=10). ⁶⁷Ga scintigraphy was performed at diagnosis (n=44) or after therapy (n=42) using 185–220 MBq ⁶⁷Ga citrate and planar and single-photon emission tomography (SPET) studies. Treatment comprised radiotherapy, chemotherapy or combined modalities. CI included plain chest radiography, computed tomography (CT) of the chest and abdomen/pelvis, ultrasound of the abdomen, lymphography, bone marrow biopsy and, when necessary, magnetic resonance imaging (MRI) and bone scintigraphy. For individual suspected sites of disease before treatment, complete agreement between clinical examination and CI on the one hand and ⁶⁷Ga scintigraphy on the other hand was observed in 25/44 patients (57%; 95% confidence interval 41%–72%). Clinical examination and CI showed more sites than did ⁶⁷Ga scintigraphy in 12/44 patients (27%) and ⁶⁷Ga imaging demonstrated more sites than CI in 6/44 patients (11%). The clinical stage of the disease as assessed using ⁶⁷Ga scintigraphy only was in agreement with that using all diagnostic procedures in 34/44 patients (77%; 95% confidence interval 62%–89%). Compared with CI staging, ⁶⁷Ga scintigraphy downstaged seven patients (16%) and upstaged three (7%). ⁶⁷Ga scintigraphy downstaged mainly because of the limited value of the technique below the diaphragm and upstaged owing to the good sensitivity in the lung. After therapy, both CI and ⁶⁷Ga scintigraphy were normal in 11 patients. All but one of these patients were in complete remission after a median follow-up of 31 months. In contrast, radiological residual mass was observed in 31/42 patients. ⁶⁷Ga imaging was normal in 22/31 (71%); 17 of these 22 patients, including nine with a large residual mass (≥2 cm), were in complete remission after a median follow-up of 32 months, while four suffered relapses 8–45 months later. The cause of death remained unknown in one patient. ⁶⁷Ga scintigraphy showed abnormal uptake in 9 of the 31 patients with a large residual mass. Active disease was demonstrated in eight patients and one patient was in complete remission 30 months thereafter. Our data show that ⁶⁷Ga imaging cannot replace CI in initial staging but can demonstrate additional individual sites of disease in more than 10% of patients and can lead to clinical upstaging with potential prognostic and therapeutic consequences. After therapy, ⁶⁷Ga scintigraphy has a clinical impact when radiological abnormalities persist because it can either avoid unnecessary complementary treatment or confirm the need to change treatment modalities. Received 5 July and in revised form 9 September 1999     

The “rolling” stones

Calcium deposition may occur in walls of blood vessels and other conduits, within solid organs and tumors, and in the lumen of nearly every hollow structure. Occasionally, calculi seen in one radiograph may present in a different location on subsequent films. These “rolling stones” can make medical management difficult, and an understanding of the forces influencing the movement of calcifications is important when interpreting radiographs. We present examples of calculi which move over time and discuss the factors involved in their movement.     

Occult and secondary injuries missed by plain radiography of the cervical spine in blunt trauma patients

Background: Plain radiography does not visualize every cervical spine injury sustained by blunt trauma victims. The purpose of this study was to examine the prevalence and types of injuries missed by plain radiographs of the cervical spine and determine how frequently such radiography fails to detect any cervical spine injury. Methods: Images from all radiographic studies performed on blunt trauma victims presenting to 21 participating institutions were reviewed to compile an exhaustive list of all CSIs sustained by each individual. These injuries were then compared with the injuries detected by plain radiography alone. Patients were classified as having a “sentinel” injury if one or more of their injuries were visible on plain radiographs. Patients were classified as having a radiographically “occult” injury if none of their injuries were visible on plain radiographs. The number and types of injuries missed on plain radiographs were then separately tabulated for the sentinel and occult injury groups. Results: Plain radiographs were completed in 570 of 818 victims of acute cervical spine injury and revealed 702 of 1,056 injuries. Plain films failed to detect 98 occult injuries present in 60 patients (10.5 %), and failed to detect 256 secondary injuries in 510 patients (89.5 %) who had a sentinel injury identified. Plain radiographs failed to reveal 79 of 136 (58.1 %) lateral mass injuries and 67 of 105 (63.8 %) lamina injuries, making these the most frequent sites of missed injury. Conclusions: Plain radiographs frequently fail to reveal injuries to the cervical spine, particularly those involving the lamina and lateral mass. The majority of the missed injuries represent secondary injuries in patients with a sentinel injury identified on these films. However, plain films fail to detect any injury in a minority of injured patients.     

Helical computed tomography diagnosis of gastrointestinal perforation in the elderly patient

Purpose: To determine the value of helical CT in a consecutive series of elderly patients referred with clinically suspected gastrointestinal perforation. Methods: Our series comprised 34 consecutive elderly patients (mean age: 68 years) presenting with acute abdominal symptoms potentially suggestive of gastrointestinal perforation. All the patients were prospectively subjected to abdominal computed tomography (CT). On helical CT, the presence of free air was considered diagnostic of gastrointestinal perforation. Other findings such as intraperitoneal free fluid, thickening of bowel wall, streaky density within the mesentery, “dirty fat” sign, and focal collection of extraluminal fecal matter (“dirty mass”) were considered indirect findings of perforation. Results: At surgery, the following sites of perforation were found: duodenum (38.2 %), stomach (29.4 %), ileum (8.8 %), sigmoid colon (8.8 %), rectum (5.8 %), and jejunum, appendix, and transverse colon (2.9 % of cases each). CT demonstrated the presence of free air in 94.1 % of cases; intraperitoneal free fluid was present in 76.4 % of patients and thickening of bowel wall in 50 %. Streaky density within the mesentery was found in one patient. Conclusion: CT is a reliable diagnostic method by which to assess gastrointestinal perforation, because it provides excellent contrast resolution to depict the presence of even small amounts of free air in the abdomen. This is particularly helpful where elderly patients are concerned.     

Improving the imaging diagnosis of cervical spine injury in the very elderly: implications of the epidemiology of injury

Purpose: To enumerate host and vector factors that affect each phase of cervical spine injury (CSI) among the elderly, and to attribute specific pathoanatomic characteristics of CSI to host and/or vector factors. Methods: Structured review of English literature references selected from MEDLINE keyword search using PUBMED and OVID search engines. Only articles addressing the role of “aging” or being “elderly” (using a variety of definitions) in CSI were included. The following information was abstracted: journal; year of publication; authors' specialty or departmental affiliation; study design; inclusion and exclusion criteria; year(s) of data collection; number of CSI vs. controls; summary findings, including rate estimates, obvious study weaknesses. Results: Seven of 13 articles were medical-record-based case series, most derived from institutional trauma registries. Four were population-based surveys. One was an assessment of Medicare claims data for all-cause trauma and one a review paper. Blunt-force CSI was most commonly related to domestic falls, then to vehicular-pedestrian collisions and finally to vehicular crashes. More than two-thirds of fractures involved CO-C3, especially in individuals with cervical spondylosis and/or osteoporosis. In 15 to 40 % of CO-C3 fractures there is a delay in diagnosis. An adult forme fruste of SCIWORA (spinal cord injury without radiographic abnormality) was a relatively common cause of central and anterior cord syndromes in the absence of observable fractures or dislocations. Conclusions: The epidemiology of CSI in elderly patients should inform triage and imaging decisions. Since most CSI diagnostic errors involve the upper cervical spine, additional attention to the radiographic anatomy of the craniocervical junction and diligent search for abnormalities in this region are warranted.     

Abnormalities on chest radiographs following radiation therapy for breast cancer

The aim of this study was to study pulmonary radiological abnormalities with chest radiography following different radiotherapy (RT) techniques for breast cancer with respect to regions and density, and their association with pulmonary complications and reduction in vital capacity (VC). Chest radiographs were performed 5 months following local or loco-regional RT in 167 breast cancer patients. The radiological abnormalities were analysed with a classification system originally proposed by Arriagada and evaluated according to increasing density (0–3) and affected lung regions (apical–lateral, basal–lateral, central–parahilar). The highest-density grades in each region were added together to form scores ranging from 0 to 9. The patients were monitored for RT-induced pulmonary complications. The VC was measured prior to and 5 months following RT. An independent evaluation of 51 patients was performed by a second radiologist to control the reproducibility of the classification system. Increasing scores were associated with loco-regional RT and pulmonary complications (P < 0.001). The mean reduction of VC for patients scoring 0–3 (–30 ml) vs 4–9 (–161 ml) was not statistically significant (P = 0.10). Scores of 4–9 were more frequently observed in older patients (P < 0.001). The independent evaluations by two radiologists revealed good agreement (P < 0.001) and no systematic inter-observer variation. Radiological abnormalities on chest radiographs, scored according to Arriagada, can be used as an objective end point for RT-induced pulmonary side effects in breast cancer. Received: 4 February 1999; Revision received: 1 April 1999; Accepted: 5 May 1999