部分脾脏栓塞术治疗肝硬化门脉高压合并脾机能亢进的临床研究

目的 :探讨部分脾脏栓塞术对肝硬化门脉高压合并脾机能亢进的治疗价值。方法 :应用PVA颗粒 ,对 4 6例门脉高压肝硬化合并脾脏机能亢进的患者施行经脾动脉部分脾脏栓塞术 ,随访术后不同时间窗内疗效并对比研究了栓塞前后的门静脉和脾静脉血流速度的变化。结果 :4 6例患者成功施行了经脾动脉栓塞技术 ,达到了临床预期的治疗目标 ,消除了脾机能亢进的症状 ,无严重并发症发生 ,白细胞和血小板术后 2 4h即有明显改善 (P <0 .0 5 ) ,4周后恢复正常水平保持平稳。脾静脉和门静脉血流速度手术后明显降低 (P <0 .0 5 ) ,随访 6～ 2 1个月 ,脾机能亢进的症状未复发。结论 :部分脾脏栓塞术简便微创安全 ,治疗肝硬化门静脉高压合并脾机能亢进疗效好 ,值得临床推广应用。     

Embolization of the splenic artery in cirrhotic patients with portal hypertension. Ultrasound results and follow-up

Over the last four years the authors performed transcatheter embolization of the splenic artery by Gianturco coils in 32 consecutive cirrhotic patients with portal hypertension, splenomegaly, cytopenia and gastro-esophageal varices endoscopically proved. This procedure was especially useful for treatment of splenomegaly and cytopenia because a constant reduction of spleen dimensions and increase in platelet count were registered. The effectiveness of transcatheter embolization and follow-up are based on clinic, hematologic and sonographic findings. We believe sonographic monitoring to be very useful both to evaluate splenomegaly and signs of portal hypertension and to reveal splenic complications (abscesses). We never registered severe complications.     

MRI of the normal portal system: the artefacts. Apropos of 45 cases

The protal system of 45 normal patients have been retrospectively studied on spin echo MRI sequences (interleaved cuts): multiple artifacts have been evaluated and 24% of them were visualized at the portal system level. Thus, partial volume effect responsible for almost 25% of the artifacts is not always easily seen on a single sequence. Respiratory and aortic artifacts can deteriorate the visualization of the vascular lumen but cannot be confused with a thrombosis. Well-known artifacts, as slice entry phenomenon and even echo rephasing, represent more than 60% of the artifacts: they are readily recognized when they are typical and indicate flowing blood. On the contrary, an other artifact, representing less than 5% of the total and seen at the level of the left portal vein, simulates a thrombus, on T2 weighed images. We conclude that the frequency and polymorphism of the artifacts are limiting factors of MRI value in the diagnosis of portal vein thrombosis.     

False image of portal thrombosis in MRI: pitfalls in portal hypertension. Apropos of Budd-Chiari syndrome

This observation illustrates how difficult it is to interpret the intravascular signal observed with MRI in cases of portal hypertension. A signal occupying the entire lumen of the portal trunk and branches can be seen, which is constantly observed in the axial as well as coronal planes in the 3 series studied. It is hypointense relative to the liver on T1-weighted images, hyperintense on T2-weighted images: this appearance therefore perfectly mimicks portal thrombosis. Ultrasound combined with pulsed Doppler demonstrates the stagnant blood within the patent portal system. This kind of artifact, which is produced by a very slow flow or even by the standstill of flow, is much more difficult to recognize than the common flow artifacts; the criteria put forward by various authors to distinguish between artifacts and thrombosis are of no avail in this case. Examinations must able to confirm or rule out portal thrombosis in the case of portal hypertension with deceleration of flow. In practice, ultrasound studies, combined with pulsed Doppler in the best cases, is therefore indicated as a first-intension technique.     

基于门静脉压力梯度等多因素的肝硬化门静脉高压食管静脉曲张破裂出血风险评估初步探讨

【摘要】 目的 探讨门静脉压力梯度（PPG）、食管静脉曲张程度、胃冠状静脉直径、门静脉直径及肝纤维化指标等在肝硬化门静脉高压食管静脉曲张破裂出血患者风险评估中的作用。方法 收集2017年1月至2019年3月青海大学附属医院明确诊断为肝硬化门静脉高压食管静脉曲张拟行颈静脉肝内门体分流术（TIPS）患者106例,分为出血组与未出血组,统计所有患者术前PPG、影像学资料、实验室检验、胃镜检查、核医学肝纤维化指标、门静脉造影等资料。结果 出血组、未出血组患者伴腹水、肝功能Child-Pugh分级、胃冠状静脉直径、食管静脉曲张程度、门静脉直径、PPG指标比较,差异均有统计学意义（P＜0.05）。出血组患者透明质酸钠（HA）、Ⅲ型前胶原氨基端肽（PⅢNP）、Ⅳ型胶原（ⅣC）均高于未出血组,差异有统计学意义（P＜0.05）,层粘连蛋白（LN）差异无统计学意义（P＞0.05）。与单因素评分相比,门静脉高压食管静脉曲张破裂出血多因素评分预测食管静脉曲张破裂出血的灵敏度、特异度更高。 结论 以PPG为核心的多因素评分评估肝硬化食管静脉曲张破裂出血,较单一因素评估具有更好的灵敏度和特异度。对曲张静脉高危患者中HA、PⅢNP、ⅣC明显增高患者进行早期干预,可能降低破裂出血风险。     

Fractures-luxations of the Lisfranc joint. Apropos of 39 cases]

Lisfranc fracture-dislocations are relatively rare (two per thousand). They generally occur in multiple trauma victims and may pass unnoticed. Open reduction followed by pinned osteosynthesis and plaster immobilisation ensures a good anatomical and functional result.     

Hepatocarcinoma invasion of the portal vein: detection using lipiodol computed tomography. Apropos of 2 cases

Portal vein involvement is a major complication of hepatocellular carcinoma and has an important impact on management and prognosis. Iodized-oil computed tomography is a well-established imaging technique for the pretherapeutic assessment of hepatocellular carcinoma because it allows detection of the primary tumor site and any daughter nodules. We report two cases of hepatocellular carcinoma extending to the portal vein which was documented by iodized-oil computed tomography. In both cases, tumor thrombus demonstrated marked retention of the iodized-oil on computed tomography. Our two cases demonstrate that iodized-oil computed tomography can depict portal vein extension of hepatocellular carcinoma. In addition, these two cases suggest that iodized-oil retention within the portal vein is a clue to the diagnosis of hepatocellular carcinoma.     

Chordoma of the base of skull. Apropos of 3 cases]

The authors report 3 cases of skull base chordomas. In 2 cases, skull radiographies and computed tomography found lytic lesions of sphenoid and clivus, with calcifications into the tumors. In the third case, radiological findings suggest a naso pharynx tumor.     

Dumbbell-shaped nerve-tissue tumors of the posterior mediastinum. Apropos of 5 cases]

The authors present 5 cases of dumbbell neurogenic tumors with intraspinal extension. There were 4 neurilemmomas in four adults and 1 ganglioneuroma in one child. These tumors were benign. Neurological signs were observed in two cases. Widening of the intervertebral foramen at the level of the tumor is a very suggestive sign of dumbbell tumor confirmed by CT-Scan or MRI. Precise morphologic features must be assessed before embarking on the operation. The procedures used were: thoracotomy only in two cases, laminectomy then thoracotomy because of neurological signs in two cases, thoracotomy then laminectomy to fully remove tumor remnants in one case. No major morbidity was noted. The neurological symptoms resolved in two cases. A combined two-team approach with thoracic and neurosurgeons working together has not been used so far, but this possibility is probably the best choice for the future.     

Recurrent multifocal chronic osteomyelitis: scintigraphy or MRI. Apropos of 2 cases]

We report two cases of chronic recurrent multifocal osteomyelitis. In both cases, MRI demonstrated the presence of asymptomatic lesions that the technetium bone scan failed to show. The asymptomatic lesions were located in the acetabelum and the distal femur. Despite the actual literature, MRI was more specific than bone scan in these two cases.     

Low flip-angle spin-echo imaging of the liver. Basic study and its application to hepatic space-occupying lesions]

Dependence on T1 contrast can be reduced by changing the excitation flip angle. Low flip-angle spin-echo imaging can reduce imaging time because repetition time (TR) is reduced. The authors assessed the efficacy of low flip-angle spin-echo images in phantoms and in liver. MR phantoms made from polyvinyl alcohol gel to model the properties of normal liver, HCC, and hemangioma were scanned with various flip angles at TR 2400 and 1200 msec. Measured signal intensities fitted well with theoretical values. The T1 contrast of signal intensity decreased as the flip angle was reduced, accompanied by a decrease in signal-to-noise ratio (S/N). Thirty patients with hepatic space-occupying lesions (23 with HCC, three with metastases and four with hemangioma) were studied by conventional SE (CSE) at 2400/60/2 (TR/TE/NEX [number of excitations]) (10 min 46 sec imaging time) and low flip-angle SE (LFSE) at 1200/60/30 degrees/2 (TR/TE/FA/NEX) (5:20) and/or 1200/60/30 degrees/4 (10:18). The sensitivity of CSE in detecting lesions was 93% (44/47). It was 92% (35/38) for LFSE with two NEX and 94% (34/36) for LFSE with four NEX pulse sequences. The contrast-to-noise ratio (C/N) for images (HCC/liver, hemangioma/liver) obtained by LFSE with four NEX was significantly higher than that for those obtained by CSE (4.8 vs 3.5, p less than 0.01; 13.4 vs 9.7, p less than 0.01, respectively). Although the C/N (lesion/liver) for LFSE with two NEX sequences was lower than that of CSE for any type of lesion (3.0 vs 3.5 for HCC; 5.1 vs 6.3 for metastases; 8.3 vs 9.7 for hemangioma), the difference was not significant. Although reducing the flip angle from 90 degrees to 30 degrees with two NEX resulted in a decrease in S/N (10.7 to 8.9 for HCC; 15.3 to 11.9 for metastases; 20.0 to 18.1 for hemangioma; 7.4 to 6.3 for normal liver; 10.7 to 10.1 for spleen), the difference was not significant. For hepatic space-occupying lesions, low flip-angle spin-echo imaging is useful to obtain T2-weighted images in a shorter imaging time without sacrificing lesion detectability.     

Cerebral miliary tuberculosis. Apropos of 5 cases and review of the literature]

The authors report 5 cases of cerebral miliary tuberculosis studied by computerized tomography and review 5 cases of the literature. Computerized tomography can see very small tuberculomas, of several millimeters. Chest miliary tuberculosis is found in all their cases, and 3 of the 5 cases of the other authors. Because of the discretion of neurological signs and the association with chest miliary, we suggest to make a computed tomography of brain of all patients who have chest miliary tuberculosis despite the absence of neurological signs and we think that we will find out other cases of brain miliary tuberculosis.     

Segmental portal hypertension due to splenic vein obstruction: imaging findings and diagnostic pitfalls in four cases.

Segmental portal hypertension due to isolated splenic vein obstruction is a rare but important entity as it is the only curable cause of portal hypertension by splenectomy. Four cases are presented illustrating the radiological features of splenic vein obstruction, and the diagnostic pitfalls that arose in patients with complicated clinical presentations.     

Mucus-secreting tumors of the appendix: a preoperative diagnosis is possible. Apropos of 2 cases]

The authors present two cases of pseudo tumoral type Mucus Secreting Tumours (MST) of the appendix. In this type (32% of the cases), the clinical presentation, barium enema, ultrasonography and most importantly CT scan generally confirm the preoperative diagnosis. We found three advantages this preoperative diagnosis. 1) Primarily it allow selection of a large surgical approach that permits full exploration of the abdominal cavity especially the ovaries (2-18% associated lesions); 2) also it allows a histopathological examination (frozen section) of the appendix to be performed during the operation; 3) and finally the surgical treatment will depend on the operative findings and the result of the histopathological examination: in the benign forms simple appendicectomy will be sufficient but the malignant forms (12% of the cases) should be treated by right hemicolectomy.     

Approach to the examination of patients with suspect portal hypertension using duplex ultrasonography. I. Quantitative evaluation of flow in the portal vein

The paper deals with the application of duplex real-time ultrasonography in the area of portal vein system. The attention is centered to the method of quantification of the flow. The author first analyzes the methodology and refers to some main technical factors influencing validity of the results obtained. The author then draws attention to basic ultrasonographic symptoms of portal hypertension. Having analyzed literature data he refers to limited importance of measuring the portal vein flow for the diagnosis of portal hypertension, draws attention to the contribution of respiratory changes in the area of portal vascular bed and the changes in blood flow velocity for this diagnosis. Finally, attention is paid to the possibility of suitable combination of these two signs by creating s. c. "congestive index" (18).