Iranian Journal of Radiology
Volume:2 Issue: 1, Autum & Winter 2004

Carotid stenting is a technical procedure that can be easily performed, and this has exposes it to the concern of the technique being over-utilized or mis-utilized. There are controversies surrounding the actual technical performance of the procedure, in addition to the ideal patients who should benefit from the clinical procedure. These controversies, compounded by the ongoing evolution of the technical procedure in addition to the evolution of the clinical benefits, have fueled numerous debates between proponents and detractors for the procedure. Compounding the debates between proponents and detractors are the devastating potential complications of inappropriately performing or neglecting to appropriately perform carotid stenting. Such considerations accentuate the significance of judicious technology implementation and appropriate clinical deployment. This discussion will address background, technical consid-erations, potential complications, and applicability of carotid stenting in clinical practice.

Background/ Thyroid nodules are a common finding, especially in our country. In this study, we evaluated the role of conventional ultrasonography (US) and color doppler sonography (CDS) in assessment of cold thyroid nodules. Ninety-seven patients with a cold thyroid nodule were examined by US and CDS before thyroidectomy. On US, the presence of a halo sign, hypoechogenicity or microcalcification was evaluated. The vascular pattern on CDS was classified as follows: Type 1, absence of blood flow; Type 2, perinodular blood flow; Type 3, intranodular blood flow. Sensitivity, specificity, negative predictive value, positive predictive value and accuracy of ultrasound and color doppler findings were evaluated. Ultrasound findings have been compared with postoperative pathological result. In 38 patients, thyroidal carcinoma was found. Absence of halo sign, presence of microcalcification and hypoechogenicity were predictive of malignancy (P < 0.001). Presence of intranodular hyper-vascularity and perinodular hypervascularity were in favor of malignancy (P < 0.001) and benignity (P < 0.01), respectively. An avascular pattern could not differentiate between benign and malignant nodules. US and CDS findings can predict malignant nodules, especially when multiple signs are simultaneously present.

We report two 11 and 14 year old girls with bilateral ulnar club hand deformity, who have the familial form of the disease. Their mother and 8 other family members are affected by the same deformity, The congenital form of deformity was first reported by Robert in 1886 and since then, one more case has been reported in the literature. Our report to our knowledge is the first that reports the case in 11 members of 3 generations of a family.

Chondrosarcomas of thorax are unusual tumors categorized as axial malignancies that also invade and destroy the adjacent bone. These tumors are known to displace soft tissue structures coming in their way without invasion. They destroy adjacent organs violently. In this report, we present a 44-year-old man with a large, expansive mass in the posterior mediastinum invading the spinal canal and epidural space through an intervertebral foramen and displacing the thecal sac. To our knowledge, this is the second case in the literature describing a chondrosarcoma of a rib with dumb-bell-shaped extension to the adjacent intervertebral foramen.

Hydatid disease is one of the oldest diseases known to humankind. In 85-95% of the cases, the liver and/or the lungs are involved and only 5-15% of other organs. The case presented here is a 38-year-old man with hydatid disease of lower lumbar vertebrae, sacrum, lumbosacral spinal canal, and left iliac bone; with extension to retroperitoneum and piriformis, sacrospi-nalis, iliacus, iliopsoas, and quadratus lumbarum muscles; without involvement of liver or lung, as diagnosed by MRI and CT scan and confirmed by surgery.

Background/ The evaluation of different aspects of subarachnoid hemorrhage (SAH) can effectively improve the outcomes of this fatal disease. This article presents some information about angiographic and epidemiologic findings in 580 cases of SAH in Iran. We reviewed the records of 580 SAH patients in whom the disease was proved by brain CT scan and/or lumbar puncture. In all of the patients, a standard subtraction brain angiography was done. Sixty percent of all patients were male and about sixty percent of patients were aged 30-60years. The angiogram showed: aneurysm in 23.4%, arteriovenous malformation in 14.1%, and miscellaneous problems in 6.3%. The angiogram was normal in the remained 56%. The mean age of aneurysm patients was 46 years, and 59% of them were male. 33.6% of aneurysms resided in A.C.A, 31% in I.C.A (14.1% of total aneurysms located in P.Comm.A), 24.8% in MCA and 10.7% of aneurysm were located in posterior circulation. The high prevalence of the disease in men could be due to the relatively high exposure of men to certain risk factors, such as smoking, or the ethnic factors may play a role. The lower mean age could be due to high percentage of men. Low prevalence of P.Comm.A aneurysms could be due to ethnic factors.

Background/ The structural changes of brain (cerebral and lateral ventricles volumes) in schizophrenia are controversial. This is partly due to the heterogenicity of the schizophrenia subtypes. In this study we compared the changes in the volumes of cerebral hemispheres and lateral ventricles in 3 subtypes of schizophrenia (paranoid, undifferentiated and residual) with normal controls. 29 schizophrenia patients (21 men, 8 women) of 3 subtypes of paranoid, undifferentiated, and residual (according to DMS-IV criteria) were compared with 29 age- and gender-matched normal controls. All cases and controls underwent 3-D brain MRI of full coronal series, 1.5 mm slices without interslice gaps. The hemispheres and lateral ventricles were outlined and their volumes were calculated using Cavalieri’s Principle. The results were statistically analyzed. The brain was slightly but insignificantly smaller in the schizophrenia patients. Only the residual subtype showed a significant reduction in cerebral and hemispheric volumes than controls (p<0.05). The volumes of right and left ventricle, separately and together were larger than controls (p<0.03). The ventricle-to-brain ratios (VBRs) were greater in the cases (p<0.05). The paranoid subtype patients had larger ventricles and VBRs than controls (p<0.05). The lateral ventricle volumes and VBRs in the undifferentiated subtype were similar to the controls. In the residual subtypes, the ventricular volumes were similar to and the VBRs were larger than controls (p<0.05). Schizophrenia is a heterogeneous disorder regarding its symptoms and neuropathological changes. The patterns of change in the cerebral and ventricular volumes differed in the studied 3 subtypes.

Optimal surgical management of the neonate with imperforate anus depends on accurate determination of the level of the rectal pouch. The use of ultrasound to determine the pouch level has been previously described, but has not become widely accepted. The goal of this study is to determine the validity of this measurement according to final surgical findings in patients with anorectal malformation. In a cross sectional study,23 children with imperfo-rated anus were evaluated by transperineal ultrasound with a 7.5 MHz sector transducer in the supine and lithotomic positions to determine the pouch level and pouch to perineum (P-P) distance. In all cases, the level of the distal pouch was confirmed by definitive surgery or distal colostogram. The agreement between sonography and surgery or colostogram as gold standard was obtained by weighted kappa test. In five children, the pouch to perineum (P-P) distance was less than 10mm. All of these low lesions were safely treated by a simple perineal anoplasty (minimal posterior sagittal anorectoplasty; i.e. minimal PSARP) and were confirmed as low type. Seven children had P-P distance of 10-15 mm. In the follow up definitive surgery, 5 cases were intermediate and two cases were high. Eleven children had a P-P distance of more than 15 mm, of which ten cases were high lesions and had colostomy at birth. During follow up, 8 cases underwent definitive surgery of PSARP and two of these high cases were confirmed by distal colostogram and one case was categorized as intermediate by definitive PSARP. Measure of agreement (Kappa) was calculated to be 0.791 (P = 0.001) Therefore, Ultrasound correctly predicted the level of the distal pouch in 20 of 23 patients. Transperineal ultrasound can be confidently used prior to surgical decision in children with imperforate anus in addition to physical exam.

Background/ Growth retardation and macrosomia are associated with increased fetal morbidity and mortality. We assessed the usefulness of sonographic measurement of abdominal subcuta-neous tissue thickness in estimating birth weight. Abdominal subcutaneous tissue thickness was measured sono-graphically in 300 fetuses between 37 and 42 weeks of gestation. The median time between sonographic examination and delivery was 11 days. The weight of newborns was measured immediately after delivery. The mean soft tissue thickness was significantly higher in macrosomic than normal fetuses (12.0±1.4 mm versus 6.6±1.6 mm, respectively; P < 0.001). There was a significant positive correlation between the abdominal subcutaneous tissue thickness and birth weight (r = 0.86, P < 0.001). Sonographic examination of the fetal abdominal subcutaneous tissue thickness is useful for estimating birth weight.

Background/ Contrast transcranial doppler has been used for detection of right-to-left shunts, such as the patent foramen ovale (PFO). All consecutive patients with cryptogenic brain infarction admitted to the Walter Mackenzie Hospital, Canada, during 2003-2004, enrolled in a prospective study. Cryptogenic stroke was determined using a standard battery of diagnostic investigations. Transcranial color coded duplex sonography (TCCDS) with saline contrast was performed with an HP Sono 5500, USA device and a 4MHz linear probe. The middle cerebral artery was insonated at a 50-55 mm depth through a transtemporal window. Microbubble signals were recorded during normal respiration and Valsalva maneuver. 114 patients (70 females, 44 males) with cryptogenic stroke had contrast TCCDS done. PFO was detected in 41 patients (30 females, 11 males; 35.9%). In the overall study group, females were more preponderant to have PFO, however the difference was not significant (P=0.053). The frequency of PFO was not significantly different between age groups =<45 years and >45 years (P = 0.96). PFO detected by TCCD is an age independent factor in cryptogenic stroke, and its detection is more feasible with Valsalva maneuver.

Background/ Two principal cardiovascular findings in end-stage renal disease (ESRD) patients who undergo hemodialy-sis are left ventricular hypertrophy (LVH) and arterial disease due to rapidly progressive atherosclerotic vascular disease that can be characterized by arterial plaques. In this study we studied the relationship of LVH and ejection fraction with carotid and femoral artery plaques in ESRD patients undergoing hemodialysis. Sixty-one ESRD patients who underwent maintenance hemodialysis (F=23, M=38) were considered. There were 50 non-diabetic hemodialysis patients (F=20, M=30) and 11 diabetic hemodialysis patients (F=3, M=8). For all the subjects echocardiography and B-mode ultrasonographic assessment of carotid-femoral arteries for plaque occurrence were performed. In this study there was a positive correlation between LVH and the duration of hemodialysis treatment; and also a significant asso-ciation between LVH and plaque score. Positive correlation was also demonstrated between hypertension and plaque score. Also an inverse correlation of plaque score with LV ejection fraction was noted. Moreover, the association of plaque score with diabetes mellitus was positive. The present study signifies the cardiac and vascular adaptation secondary to ESRD and demonstrates the potential contribution of structural and functional alteration in the large arteries to the pathogenesis of left ventricular hypertrophy, which requires more attention in hemodi-alysis patients.

Uterine anomalies have different types and are classified in different ways. Here, we report three hysterosalpingographically unique cases of uterine anomalies selected from more than 30,000 cases over duration of 40 years. Case 1 is a branching out bicornuate uterus, in which the left uterine horn and cervix branch from the cervical canal. The second case is a unicornuate uterus, in which a fallopian tube without uterine cavity directly branches from this corn. The third case is a cross-shaped bicornuate uterus. Considering the embryologic development of uterus, we concluded that these three cases had abnormalities in different stages of their Müllerian ducts'' development

Background/ Of congenital malformations of the central nervous system 46% are abnormalities of the spinal cord, which includes spina bifida occulta (SBO). The occurrence and significance of spina bifida occulta in patients with persistent primary nocturnal enuresis (PPNE) were evaluated. Between January 2000 and February 2001, 109 consecutive children who had nocturnal enuresis more than once a week after the age of 7 years for an uninterrupted period of at least 3 months, with less than 50% reduction in wet nights despite different treatments for at least 6 months, were prospectively evaluated for the presence of associated spina bifida occulta. The results were com-pared with data from a group of 40 normal children. The mean age was 9.9 years in PPNE patients and 7.5 years in normal group. SBO was present in 86 (78.9%) of PPNE patients and 10 (25%) of normal children. This difference was statistically significant using chi-square test. (P-value < 0.001) Spina bifida occulta was thought to have no clinical significance but our results showed its significant higher rate among PPNE patients. There is no direct causal relation between spina bifida occulta and enuresis, apparently, but the findings suggest a common developmental etiology.

Xanthogranulomatous pyelonephritis (XGPN) is a rare chronic inflammatory disorder in children that results from infection usually associated with longstanding urinary obstruction. There are two morphologic types: diffuse and focal. In the more common diffuse form, the entire kidney is involved. We present a case of diffuse type, in which some foci in the kidney are spared.

Background/ Liver biopsy in patients with congenital bleeding disorders (CBD) and hepatitis C virus (HCV) infection is still a challenge between risk of procedure and effect of biopsy result on management. We did transjugular liver biopsy (TJLB) on 12 patients with CBD with chronic HCV infection and elevated liver enzymes to determine its safety, efficiency and therapeutic conse-quences. All patients were men, with a median age of 29.5 years (14–54 years). Eleven patients had haemophilia A (10 severe, one moder-ate) and one patient had factor XIII deficiency, with no titer of inhibitor. HCV genotyping was carried out with type 1a (7 patients), type 1b (2 patients), type 3 (2 patients) and genotype 1a and 1b (1 patient). HIV and HBV co-infection was negative in all patients. We used the modified Ross needle with 100% transjugular access rate to the hepatic veins and 92% success rate in tissue obtaining. The specimen obtained was satisfactory but limited for histopathologic diagnosis in 54.5%. Mild hepatitis was revealed in 4 patients (36.4%), moderate hepatitis in 5 (45.4%) and extended fibrosis or cirrhosis in 2 (18.2%). There were 2 procedure-related complications (16.6%). The major limitation of technique was low number of portal area in liver biopsies. TJLB with some limitations is useful in patients with CBD. Transjugular approach to liver biopsy is a safe and effective alternative to the percutaneous approach in patients with CBD and could be requested to determine their liver prognosis and considered for diagnostic liver biopsy prior to anti-HCV therapy.

A 35 year-old woman underwent uterine artery embolization (UAE) for uterine fibroid. Just the fibroid was expelled (seventy days after UAE), massive uterine bleeding occurred which was treated by super-selective uterine artery re-embolization. Three hours after the re-embolization, bleeding stopped and follow-ups showed complete elimination of menstrual, urinary and bulk-related symptoms. Massive hemorrhage after fibroid expulsion is probable and embolization of uterine arteries is a favorite alternative treatment for this condition.