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NCOLOGY 
June 2000 Vol. 34 No. 2 Ljubljana 
ISSN 1318-2099 


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Editorial office Radiologij and OncologiJ June 2000 Institute oj Oncology Vol. 34 No. 2 Vrazov trg 4 Pages 79-215 SI-1000 Ljubljana ISSN 1318-2099 S/ovenia UDC 616-006 Phone: +386 61 1320 068 CODEN: RONCEM Phone/Fax: +386 61 1337 410 E-mail: gsersa@onko-i.si 
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Radiology and Oncology is a journal devoted to publication oj original contributions in diagnostic and interventional radiology, computerized tomography, ultrasound, magnetic resonance, nuc/ear medicine, radiotherapy, c/inical and experimental oncology, radiobiologtj, radiophysics and radiation protection. 
Editor-in-Chief  Editor-in-Chief Emeritus  
Gregor Serša  Tomaž Benulic  
Ljubljana, Slovenia  Ljubljana, Slovenia  
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Ljubljana, Slovenia  Ljubljana, S/ovenia  

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Marija Auersperg Be1a Fornet Maja Osmak 
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Nada Bešenski Tullio Giraldi Branico Palcic 
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Nataša V. Budihna Berta Jereb Stojan Plesnicar 
Ljubljana, Slovenia Ljubljana, Slovenia Ljubljana, Slovenia 
Marjan Budihna Vladimir Jevtic Ervin B. Podgoršak 
Ljubljana, S/ovenia Ljubljana, Slovenia Montreal, Canada 
Malte Clausen H. Dieta Kogelnik Jan C. Roos 
Hamburg, Germany Salzburg, Austria Amsterdam, Netherlands 
Christoph Clemm Jurij Lindtner Slavko Šimunic 
Miinchen, Germany Ljubljana, Slovenia Zagreb, Croatia 

Mario Corsi Ivan Lovasic Lojze Šmid 
Udine, Italy Rijeka, Croatia Ljubljm.a,Slovenia 
Christian Dittrich Marijan Lovrencic Borut Stabuc 
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Ivan Drinkovic Luka Milas Andrea Veronesi 
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Melbourne, Australia Ljubljana, Slovenia Ljubljana, Slovenia 



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Ljubljana, Slovenia June 2000 Vol. 34 No. 2 
CONTENTS 


Foreword 

Jevtic V 

Prof. Ivo Obrez, M.O., Ph.D., (1930-1989) 

Jevtic V 

DIAGNOSTIC RADIOLOGY 



.TI. 
ISSN 1318-2099 UDC 616-006 CODEN: RONCEM 
79 
81 

Defecography: a report on 35 cases Jamar B, Šurlan K 
INTERVENTIONAL RADIOLOGY 

Transjugular intrahepatic portosystemic shunt (TIPS) Šurlan M, Jereb J  93  
Diagnostic imaging, indications and measurements for treatment of aortic aneurysm by endoprosthesis Šurlan M, Salapura V, Kunst T  101  
Endovascular treatment of aortic aneurysm by endoprosthesis Šurlan M, Salapura V  107  
Ultrasound-guided aspiration biopsy of subclinical regional metastases of head and neck carcinoma  

Višnar-Perovic A, Anicin A, Zupancic Ž, Cernelc B, Šmid L, Vidmar DB, Gorenc M 
COMPUTED TOMOGRAPHY 

Computed tomographic angiography in intracranial vascular disease  
Miloševic Z  123  
Computed tomographic angiography of body vasculature  
Kunst T, Berden P  137  
MAGNETIC RESONANCE  

Magnetic resonance arthrography of the glenohumeral joint Jevtic V, Praprotnik A  145  
Magnetic resonance of cardiac tumors and masses Berden P  151  
Magnetic resonance of the thoracic aortic disease Berden P  159  
SONOGRAPHY  
Hydrocolonic sonography in the detection of large bowel disease Vidmar D  165  
Strictures of the male urethra: how to perform and evaluate radiourethrography and sonourethrography and avoid mistakes Babnik Peskar D, Višnar Perovic A  175  
The role of sonographic evaluation of spinal canal in children Zupancic Ž  185  
Renal cell carcinoma in the ectopic kidney prospects of diagnosing and treatment of the carcinoma of the kidney: case report Brencic E, Stanovnik M, Glušic M  191  
IN MEMORIAM  
Prof. Mira Vurnik-Žumer, M.D., Ph.D., (1916-1998) Jevtic V  199  
SLOVENIAN ABSTRACTS  201  
NOTICES  211  

Foreword 
Radiology is today one of the fastest expanding medical fields. The introduction of new imag­ing modalities, such as magnetic resonance, substantially increases diagnostic accuracy and influences favorably the therapy of different diseases. Novel interventional radiology procedures allow non-invasive treatment of diseases that were traditionally cured by operative surgery. However, the cost of new radiological imaging modalities is high and catching up with fast devel­opment of modem radiology is difficult even for rich countries. On the other hand, the techni­cal level of central radiology departments reflects closely the quality of university medical cen­tres. During the last decade, in spite of numerous difficulties which, unfortunately, were not always only financial, Clinical Radiology Institute was able to overcome all the obstacles and to follow general trends of radiology in developed countries. 
This issue of Radiology and Oncology reflects the status of different fields of diagnostic and interventional radiology not only at the University Clinical Centre of Ljubljana but also in Slovenia. The issue is dedicated to Professor Ivo Obrez, M.D., (1930 -1989), Head of the Institute of Radiology for many years, an outstanding radiologist with intemational recognition. With his contribution to Slovenian radiology, and Clinical Radiology Institute in particular, he laid the foundation for further development of modem radiology in Slovenia. 
Vladimir Jevtic (Guest Editor) 

Prof. Ivo Obrez, M.O., Ph.D. (1930-1989) 

Ten years have passed since the death of Professor Ivo Obrez, head of the Institute of Radiology for many years, a teacher of sever­al generations of Slovene radiologists, a founder of invasive and interventional radiol­ogy in Yugoslavia and Slovenia, and a resear­cher whose innovative work received wide international recognition. 
Professor Ivo Obrez was born in Novo mesto in 1930. He graduated M.D. from the Faculty of Medicine in Ljubljana in 1955. He embarked on his radiology specialist training in 1958 and cotDpleted it in 1961. During the period 1961-1965 he headed the radiological unit of the Novo mesto General Hospital. 
In 1963, during his study visit to Lund and Stockholm, where the first centralised radio­logical departments were set up, he wit­nessed an explosive development of modern radiology. There, he was introduced to the invasive angiocardiography, a special diag­nostic technique to which he was devoting his limitless energy until his premature death. Professor Stanko Hernja, who headed the Institute of Radiology at the tirne, realised that it was necessary for his talented and am­bitious colleague to forward his career in a larger medical centre. Professor Obrez accep­ted his invitation and in 1965 joined the Ljubljana Institute of Radiology. 
After the initial impetus given to radiologi­cal science in Sweden, further advances in radiology were made in the U.S.A. Professor Obrez was convinced that radiologists from a relatively small and technologically inade­quately developed country should extend and enhance their knowledge abroad, in institu­tions offering innovative programmes, and then apply the acquired knowledge to the radiological practice in their country. He, therefore, applied for the postdoctoral training post at the Stanford University, California, one of the leading medical centres in the world, which boasted an outstanding radiological department headed by Professor Margulis, a descendant of a Novi Sad family. Prompted by unconditional professional support given by Professor Hernja, hospital authorities in Ljubljana awarded Professor Obrez a scholar­ship for the proposed continuing education. The investment in his training paid off very soon. In the U.S.A., Professor Obrez was awarded the Newel Frize for his innovative 

Prof Ivo Obrez, M.O., Ph.D. (1930-1989) 
work. Immediately upon returning home, he set to introduce the new invasive angiocardio­graphic technique which was practically un­known at the tirne. He applied the knowledge and skills acquired in Sweden and the U.S.A. to the radiologists in Slovenia and Yugoslavia, pioneering routine use of catheterization of cardiac chambers and vessels. He unselfishly communicated his knowledge to his col­leagues and soon brought together a team of competent invasive radiologists. Their close collaboration with clinicians, particularly with cardiovascular surgeons, resulted in markedly improved results of treatment in the University Medica! Centre Ljubljana. In 1971, Professor Obrez and his co-workers from the Institute of Oncology won the Boris Kidric award for their achievements in radiology. The same year, Professor Obrez defended his doc­tor's thesis »Rena! angiogrnphy-A clinical and experimental study« at the Faculty of Medi­cine Ljubljana. The status of an Assistant Pro­fessor of Radiology was conferred on him in 1972. In 1973 he was elected lecturer at the Chair of Radiology, University of Ljubljana, and in 1979 Associate Professor of Radiology. He advanced to the rank of a Full Professor in Radiology in 1984. 
In the 1970s it became evident that in the 

coming decades the trend in radiology would be towards interventional radiological tech­niques. In the school year 1971/72, Professor Obrez was staying at Stanford University as a visiting professor. On returning home, his primary aim was to initiate the new radiolog­ical procedures in Slovenia. The Ljubljana Institute of Radiology became a well-known teaching institution attracting prominent experts in interventional radiology from the whole territory of Yugoslavia. The develop­ment of radiology in the world continued at an extremely fast rate. To keep abreast of these advances, Professor Obrez held a visit­ing professorship at the Harvard University, Boston and at the University of California, San Francisco in the year 1981/82. His profes-
Radiol Oncol 2000; 34(2): 81-3. 
sional activities met with great acclaim. He was a member of the executive board of the European Society of Cardiovascular and Interventional Radiology, and its president for the period 1982-1983.In 1983, he organi­sed the congress of European and American interventional radiologists in Dubrovnik, fol­lowed in 1984 by a very successful interna­tional symposium on contrast media and new technologies in radiology, which was held in Portorož, Slovenia. Professor Obrez was appointed a national representative in the bureau of European Association of Radiology in 1985, a honorary member of radiological societies of Czechoslovakia in 1981, of Hu­ngary in 1984 and of Polanci in 1986. 
He was a member of the editorial boards of 
the following professional journals: Zdrav­
stveni vestnik, Radiologia Iugoslavica, Radio­
logia Diagnostica, Cardiovascular and Inter­
ventional Radiology, European Journal of Ra­
diology, Der Radiologe, Frontiers in European 
Radiology and Annales de Radiologie. 
His bibliography includes more than one 
hundred papers published in the national and 
international literature. He contributed a 
number of chapters on radiology to profes­
sional manuals and handbooks. He was one 
of the pioneers of interventional radiology at 
the national and international levels, as 
shown by his numerous contributions to re­
nowned international journals, such as 
Radiology, Investigative Radiology, Journal of 
Canadian Association of Radiology, most of 
them written together with the most distin­
guished experts in the field, like Professor Abrams. 
During the period 1974-1989, Professor 
Obrez headed the Institute of Radiology in 
Ljubljana. After the restructuring of the 
University Medical Centre he was appointed 
a director of the Institute, and he held this 
office until his premature death in 1989. His 
taking office at the Institute of Radiology 
coincided with the moving of the Institute to 
new premises which boasted modem techno­

Prof Ivo Obrez, M.O., Pii.O. (1930-1989) 
logical equipment. His predecessor, Professor Hemja, had set up a modem centralised radi­ological department separated into severa! diagnostic units according to the Swedish model. Professor Obrez continued with estab­lishing the CT, ultrasound and cardiovascular radiology units, and with renovating the units at other locations. With great dedication and tenacity he strove to get quality technological equipment for the Institute and to ensure the funds required for its work. Like his prede­cessors, he frequently fought bureaucratic battles with those who tended to lessen the role of radiology in the clinical medicine. 
Professor Obrez initiated a number of modem diagnostic and therapeutic proce­dures, many of which are still in routine use today. Also, he attracted and trained a skilled team of specialists who successfully carried on his work in the interventional radiology. Professor Obrez was known as an excellent teacher. His meticulously prepared lectures were admired not only for their high profes­sional standard but also for the visual experi­ence they provided. 
Professor Obrez devoted the largest share of his time and energy to radiology, yet his interests were not restricted only to the field of medicine. History was his main interest away from hospital, and he intended to pur­sue his hobby after the retirement. Yet, his early death prevented him from carrying out his plans. 
Professor Obrez will always be remem­bered as an outstanding radiologist and a Slovene intellectual with international repu­tation. Thanks to his professional excellence, language skills, and self-confidence and warmth in his behaviour towards other peo­ple he easily made friends world-wide. He was a true ambassador of Slovenia in the world. 
Professor Obrez occupies a very special place in the history of Slovene medicine. In the memory of his colleagues who had the fortune to meet him and to work with him he will always stay as an understanding col­league, outstanding teacher and talented radi­ologist who had made invaluable contribu­tions to the development of radiological sci­ence. His work constitutes a firm foundation on which we continue to build the edifice of modem radiology. 
Vladimir Jevtic 


Defecography: a report on 35 cases 
Breda Jamar, Katarina Šurlan 
Clinical Radiology Institute, University Medica/ Centre, Ljubljana, Slovenia 
Purpose. To evaluate indications in the patients referred for defecography to our Institute between October 1996 and December 1999. Patients and methods. In this period, 35 patients (31 women and 4 men, their mean age being 56,5 and 34,5 years, respectively) with defecation disorders oj 1 month to 17 years oj duration were referred to us far defecography -26 from proctology specialists and 9 from interna/ medica[ out-patient departments. After the rectum was filled with thick barium paste, spot slwts from lateral position were made in different phas­es oj defecation, with the patient sitting on a specially designed commode. Results. Rectocele was found in 21 cases, in 9 cases in association with rectorectal intussusception, in 3 with rectoanal intussusception and in 2 with herniation oj rectal wall into ishiorectal fossa. Prolapse was found in 2 cases, and 4 rectorectal intussusception, 1 rectoanal intussusception and 3 fistulas were diag­nosed. The findings were normal in only one case, while in 3 cases defecography showed functional abnor­malities. In Jemale patients, symptoms started after gynaecological operation in 11 cases and in 6 cases after delivery. Eight women had to press perineum with their hand to facilitate defecation. 
Conclusions. Defecography proved useful in clarifying the pathology underlying patients' difficulties. 
Key words: defecation; rectal diseases -radiography; intussusception; ulcer 
Introduction 
Defecography is a very simple functional X-ray examination. It evaluates the anatomy and the function of the anal canal and rectum, and assesses movements of the pelvic floor in peo­ple with defecation disorders.1 It was first de­scribed in 1952 2, but only a few reports on the 
Received 15 May 2000 Accepted 30 May 2000 
Correspondence to: Prim. Breda Jamar, M.D., Clinical Radiology Institute, University Medica! Centre Ljubljana, Zaloška 7, SI-1525 Ljubljana, Slovenia. Phone: +386 1 131 31 23 (38-34); Fax: +386 1 133 31 044; E-mail: Breda.Jamar@kclj.si 
topic were published by 1984, when the inter­est in defecography started to rise again.3 Since then, the examination has obtained an important role in the diagnosis of functional and structural abnormalities of the anorectum. 
In Slovenia, the first defecografy was per­formed at the Ljubljana Clinical Institute of Radiology in 1993. Chronic constipation, dif­ficult or prolonged evacuation, and inconti­nence were the most common referring diag­noses in our series. We were interested in whether the examination could clarify the pathology underlying the patients' problems, which -by their nature not life-threatening but quite often rather embarrassing -make 

jamar B et ni./ Defecography: a report on 35 cases 
patients uneasy to seek medica! help and thus prolong their suffering. 

Patients and methods 

From October 1996 to December 1999 we per­formed defecography in 35 patients, 26 women (mean age 56,5 years) and 4 men (mean age 34,5 years). The referring physi­cians were proctologists in 26 cases and spe­cialists of gastroenterology in 9 cases. The indications for the examination were: sus­pected rectocele (11), chronic obstipation (10), incontinence (3), solitary rectal ulcer (3), fis­tula (3), prolapse (2), psychoorganic syndro­me (2), and pain at defecation (1). 
The procedure of defecography was care­fully explained to the patients. They were in­structed to apply a laxative suppository (Dul­colax) two hours prior the examination. With the patient in the left decubitus position, the empty rectum was then filled with 250-300 ml 


Figure 2. Rectum and anal canal at rest. 
of thick barium paste (Prontobario esofago, 
Bracco, Milan, Italy) by means of rectal sound 
and plastic syringes. The patient was seated on a specially designed commode (Figure 1), mounted on the footboard of fluoroscopy stand in an upright position. Spot films of the anal canal and rectum in lateral position were made at various phases of defecation: 1 -at rest (Figure 2), 2 -during squeezing (Figure 3), 3 -during straining (Figure 4, 5), and 4 -at the end of evacuation (Figure 6). Movements (ele­vation and descent) of the pelvic floor were observed as well as any structural anomalies which may have become evident during defe­cation (e.g. rectocele, intussusception etc.), and the tirne and the extent of rectal empty­ing were evaluated. 


Results 
In our group of patients, rectocele was diag­nosed in 21 cases, many of them in associa­tion with other structural abnormalities. Anterior rectocele was found in 7 cases. The 

Jamar B et ni. / Defecogrnphy: a report on 35 cases 

Figure 3. Rectum and anal canal during squeezing -pelvic floor is elevated. 
indications for defecography were: suspected rectocele in 4, chronic obstipation in 2, and solitary rectal ulcer in l. Rectocele in associa­tion with rectorectal intussusception was found in 9 cases, with indications as suspect­ed rectocele in 5, and chronic obstipation in 4. Rectocele with rectoanal intussusception was found in 3 patients, all with the diagnosis of chronic obstipation. Rectocele with hernia­tion of a part of rectal wall into ischiorectal fossa was diagnosed in 2 cases, in 1 patient with the diagnosis of chronic obstipation and in another with the diagnosis of psychoorgan­ic syndrome. Rectorectal intussusception was found in 4 cases: 2 patients had diagnosis of suspected rectocele and 2 had solitary rectal ulcer. In 3 patients with clinically suspected fistulas we proved ali three, one rectovaginal, one intraanal and one rectocutaneous. In 2 cases we confirmed the clinical diagnosis of prolapse, with no other structural changes. Rectoanal intussusception was diagnosed in 1 case of incontinence. Functional disturbances were found in 3 cases: in 2 clinically inconti­nent patients poor movement of pelvic f!oor and a wide open anal canal were observed, in 1 patient with the diagnosis of psychoorganic syndrome prolonged evacuation tirne and incomplete evacuation were noted. 
The shortest period from the onset of sym­ptoms to defecography was one month. This was the case of a woman, the oldest in our group, who had rectal prolapse. The patient, who had been suffering from disturbed defe-

Jamar B et al. / Defecography: a report on 35 cases 

Figure 4. Rectum and anal canal during straining -formation of an anterior rectocele. 
cation for 17 years, was a woman, a mother of four children. Her symptoms started at the birth of the first child and were getting worse with each delivery. In most female patients the symptoms lasted for severa! years, 4-5 years on the average. In 11 female patients the symptoms started after gynaecological opera­tion, in 6 after birth delivery. Eight of these women had to help themselves to begin and/or to facilitate defecation by hand manip­ulation. 
There were only 4 male patients in our group. Their symptoms were different from the women's: 2 had solitary rectal ulcer syn­drome and 2 had fistulas. 

Discussion 
Defecography is a dynamic radiologic investi­gation of the rectum and anal canal in which the patient is studied seated on a special com­mode and recordings are obtained at rest, during straining and during evacuation.4 Double contrast barium enema and endo­scopy are static examinations that do not allow a detection of functional anomalies. Even proctoscopic examination during strain­ing cannot reveal ali the abnormalities. 
The advantage of defecography is its ability to reveal interna! (rectorectal or rectoanal) intussusception, as this may develop into rec­tal prolapse. Thirteen of our patients had intu-

Jn111nr B et ni./ Defecogrnpliy: n report 011 35 cases 

Figure 5. Rectum and anal canal during straining -fonnation of recto-anal intussusception. 
ssusception of the proximal portion of the rec­tum into the <listal one and 4 had intussus­ception into the anal canal. The internal rectal intussusception has various stages of severity and milder forms are now considered nor­mal.1 Elsewhere,4 instussusception was found in only 19% of cases. Most likely, our relative­ly high number can be explained by two facts: first, also milder forms were found in our ret­rospective study, and second, only severe cases of difficult defecation were referred to us for defecography, the examination not being well known or even recognised as yet in Slovenia. It is only performed at our Institute. 
Solitary rectal ulcer syndrome is an entity that consists of a benign rectal lesion, accom­panied by disorders of defecation, most often caused either by rectal intussusception or spa­stic pelvic syndrome.3 Three of our patients had endoscopically diagnosed solitary rectal ulcer. At defecography, rectal intussusception was found in two cases, and rectocele in one. 
Rectocele is an outpouching (hernial pro­trusion) of the anterior rectal wall. It is a quite common finding, but most likely of no clini­cal importance unless large and associated with the retention of contrast material.1 In our group of patients rectocele was found in 21 cases, the incidence being high, if com­pared to other studies.1, 3 However, in ali our cases the retention of contrast material in the rectum was observed. 
Radio/ Onco/ 2000; 34(2): 85-91. 

Jamar B et al. / Defecography: a report on 35 cases 

Figure 6. End of evacuation -recturn is ernpty, a srnall anterior rectocele is formed. 
Defecography is a dynamic X-ray examina­tion of functional and morphologic abnor­malities of the anorectal region. It is also very useful and, as proved in 3 of our cases, some­times the only imaging modality to detect fis­tulas. A young woman suffering from Crohn' s disease was examined by a gastroenterologist, gynaecologist, proctologist, and abdominal surgeon because of her complaints suspective of a fistula. When it was not found at repeat­ed endoscopic examinations, the patient's complaints were disbelieved by the examin­ers. At defecography, a rectovaginal fistula was proved. In the other two cases, both male patients with clinically suspected fistula and no prior examinations, fistulas were found at defecography: in the first one -a patient suf­fering from Crohn's disease -rectocutaneous fistula with subcutaneous abscess, and in the other -with previous surgical procedure -intraanal fistula was demonstrated. 
In our series we found only three cases of functional anomalies with no structural changes: in two incontinent patients wide open anal canal and poor movement of pelvic 
Radio! Oncol 2000; 34(2): 85-91. 
floor, also reported by other studies 5, and in one patient with the diagnosis of psychoor­ganic syndrome, prolonged evacuation tirne and incomplete evacuation were noted. The latter abnormality was described as anismus ­impaired rectal evacuation secondary to a functional disturbance of defecation.6 
Two cases of lateral outpouching of the rec­tal wall were found in our group of patients. Since defecography is usually done in the lat­eral projection, the anomaly which could be described as lateral rectocele or herniation into the ischiorectal fossa, i.e. ischio-rectal hernia 7, was observed in the AP projection. Hence the recommendation given by Kaasbol et al.8 that not only lateral but also AP and/or oblique projections should be used at de­fecography, gained validity. 
As in other studies1,6 , 9 , the majority of our patients were women (31 out of 35). It has been well established10,11 that symptoms of disturbed evacuation may start after gynaeco­logical operation (11 cases in our group) or after birth delivery (6 cases ). Most disturbing in our series is the long history of symptoms: women, especially those 8 in our group who had to help themselves with their hands at defecation, were too embarrassed to seek me­dical help earlier. And after they did, they were »treated« by bulk laxatives, given dieta­ry advice and, two of them, even prescribed sedatives. 

Conclusion 
Defecation disorders have many causes and defecography is a useful imaging modality for detecting functional and structural abnormal­ities in the anorectal region. In our study the correlation between symptoms and defeco­graphic findings was good, while in other studies this correlation was poor.1,12 Our good result is most likely based on the fact that defecography is not yet a widely recognised examination in Slovenia, so that only patients 

Jamar B el a/. / Defecogrnplzy: a report on 35 cases 
with long-lasting and severe symptoms were referred for the examination. This is also the cause of the small number of patients in our series. 
We have no <lata of the impact of our defecographic results on clinical decisions or treatment of our patients. If nothing else, we could objectively assess the reasons for defe­cation problems and to explain them to the worried patients. It was quite a relief to many of them to hear their problems really had anatomic and physiologic explanation. 
References 
l. Ott DJ, Donati DL, Kerr RM, Chen MYM. Defecography: Results in 55 patients and irnpact on clinical rnanagernent. Abdom Imaging 1994; 19: 349-54. 
2. 
Wallden L. Defecation block in cases of deep rec­togenital pouch. Acta Chir Scand 1952; (Suppl 165): 1-121. 

3. 
Yang XM, Partanen K, Farin P, Soirnakallio S. Defecography. Acta Radio/ 1995; 36: 460-8. 

4. 
Ekberg O, Nylander G, Fork FT. Defecography. Radiology 1985; 155: 45-8. 



5. 
Karasick S, Karasick D, Karasick SR. Functional disorders of the anus and rectum: findings on defecography. A]R 1993; 160: 777-82. 

6. 
Halligan S, Bartrarn CI, Park HJ, Kamm MJ. Proctographic features of anismus. Radiology 1995; 201: 233-8. 

7. 
Grassi R. Defecography study of outpouching of the external wall of the recturn: posterior rectocele and iscio-rectal hernia. Radio/ Med 1995; 90: 44-8. 

8. 
Kaasbol MA, Hauge C, Nielsen MB. Case report: impaired rectal emptying caused by perineal her­niation of the rectum: defaecographic demonstra­tion using oblique projections. Brit J Radio/ 1993; 66: 171-2. 

9. 
Reginald G, Baeten C, Arends JW. Solitary rectal ulcer syndrorne: Findings at barium enema study and defecography. Radiology 1988; 168: 303-6. 

10. 
Karasick S, Spettell CM. Defecography: does pari­ty play a role in the development of rectal pro­lapse? Eur Radiol 1999; 9: 450-3. 

11. 
Karasick S, Spettell CM. The role of paritiy and hysterectomy on the development of pelvic floor abnormalities revealed by defecography. Am J Roentgenol 1997; 169: 1555-8. 

12. 
Felt-Bersrna RJF, Luth WJ, Janssen JJWM, Meuwissen SGM. Defecography in patients with anorectal disorders: which findings are clinically relevant ? Dis Co/011 Rectum 1990; 33: 277-84. 









Transjugular intrahepatic portosystemic shunt ( TIPS ) 
Miloš Šurlan1 and Janez Jereb2 
1 Clinical Institut of Radiology, 2 Gastroenterology Departmant of Interna/ Clinic, Clinical Centre, Ljubljana, Slovenia 
Baclcground. A clear presentation of TIPS indications and contraindications, which can be divided into 
absolute and relative, is given. Absolute indications are fresh and renewed bleeding oj varices and inveter­


ate ascites. Relative indications, on the other hand, are splenomegaly with hypersplenism, Budd-Chiari syn­
drome, /iver transplantation and hepatorenal syndrome. Absolute contraindications are severe /iver dys­
function and right heart failure, while the relative ones are polycystic /iver degeneration, neoplasm, obstruc­
tion of the portal vein and severe local and systemic infection. Before the TIPS procedure, the leve/ of dys­
ftmction oj the /iver, right heart and kidneys is determined. Biochemical and blood tests, including a blood coagulation test, are made, the ammonia leve/ in the serum is determined and possible obstructions/stric­tures oj the portal vein are checked. A detailed description oj the procedure, a care far patient and a post­operative monitoring are given. The success rate oj the procedure is between 93 % and 100 % and the mor­tality rate within 30 days because TIPS is between 1 % and 3 %. The hemorrhage is stopped in 95% to 100%, the ascites is improved in 87 % to 92 % and the kidney function in 81 %. In case oj hypersplenism the trombocytopenia is improved in 75 % and levcopenia in 50 % oj patients. There are relatively few com­plications during the procedure. Postoperative complications are more frequent due to the stricture and obstruction oj the shunt. After a two-year treatment the shunt is passable in 50 % oj patients. Thus, in a group oj 29 patients, who were treated in the period of four years with an average monitoring period of two years, 22 patients (75,9 %) are stili alive and only 7 died (24,1 %). Six oj the dead patients suffered from alcoholic cirrhosis oj the /iver. In two cases the cause oj death was not related to the TIPS and the cirrhosis oj the /iver. Conclusions. TIPS is an efficient method in stopping recent varicose bleeding, unsuccessft1lly treated with endoscopic sclerosation ar medicaments. It is the most efficient method to lower portal pressure before /iver transplantation and ensures saje waiting far /iver transplantation and improves conditions far its success. 


Key words: protosystemic shunt, transjugular intrahepatic 
Received 22 May 2000 Accepted 5 June 2000 Correspondence to: Prof. Miloš Šurlan, M.D., Ph.D., 
Clinical Institut of Radiology, Clinical Centre, Zaloška c. 7, SI-1000 Ljubljana, Slovenia. 

Šurlan Meta/./ Transjugular intrahepatic portosystemic s/umi 
Introduction Contraindications 
The creation of TIPS is a procedure of inter­ventional radiology to lower the portal pres­sure and treat or avoid complications of the portal hypertension due to !iver cirrhosis. 
The portal hypertension is defined as a pressure in the portal vascular system over 10-12 mm Hg, or 17-20 cm H2O. 

Due to a high portal pressure, severa! com­plications are obtained: GI bleeding, ascites, splenomegaly with hypersplenism and !iver encephalopathy. Complications can be treat­ed conservatively, with endoscopic sclerosa­tion and operative procedures -ligation of varicose veins, portal and mesocaval shunts and splenorenal shunts, and nowadays with TIPS. 
The first report\on TIPS was given by Rosch in 19691, and it was clinically intro­duced by Colopinto in 1982.2 
After the use of a metallic stent for forming the shunt by Richter in 200 patients, the pro­cedure became used more often. 3 Colopinto used only a balloon dilatation for the shunt formation through the !iver tissue before that. 
In Slovenia we performed our first TIPS in 1994 in a patient with re-bleeding from vari­cose veins. 

Indications 

Indications for TIPS are complications of por­tal hypertension due to !iver cirrhosis. We divide them into absolute and relative. Absolute indications are acute bleeding from varicose veins, in cases where other less inva­sive methods are unsuccessful, varicose veins re-bleeding and ascites and/or hydrothorax unsuccessfully treated conservatively.3,5-7 Relative indications are hypersplenism , avoi­dance of complications before and after !iver transplantation, Budd-Chiari syndrome and hepatorenal syndrome.3 , 5-7 
Contraindications are also divided into absolute and relative. Absolute are profound !iver dysfunction and right heart failure. 5-7 Relative contraindications are polycystic !iver disease, portal vein thrombosis, !iver neo­plasm, profound !iver encephalopathy and systemic or local !iver infection.5-7 


Preprocedure patient preparation 
Before performing TIPS we grade the !iver dysfunction according to Child-Pugh, evalu­ate the right heart function and the renal function because of the use of contrast media. Laboratory !iver tests are performed, with serum NH3 measurement. Basic lab tests of prothrombin time and partial thrombin time are done. We determine the patients' blood group and Rh factor. 
With a Doppler US or an indirect portog­raphy we obtain the portal vein patency. 
Patients' clinical state must be stabile. In case of active bleeding the Blakemore's tube is placed to compress the varicose veins. 


Technique 
A patient is introduced with the plan and the purpose of the procedure. Most procedures are performed in general anesthesia with intubation. The procedure is performed with DSA equipment. The patient is in supine position, with head turned slightly to the left. The right side of the neck is sterile washed, the upper part of the body and head are then sterile covered. We use transjugular approach, with the punc­ture of right interna! jugular vein with 18 gauge puncture needle. The puncture is con­trolled by US, which is especially important in coagulopaths. A guide-wire of 0,035 inches is entranced into the right or intermediate !iver 

Šurlnn M et ni./ Trnnsjugulnr intrnhepalic portosyste,nic shunt 
vein with the help of curved catheter of 5 F. A catheter sheath of lOF and 40 cm long, with a haemodynamic valve is introduced over guide-wire in the !iver vein. A balloon catheter is entranced to close the hepatic vein and 20 ml of CO2 is injected to obtain a portal venography with DSA. This is important for the determination of the direction and the site of the puncture of the portal vein. We intro­duce the catheter needle set for the puncture of one of portal veins into the chosen hepatic vein. It contains Teflon tapered catheter of 9 F, with Colapinto needle of 14 gauge inside. The needle has a curved edge to point the direc­tion of the portal vein. The angiographic catheter of 5 F is introduced into the Cola­pinto needle, to help us, under the support of guide-wire, to introduce a quite rigid needle through the catheter sheath into the hepatic vein. At the puncture site, which is 2-3 cm away from hepatic vein branching, we remove the guide -wire and the catheter. The Cola­pinto needle is rotated, so its edge is pointed toward a chosen portal vein close to the bifur­ca tion. This is controlled by fluoroscopy in a side projection. If the needle is in the right hepatic vein, the edge is rotated anteriorly and if it is placed in the intermediate vein, it is rotated posteriorly because the intermediate vein lies more anterior than the bifurcation of portal veins. The puncture is performed with a long, sharp needle coa ted in 5F smooth, Teflon catheter. The needle is 8 cm longer than the Colapinto needle. The distance between a puncture site and big branches of the portal vein is usually 4-6 cm. The puncture is blind or performed under the control of Doppler US. After the puncture, the needle and the catheter are removed slowly, with aspiration. When we aspirate greater amount of blood, we inject contrast. If we, therefore, see one of bigger portal veins, we introduce guide-wire, usually Terumo »J« 0,035 inches or Teflon wire of the same diameter with a very soft edge. The guide-wire is introduced into the superior mesenteric or splenic vein. The 
catheter is then pushed into a portal vein stem. Through this catheter the guide -wire is exchanged, for 180 cm long, with 0,035 inches diameter, firmer, for better support during the further catheterisation. The first catheter is exchanged for the aortographic catheter thro­ugh which we measure the portal pressure and perform the portography. After removing the Colapinto needle and the catheter we per­form a dilatation of the tract between the por­tal vein and hepatic veins in the liver tissue with the use of two balloon dilatation cathe­ters, with 8 and 10 mm in diameter. The len­gth of the tract is measured, and a metallic stent of 12 mm in diameter is placed into it. The metallic stent can reach as deep in the right portal branch as is the bifurcation and 0,5-1 cm deep into the hepatic vein. If the hepatic veins' orifice is narrowed, the stent is placed deep into the veins towards the orifice 
(Figu res la, lb).We mostly use self-expanding stents-Wallstents for TIPS, because it is flexi­ble, with grate radia! force.8 Its disadvantage is the uneven shortening of the stent while expanding, so the precise positioning is de­manding. It has been improved lately, but not completely. After the stent placement the aor­tography catheter is introduced and the con­trol portography is obtained (Figure 2), with the measurement of the portal pressure. If the shunt is adequate on portogram, with smooth contours, and without grater flow through varicose veins, the portal pressure is usually satisfactory. If not, a dilatation is repeated with a balloon dilatation of 10 mm, in particu­lar the sites of a passage through the vein wall. If the bifurcation of hepatic veins is narrowed, and the portal pressure is therefore stili high, due to regenerated !iver tissue pressure, ano­ther stent is placed into the stenosis (Figures la, b). When the portal pressure is satisfacto­ry, which is usually between 20-28 mm Hg, the procedure is finished and the catheter sheath is removed from the jugular vein. 
Patients, who are coagulopaths of under­
went complications during the procedure, are 

Šurlan Metal. / Transjugular intrahepatic portosystemic shunt 

Figure la, lb. Control portography and pressure mea­surement in portal vein. 
a. 
Ostial stenosis of hepatic veins and hepatic segment of VCI, caused by regenerated !iver tissue in cirrhotic !iver and fibrosis. Pressure drop in portal vein to 30 cm H20 was insufficient for the ascites treatment. This was confirmed with a collateral blood flow. 

b. 
With a dilatation of stenosis we showed that steno­sis was elastic. After the additional Wallstent place­ment the pressure in the portal vein dropped to 20 cm H20 and the vein collateral system was not seen any more. With a diuretic support ascites resolved. 



Figure 2. TIPS was preformed in a patient with recur­rent bleeding from varicose veins. Quite a long shunt created with Wallstent connects the right branch of the portal vein with hepatic veins close to its orifice. A stent is placed in the portal vein peripheral from the bifurcation. Portal blood flow through the branches is preserved. Collateral blood flow is not seen. 
transported to the intensive care unit, and otherwise into the half-intensive care for the first 24 hours. During hospitalization the con­trol laboratory liver tests are performed and serum NH3 level is measured. The control Doppler US is performed to obtain blood flow in the shunt and portal vein. 


Long term TIPS patency 
TIPS patency is first controlled after 3 months and then every 6 months. The patency is diag­nosed with Doppler US and portal venogra­phy. Doppler US is a very reliable method.9,10 The signs of the shunt malfunction are drop of shunt velocity below 90 cm/sec, change in blood flow direction, and greater drop in por­tal vein velocity. According to US, we can decide to do the venography with the pres­sure measurement, which is a golden stan­dard for the definitive diagnosis of the shunt patency. 
The shunt occlusion is important if stenosis over 50 % of pressure gradient between the portal vein and the right atrium is greater than 15 mm Hg and if varicose veins are fulfilled 

Šurlan M el al. / Transjugular intrahepatic portosystemic sllllnl 

again. Varicose vein bleeding or any other clinical sign is, of course, the sign of shunt occlusion. Patients suffering with shunt occlu­sion have clinical problems in 25%.11 
A success rate in TIPS 
TIPS is successfully performed in 93-100 %. The mortality rate is inside first 30 days approximately 10 %,11 due to TIPS procedure in 1-3 % of cases. TIPS does not effect the orig­inal disease. The survival rate is not only dependent on the shunt function, but also on the !iver function and original disease. 

Success rate in different indications 
Varicose veins bleeding is stopped in 90­100 %. Re-bleeding after TIPS occurs in 20 % of cases in longer tirne period.11 
Re-bleeding can be stopped with sufficient procedures on TIPS -dilatation, thrombolysis, thrombectomy, another stent placement and additional TIPS. Inveterate ascites and hydro­thorax , unsuccessfully treated conservatively are improved in 87-92 %.12 Secondary hyper­splenism is improved in 30 days after TIPS, thrombocithopenia in 75 %, leucopenia in 50 % and both together in 33 %.13 In hepatore­nal syndrome the kidney function is impro­ved in 81 % after TIPS.14 

Complications 
A bigger haematoma due to arterial puncture in coagulopaths is obtained. 
Severe cardiac arrythmia is experienced due to guide-wire and catheter entrance through the right atrium. 
Due to almost blind puncture of the portal vein, hepatic artery injury, biliary tract injury, or hepatic capsular damage and consequently abdominal bleeding can occur. 
Pneumothorax and right atrium injury can occur. To avoid these complications an expe­rienced radiologist is essential. The stent can be misplaced or moved by itself or can bent during the entrance and shunt can be occlud­ed by additional thrombosis. 

Late complications 
Late complications are related to the shunt patency, which progressively lowers with tirne, due to intimal hyperplasia in the paren­chimal part of the shunt and/or neointimal hyperplasia in the hepatic vein. The patency after first 6 months is 71 %,11 after 12 months 58-66 %11,15 after 2 years 42-49 %.11,15 One of the main reasons for intimal hyperplasia in the shunt is biliary fistula. The entrance of bile and thrombogenic mucin into the shunt accelerates thrombosis and hyperplasia. Some authors, therefore, suggest the exchan­ge of the stent for endoprothesis.12 
The causes of neointimal hyperplasia are probably hepatic vein reaction on the injury during the shunt performance, chronical irri­tation due to the stent placement, and change in haemodynamics in the hepatic vein due to the stent placement.16 In our cases stenosis in the upper part of the shunt was caused by too low placement of the stent or by stenosis of veins at or around bifurcation, due to the regenerated !iver tissue in the cirrhotic liver. 


TIPS and liver encephalopathy 
After TIPS the !iver encephalopathy occurs in 12-36 % of cases.11 ,17 It is often hard to find out if the complication preexisted or not.18 The causes of higher probability for the devel­opment of encephalopathy are: preexisting !iver encephalopathy, non-alcoholic !iver dis­ease, a grade of !iver dysfunction, age over 60 years, shunt diameter , gradient pressure bet­ween the portal and the systemic vein blood flow. 7,8,19,20 

Šurlan M et al. / Transjugular intrahepatic portosystemic shunt 
Experience of The Clinical Institute of Radiology in Ljubljana with TIPS 

In The Clinical Institute of Radiology we treated 41 patients between March 1994 and December 1998, mostly from The Interna! Clinic of Gastroenterology in Ljubljana. 
The procedure was successful in ali cases. We have known <lata for 29 patients, treated and followed between March of 1994 and March 1998, with average follow up tirne of 2 years. The cause of the portal hypertension was alcoholic liver disease in 15 patients (50,4 %), inflammatory liver cirrhosis in 13 patients (44 %) and Budd-Chiari syndrome in one patient (3,4 %). According to Child-Pugh's clinical grading, 3 patients (10,3 %) were in group A, 12 (41,3 %) in group B and 14 (48,2 %) in group C. 
The indication for TIPS was in 24 (82 %) re­bleeding from varicose veins. 3 (10,3 %) need­ed TIPS due to inveterate ascots. In one case TIPS was performed before the !iver trans­plantation to avoid complications before and during the transplantation. In a young pati­ent, 23 years old, we performed TIPS because of hepatic vein thrombosis and saved her life. 
Treatment evaluation 
Out of 29 patients 22 are stil! alive (75,1 %), 7 patients died. Four patients haven't survived 6 months. One of those, 34 years old alcoholic died 3 month after in a car accident, and 23 years old patient died from bleeding out from the undiagnosed aortic aneurysm of descend­ing aorta. Six out of 7 patients, who died, were alcoholics. 
Complications 
Two patients had severe bleeding after TIPS. One was bleeding into the pleural space one day after the procedure. The bleeding started after the removal of a portal vein catheter, used for the portography during TIPS. The 
Radio/ Oncol 2000; 34(2): 93-9. 
other was bleeding due to, probably, the injured !iver capsule. Both received transfu­sion. In the first case thoracic drainage was performed. Both patients were alcoholics, age 34 and 35. The first lived 2 years after TIPS. In the second patient the shunt occluded due to stent bending. He refused the additional TIPS, and died 2 months after leaving the ho­spital, probably from varicose vein bleeding. 
We had 3 late complications with theshunt occlusion, in 2 patients we performed the dilatation and in the third we placed a stent. Occlusion was diagnosed with Doppler US in 2 patients, and in one the varicose bleeding occurred. 



Conclusion 
TIPS is an efficient method in stopping the r.ecent varicose bleeding, unsuccessfully treated with the endoscopic sclerosation or medicaments. It is usually the bleeding from gastric varicose veins. Most often we lower the portal pressure in re-bleedings and invet­erate ascites. Shunt stenosis or occlusion pre­vents the primary long or life lasting pressure control in the portal system. The secondary shunt patency can improve that, but for that we need a good follow up of patients, which is especially hard in patients with alcoholic !iver disease. TIPS is the most efficient method to lower the portal pressure before the liver transplantation and ensures the safe waiting for the !iver transplantation and improves conditions for its success. 


References 
l. Rosch J, Hanafee WN, Snow H. Transjugular por­tal venography and radiologic portocaval shunt: an experimental study. Radiology 1969; 92: 1112-4. 
2. Colapinto RF, Stronell RD, Birch SJ, Langer B, Blendis LM, Greig PD, et al. Creation of an intra­hepatic portosystemic shunt with a Gruntzig bal­Ioon catheter. Can Med Assoc J 1982; 126: 267-8. 


Šurlan M et al. / Transjugular intrahepatic portosystemic shunt 
3. Richter GM, Noeldge G, Roessle M, Siegerstetter V, Franke M, Palmaz JC, et al. Transjugular intra­hepatic portosystemic stent shunt (TIPSS). Radio­logy 1990; 174: 1027-30. 
l. Šurlan M. Transjugularni intrahepaticni portosis­temski spoj (TIPS) [abstract]. l. kongres radiologov Slovenije (z mednarodno udeležbo); 1996 10-12 Oct; Portorož, Slovenia; 1996. p. 42. 
5. 
Namyslowski J. Transjugular intrahepatic por­tosystemic shunt: lndications, technique and short-term results. 5th International Workshop on Interventional Radiology [abstract]. Prague: Dotter interventional institute, Portland, Oregon & Section of interventional radiology of teh Czech radiological society; 1998. p. 218-20. 

6. 
Lakin PC, Saxon RR, Barton RE. TIPS: Indications and techniques. Semin Intervent Rad 1995; 12: 347­54. 

7. 
Roessle M, Haag K, Ochs A, Sellinger M, Noldge G, Perarnau JM, et al. The transjugular intrahepat­ic portosystemic stent-shunt procedure for variceal bleeding. N Engl J Med 1994; 330: 165-71. 

8. 
La Berge JM, Ring EJ, Gordon RL, Lake JR, Doherty MM, Somberg KA, et al. Creation of tran­sjugular intrahepatic portosystemic shunts with teh wallstent endoprosthesis: results in 100 patients. Radiologi; 1993; 187: 413-20. 

9. 
Ferral H, Foshager MC, Bjarnason H, Finlay DE, Hunter DW, Castaneda-Zuniga WR, et al. Early sonographic evaluation of the transjugular intra­hepatic portosystemic shunt (TIPS). Cardiovasc Intervent Radiol 1993; 16: 27 5-9. 

10. 
Zeme! G, Katzen BT, Grubbs GE, et al.: Sonogra­phic indicators of unsuccessful transjugular intra­hepatic portosystemic shunts. Radiology 1994; 193(P):167. 

11. 
Barton R, et al. TIPS: Short and Iong term results: A survey of 1750 patients. Semin Intervent Rad 1995; 12: 364-83. 

12. 
Ochs A, Rossle M, Haag K, Hauenstein KH, Deibert P, Siegerstetter V, et al. Teh transjugular in­trahepatic portosystemic stent-shunt procedure for refractory ascites. N Engl J Med 1995; 332: 1192-7. 


13. 
Pursnani KG, Sillin LF, Kaplan DS. Effect of tran­sjugular intrahepatic portosystemic shunt on sec­ondary hypersplenism. Am J Surg 1997; 173: 169­73. 

14. 
Brensing KA, Textor J, Strunk H, Klehr HU, Schild H, Sauerbruch T. Transjugular intrahepatic por­tosystemic stent-shunt for hepatorenal syndrome. Lancet 1997; 349: 697-8. 

15. 
LaBerge JM, Somberg KA, Lake JR, Gordon RL, Kerlan RK Jr, Ascher NL, et al. Two year outcome following transjugular intrahepatic portosystemic shunt for variceal bleeding: results in 90 patient. Gastroenterology 1995; 108: 1143-51. 

16. 
Saxon RR, Mendel-Hartvig J, Corless CL, Rabkin J, Uchida BT, Nishimine K, et al. Bile duet injury as a major cause of stenosis and occlusion in tran­sjugular intrahepatic portosystemic shunts: com­parative histopathologic analysis in humans and swine. J Vase Interv Radiol 1996; 7: 487-97. 

17. 
Saxon RS, Ross PL, Mendel-Hartvig J, Barton RE, Benner K, Flora K, et al. Transjugular intrahepatic portosystemic shunt patency and the importance of stenosis Iocation in the development of recur­rent symptoms. Radiology 1998; 207: 683-93. 

18. 
Sanyal AJ, Freedman AM, Shiffman ML, Purdum PP, Luketic VA. Portosystemic encephalopaty fol­Iowing transjugular intrahepatic portosystemic shunt (TIPS): results of prospective controlled study. Hepatology 1994; 20: 46-55. 

19. 
Sahagun G, Benner KG, Saxon R, Barton RE, Rabkin J, Keller FS, Rosch J. Outcome of 100 patients after transjugular intrahepatic portosys­temic shunt (TIPS) for variceal hemorrhage. Am J Gastroenterol 1997 ; 92: 1444-52. 

20. 
Somberg KA, Riegler JL, LaBerge JM, Doherty­Simor MM, Bachetti P, Roberts JP, et al. Hepatic encephalopaty after transjugular intrahepatic por­tosystemic shunts: incidence and risk factors. Am J Gastroenterol 1995; 90: 549-55. 







review 

Diagnostic imaging, indications and measurements for the treatment of aortic aneurysm by endoprosthesis 
Miloš Šurlan, Vladka Salapura, Tomaž Kunst 
Clinical Institute of Radiology, University Medica/ Center, Ljubljana, Slovenia 
Background. This paper presents imaging diagnostics of an aneurysm of the aorta, indications, common contraindications and measurements far the construction and selection of an endoprosthesis. The examina­tion using ultrasound is the most handy and economically justifiable method far detecting an aneurysm of the aorta, far monitoring asymptomatic aneurysms as well as patients having undergone an operation ar those with an endoprosthesis. Another examination to visualise the aortic aneurysm is CT with ar without contrastive medium. The plan far treating an aneurysm can be made with the help of a DSA, helical CT angiography and/or MRA. DSA shows well the lightness of the aneurysm and the aorta, as well as the changes inside of it, large arteries close to the aneurysm and the condition of pelvic arteries far the selection of the approach. The helica/ CT angiography and MRA in two ar three dimensional reproduction in sever­a/ directions enable an accurate measurement of an aneurysm, the aorta diameter above and below the aneurysm, and the evaluation of the quality of its wall. 
Conclusions. The indication areas for endoprosthesis are aneurysms of the abdominal aorta and those of the descending part of thoracic aorta. The treatment with endoprosthesis as a less invasive method is indi­cated in patients who risk a number of complications and even high mortality when treated surgically. Endoprosthesis is made of metal stent and prosthesis. The stent attaches the endoprosthesis to the unaf­fected part of the aorta above and below the aneurysm, it sets the stent asunder and provides support. The prosthesis is made of Dacron synthetic fabric, which has very good properties for this purpose such as small compliance, porosity, permeability and extensibility. The endoprosthesis is introduced into the aorta through a catheter system with the help of a special guide wire. The entering point is surgically opened com­
mon f emoral ar iliac artery. 

Key words: aortic aneurysm-diagnosis-therapy; tomography, x-ray computed; magnetic resonance angiog­raphy; angiography, digital subtraction; blood vessel prosthesis 
Received 22 May 2000 Accepted 5 June 2000 Correspondence to: Prof. Miloš Šurlan, M.D., Ph.D., 
Clinical Institute of Radiology, University Medica! Center Ljubljana, Zaloška 7, SI-1000 Ljubljana, Slovenia. 

Šurlan Metal. / Treatment of aortic aneurys m by endoprosthes is 
Introduction 

Aortic aneurysms are consequences of ather­osclerosis, inflammatory and degenerative changes in the aortic wall and posttraumatic changes of its wall. It is most commonly found in abdominal aorta, followed by the ascendent part of thoracic aorta and aortic arch, and less frequently in descendent aorta. The frequency of aneurysms, especially abdominal, is growing.1, 2 The reason for this is probably higher life expectancy and wider use of ultrasound and CT diagnostics. 
Aneurysms are classified as asymptomatic and symptomatic. Symptomatic and very large asymptomatic lesions with the weak­ened vessel wall are life-threatening, the oth­ers being followed for enlargement. The treat­ment is by means of a surgical repair, lately being replaced by the percutaneous insertion of endoprosthesis3.4 without actually opening the thorax or abdominal wall. This, less inva­sive approach, is becoming increasingly pop­ular as alternative method, opposed to a sur­gical treatment of descending part of thoracic aorta and abdominal aorta. To be successful, it is very important to exactly plan the proce­dure, and various imaging techniques play a major role in it. 

Imaging diagnostics 

Aneurysms are most commonly found at ultrasound examination and native x-ray films. Especially ultrasound is very useful as the primary method for the detection of abdominal aneurysms. With ultrasound, it is possible to assess the extent of the aneurysm, and the presence of the thrombus in it or near it. Doppler US enables the evaluation of the remaining flow rate, its direction and quality. Ultrasound is most suitable for the follow-up of asymptomatic aneurysms and of postoper­ative assessment, having a very high cost-ben­efit as well.5 
Aneurysms of thoracic aorta are usually found accidentally at chest radiograms or CT; less frequently it is specifically looked for due to dissection, local rupture, local pressure or haemorrhage. On chest films, it is often indis­tinguishable from expansive mediastinal lesions. In case of localised haemorrhage, a chest film demonstrates a local mediastinal widening or a pleural effusion. Diagnosis can be confirmed by an transthoracic or transoe­sophageal ultrasound examination, the latter being more reliable and accurate. It demon­strates aneurysm, dissection of the aortic wall, thrombus in the lumen or in surrounding tis­sues. The next diagnostic modality is CT with and without contrast material, defining ane­urysms of thoracic and/or abdominal aorta, its wall, possible haemorrhage, thrombosis and contrast extravasation. It also delineates aorta above and below the affected segment. 
Next, imaging modalities are directed towards the treatment planning. »Gold stan­dard« remains digital subtraction angiogra­phy (DSA), which reliably shows aorta, ane­urysms and her branches as well as iliac arter­ies and thus enables the possibility of treat­ment by stent-graft, the choice of the most appropriate entry site and implant route. DSA only demonstrates the lumen of the ves­sel and aneurysm. By contrast, CT angio­graphy (CTA) and MR angiography (MRA) enable the visualisation of the aortic and aneurysmal wall, the demonstration of thrombus and the assessment of the flow within the aneurysm.6,7 
It is important for the assessment of aortic wall quality that the endoprosthesis is firmly and permanently attached to the normal ves­sel wall, as opposed in the case of attaching it onto the thrombus or diseased aortic wall, where the permanence is not guaranteed. CTA (Figure 1) and MRA are very accurate imaging modalities for the procedure plan­ning, due to the multidirectional view of tree­dimensional reconstructed images. CTA pro­tocol is as follows: 50 rotations With the slice 





Šurla11 Met al./ Treat111e11t oj aortic m1e11rys111 by endoprostl1esis 
..,.__ 
y 
1 

Figure l. Schernatical dernonstration of spiral scan, made by x-ray tube during the table movernent with the patient during CT angiography (CTA). Arrowhead indicates the scanning direction, and arrow the table direction. 
thickness of 5 mm and table speed of 5 mm/ sec and the continuous application of con­trast material. The primary reconstruction is made with 2 mm interval so that overlapping slices improve the picture quality. Slices can be viewed in cine mode as well, so that the first impression about the endoprosthesis attachment site and the shape and the size of the aneurysm are noted. The exact measures of the width of aorta and the length of the aneurysm are possible on multiplanar recon­structed (MPR) images.6 The alternative method is MRA, which also enables us to define the upper and the lower extent of aneurysm and its size, shape, thrombus and flow type within it.7 As with CTA, the exact measurements are possible by MPR. Using different sequences, like two-and three­dimensional time-of-flight, turbo flash, and contrast enhancement, enables the increased diagnostic and prognostic accuracy of MRA.8 

Indications 
Indications for percutaneous treatment of aneurysms by the insertion of endoprosthesis are the same as for the surgical approach, yet the fact, that in contrast with the endopros­thesis insertion, the short-and long-term results of surgery are well known.9, 10 Planned surgical operations on aneurysms of ascen­dent thoracic and abdominal aorta in younger patients without additional vessel pathology are successful, but less favourable with the aneurysms of a descendent part of thoracic aorta.10 A less favourable outcome is reported with urgent procedures, reoperations, and operations on the patients with coronary ar­teries disease, heart, lung or renal failure and other pathological conditions. A surgical treatment is less successful with older patie­nts and severely diseased ones as well. In this part of the indication field, associated with a very high complication rate and high mortali­ty, the insertion of endoprosthesis is becom­ing increasingly popular despite the ]ack of definitive long-term results, especially in the abdominal aorta, and carry a relatively high risk of complications. According to numerous reports by the group of authors from Stan­ford, USA, the insertion of endoprosthesis in the thoracic aorta is the treatment of choice within a definite range of indications. 

Šurlan Metal. J Treatment oj aortic aneurysm by endoprosthesis 
General contraindications 
Contraindications for the insertion of aortic endoprosthesis are i.e. sepsis, coagu­lopathies, contraindicated systemic anticoag­ulant protection during the procedure, infla­med aneurysm, extreme tortuosity and ste­nosed or occluded iliac arteries and/or termi­nal aorta. Patients with severe lung dysfunc­tion need ventilatory support during the pro­cedure. 

Measurements 
The aortic endoprosthesis is chosen individu­ally for each patient on the basis of different diagnostic modalities, like chest radiograph, DSA, CTA and/or MRA. Chest radiograph is used to define the presence of pathology. DSA is used to assess the relations of aneurysms towards the aortic arch and great neck vessels in the upper part and celiac trunk in the lower part of descendent thoracic aorta; it also demonstrates intercostal and pelvic vessels as well. In the cases of abdominal aneurysms, the relations toward renal and iliac arteries are demonstrated. We use the calibrated catheter with measuring units, enabling us to measure the luminal diameter, as the vessel width is not a fixed constant at DSA and all units do not have associated measuring devices. CTA and/or MRA are very important for the accurate assessment of the diameter of aorta and the length of aorta above and below the aneurysm, where the stent-graft is to be inserted. The aortic length and the length of aneurysm can be different in each projection. Abdominal aneurysm and aorta above and below the lesion can produce different angles, as well as the overbifurcational aneurysm can deform the pelvic arteries angles (Figure 2). In these cases, CTA and MRA are invaluable tools to avoid the mismeasurements due to multidirectional views in three dimensions. With these multidirectional modalities, it is 

Figure 2. Morphology of the aneurysm in different stages. 
possible to determine the angle of bending for easier planning of treatment and to choose the most appropriate therapy. The length of unaffected segment cranially and caudally from the aneurysm should be at least 15 mm, as most of the endoprostheses have 10 mm of uncovered metallic parts for the increased longitude of the contact area with the aortic wall. It has been shown that the uncovered part of endoprosthesis does not significantly interfere with the flow through the vessels, even if it is partially inserted over them.11,12 This is useful in cases, in which the distance between the aneurysm and renal or subcla­vian arteries is less than 15 mm. 


Description of endoprosthesis 
The aortic endoprosthesis is made of metal stent and prosthesis. A metal stent is often used for supporting the vessel wall at endolu­minal dilation at the site of stenosis.13 It is also used in the case of the endoprosthesis 

Šurlm1 Met al./ Treatment oj aortic a11e11rys111 by endoprosthesis 
insertion for its fixation towards the vessel wall, instead of sutures, and so the blood flow through the aneurysm is excluded, as well as the danger of a rupture. It sets the endopros­thesis asunder and provides it support. The stent can be of the same length or longer than the prosthesis itself. It is usually made of stainless steel or nitinol, in the first case being made on the basis of Gianturco or Palmaz stent,3A,11 and in the second case on the basis of therrnical rnernory processed nitinol (rnix­ture of nickel and titaniurn). Stents of this material are designed at 500°C, but during the cooling they are compressed to the lower diameter. At the body temperature it regains its former shape. Palmaz-type endoprosthesis is packed and pressed to the balloon part of the catheter, and after the release it is expand­ed by the same balloon to the fina! diameter. Other types are self-expandable, being ex­panded imrnediately after the release. Stain­less steel endoprostheses expand like the spring coils, while the nitinol ones on the ba­sis of thermal memory. Usually, the self­expandable type of endoprosthesis is being used, and it attaches itself by means of the radia! pressure, forcing it to the width of two rnillimetres greater than aorta. 
The prosthesis is made of Dacron synthetic fabric, industrially named polyethylene tere­phtalate (PET), which has very good proper­ties for this purpose such as srnall cornpliance, porosity, permeability and extensibility. In­side, it is impregnated with collagen, gelatin, or albumin in order to reduce its thromboge­neity. The prosthesis is attached to the stent at many sites with 6-0 polypropylene sutures. 
The endoprosthesis is introduced into the aorta through a catheter system, the width of which ranges frorn 17 to 27 F, depending on the size and structure of the prosthesis. The size of device is depending upon the width of aorta, the extent of pathology to be treated, and upon the quality and amount of the mate­rial used for the planned endoprosthesis. The catheter insertion systems are alike, yet every rnanufacturer has its special properties. All are equipped with the insertion catheter into which we insert the endoprosthesis or it is already inserted into it. It is introduced in the aorta with the use of vascular sheath or with­out it. Without sheath, the insertion catheter is being applied with the help of a special guide wire, measuring 0,0035 inches and 260 cm long. The entering point is surgically opened cornmon femoral or iliac artery. 



References 
1. 
Melton LJ III, Bickerstff KL, Hollier LH, Van Peenan HJ, Lie JT, Pairolero PC, et al. Changing incidence of abdominal aortic aneurysms: a popu­lation based study. Am] Epidemiol 1984; 120: 379­86. 

2. 
Nevitt MP, Ballard DJ, Hallett JW. Prognosis of abdominal aortic aneurysms: a population-based study. N Ellgl J Med 1989; 321: 1009-14. 

3. 
Dake MD, Miller DG, Semba CP, Mitchell RS, Walker PJ, Linde!! RP. Transluminal placement of endovascular stent grafts far the treatment of descending thoracic aortic aneurysrns. N Engl ] Med 1994; 331: 1729-34. 

4. 
Paradi JC, Palrnaz JC, Barone HD. Transfernoral intralurninal graft irnplantation far abdorninal aor­tic aneurysrns. A1111 Vase Surg 1991; 5: 491-9. 

5. 
Bengtsson H, Bergqvist D, Jendteg S, Lindgren B, Persson U. Ultrasounographic screening far ab­dorninal aortic aneurysrn: analysis of surgical deci­sions far costeffectiveness. World] Surg 1989; 13: 266-71. 

6. 
Balrn R, Kaatee R, Blankensteijn JD, Mali WP, Eikelboorn BC. CT angiography of abdorninal aor­tic aneurysrns after transfernoral endovascular aneurysrn rnanagernent: diarneter and volurne measurernents. Eur J Vase Endovasc Surg 1996; 12: 182-8. 

7. 
Durharn JR, Hackworth CA, Tober JC, Srnead WL. Magnetic resonance angiography in the preopera­tive evaluation of abdorninal aortic aneurysrns. Am J Surg 1993; 166: 173-8. 

8. 
Prince MR, Narasirnharn DS, Stanley JC, Cho KJ. Gadoliniurn-enhanced rnagnetic resonance angio­graphy of abdorninal aortic aneurysrns. J Vase Surg 1995; 21: 656-69. 



Šurlan Met al./ Treatment of aortie aneurysm by endoprosthesis 
9. 
Ernst CB. Abdominal aortic aneurysm. N Engl J Med 1993; 328: 1167-72. 

10. 
Moreno-Cabral CE, Miller DC, Mitchell RS, Stin­son EB, Oyer PE, Jamieson SW, et al. Degenerative and artherosclerotic aneurysms of the thoracic aorta. Jour Thor Cardiovase Surg 1984; 88: 1020-32. 

11. 
Paradi JC. Endovascular repair of abdominal aortic aneurysms and other arterial lesions. J Vase Surg 1995; 21: 549-55. 


12. 
Becker GJ. Intravascular stents: general principles and status of lower extremity arterial applications. Circulation 1991; 83 (Suppl I):!122-136. 

13. 
Malina M, Brunkwall J, Ivancev K, Lindh M, Lind­blad B, Risberg B. Rena! arteries covered by aortic stents: clinical experience from endovascular grafting of aortic aneurysms. Eur J Vase Endovase Surg 1997; 14: 109-13. 






Endovascular treatment of aortic aneurysm by endoprosthesis 
Miloš Šurlan, Vladka Salapura 
Clinical Institute oj Radiology, University Medica/ Centre, Ljubljana, Slovenia 
Aortic endoprosthesis are divided according to its shape, site oj application, and construction material. Regarding the shape, there are tubular, unilateral and bifurcational endoprosthesis. Tubular are used mostly far treatment the thoracic aneurysms, and less far treatment oj the abdominal aneurysms. Far exclusion oj abdominal aneurysm the bifurcational prosthesis is mostly used. Aortic endoprostheses are made oj metal­lic support and prosthethic part. Supportive elements are made oj stainless stee/ ar nitinol, while the pros­thetic part is made oj dacron or PTFE. Meta/lic part oj prosthesis attaches prosthesis to healthy part oj aorta, above and below aneurysm, like sutures. It expands and gives support to the prosthesis. The proce­dure is precisely described far tlwracic and abdominal aortic aneurysms. We describe the possible compli­cations and the mechanism oj leakage and its diagnosis. In the study are presented two cases oj patients with aneurysm oj thoracic aorta and one case with abdominal aorta, successjully treated in our Institution. The jollow-up results after 2 years, in the patients with thoracic aortic aneurysm, and 6 months follow up in the patient with abdominal aortic aneurysm showed no signs oj clinical ar imaging complications. In con­clusion, we were trying, on the basis oj our experiences and results that have been recently published, to 
evaluate this method oj treatment. 
Key words: aortic aneurysm; blood vessel prosthesis 


Introduction 
Aortic endoprosthesis is used for exclusion of aortic aneurysm in abdominal and des­cending part of thoracic aorta. It is indicated as an alternative treatment to operation in high risk patients. It is introduced into aorta through delivery catheter system from femo-
Received 15 May 2000 Accepted 30 May 2000 Correspondence to: Prof. Miloš Šurlan, M.D. Ph.D., 
Clinical Radiology Institute, University Medica! Centre Ljubljana, Zaloška 7, SI-1525 Ljubljana. Phone: +386 1 143 15 30; Fax: +386 1 133 31 044 
ral artery. First report about successfully treated aortic aneurysm of abdominal aorta was given by Benko in 1986.1 The first results of treatment in human beings were published in 1991 and 1994.2, 3 The first placement of endoprosthesis in Slovenia was performed in 1994, under the American professor (prof. dr. Keller) supervision.4 It was performed by our­selves in two patients with thoracic aneurysm in 1998 and in one patient with abdominal aneurysm one year later. 

Šurlm1 Met al. / E11dovascular treatment oj aortic aneurysm by endoprosthesis 
Types of endoprostheses 
Endoprostheses are divided according to shape, site of application and construction material. We define tubular (Figure la), uni­lateral and bifurcational (Figure 1 b) prosthe­sis by shape. Endoprosthesis for descending part of thoracic aorta is tubular (Figure la), big, with diameter of 34-40 mm and 50 mm long or otherwise made by special order. It is made of self-expanding metallic support (Fi­gure 2a) and prosthesis from dacron (Figure la).3, 4 Endoprostheses for abdominal aorta are tubular, unilateral or bifurcational (Figure lb). They are made of Palmaz sent and dacron 
5 
or PTEF 2, prothesis or Gianturco or nitinol self-expanding sent and dacron prosthe­sis. 3, 4 , 6 Palmaz prosthesis is expanded with balloon catheter, others are self-expanding.2, 5 Tubular type is used for exclusion of aneurysm, which is 15-20 mm away from bifurcation. Bifurcational or unilateral type is used when aneurysm reaches bifurcation or one or both iliac arteries (Figure 1 b). Tubular measure 22-30 mm, bifurcational 22-35 mm, iliac artery part 10-18 mm. 


Figure l. Schematic figure of tubular and bifurcational endoprosthesis and one of the delivery systems. A) Tubular endoprosthesis from dacron and nitinol crosses the aneurysm of descendent thoracic aorta. Endoprosthesis cross­es the edges of dacron prosthesis to enlarge the attachment segment with aortic wall. B) Bifurcational endopros­thesis crosses the abdominal aneurysm, bifurcation and iliac arteries. Aortic neck between renal arteries and aneurysm is short, attachment site is enlarged by uncovered part of endoprosthesis, which goes over right renal artery orifice. Left part of endoprosthesis is introduced separately, through left cornmon femoral artery. C) Delivery system with endoprosthesis is introduced over guide-wire, it is narrower in the front part and flexible to ease the introduction over stenosis and edges. Endoprosthesis is released with quick pulling down of outside catheter at chosen site. Latex balloon placed over endoprosthesis to improve its attachment to aortic wall above and bellow aneurysm. 
Šurlnn Met ni. / Endovnscu/nr tren/111ent oj aortic aneurysm by endoprosthesis 

Figure 2. Late complication of endoprosthesis treatment in thoracic aorta and its cure. A) Transversal slice on spi­ral CTA shows bending of endoprosthesis with leakage into big aneurysm, which eroded thoracic spine segments. 
B) DSA of thoracic aorta in LAO shows movement and bending of prosthesis towards aneurysm, widened aorta over endoprosthesis and leakage to aneurysm. C) 3D reconstruction of spiral CTA in LAO projection confirms 
angiography. D) lntroduction of delivery system with endoprosthesis over bending and curves as also highly posi­tioned aortic arch towards subclavian artery, after which there is attachment site of new endoprosthesis. It is 
achieved with guide-wire, which is pulled through brachiocephalic and axillary artery out and additionally firmed. 
E) New endoprosthesis reaches up to left subclavian artery orifice and down to straight part of pre-existing endo­prosthesis (marks shaped as no.S). Bending of endoprosthesis is sufficiently corrected, leakage is not obtained any more. F) Spiral-CTA in 30 reproduction shows good position of endoprosthesis, correction of bending and no leak­age. 
Radio/ Oncol 2000; 34(2): 107-13. 

Šurlan Met al. / Endovascular treahnenl of aortic aneurysm by endoprosthesis 
Procedure performance 

Endoprosthesis for the thoracic aorta is intro­duced in general anaesthesia with intubation and ventilation. Catheter is placed into pul­monary artery and tube is placed into oesophagus for US control. Angiography catheter is introduced into ascendent aorta through one of brachial or axillary arteries for DSA control. Patient is given antibiotic pro­tection, with cephalosporin application every 4 hours for 8 times. In Standford, USA 3, the procedure is performed on operation table, permeable for X-rays. Patient is sterile washed and placed in a way that immediate sternoto­my can be performed, if necessary. In Slovenia procedure is performed on X-ray table in intervention radiology room, addi­tionally prepared for this procedure. We have stand-by surgery team with extracorporeal equipment prepared. We are working under fluoroscopy and DSA control. Control angiog­raphy is performed at the beginning, to obtain the starting position. The surgeon pre­pares the femoral artery, on the site of arteri­otomy we do the puncture of common femoral artery and introduce the guiding-wire (type »J« 0,035 inches, 260 cm long), with greater stiffness and better support. The front part, i.e. the softer part, is introduced into the ascending aorta. The patient receives 5000 LE. heparin i.v. Through arteriotomy site, introducing sheath with haemodynamic valve is implanted over the guiding-wire. Sheath is placed on plastic dilator for support during the introduction. The choice of length and diameter of the sheath depends on aortic width, position of aneurysm and size and construction of the prosthesis. The front part of the sheath is placed over aneurysm, or oth­erwise over the site where the endoprosthesis will be released (Figure le). Endoprothesis is placed inside short catheter, from which it is introduced into sheath by using pushing catheter and placed at its edge. Introduction and precise positioning is controlled by DSA 
Radio/ Oncol 2000; 34(2): 107-13. 
(Figure 2d). Endoprosthesis is released by holding pushing-catheter in a position and quickly pulling sheath down (Figure la,c). Endoprothesis is according to its self-expand­ing mechanism pressed against aortic wall and so excludes the aneurysm from the blood flow. Displacement of endoprosthesis during the procedure is disabled by lowering of aor­tic pressure to 50-60 mmHg for short tirne. Control DSA shows the exclusion of the aneurysm. After the catheter's removal the surgeon sutures the arterial opening and the operation site. Shorter iliac part may become longer with additional endoprosthesis, percu­taneously introduced on the same side. For aneurysm exclusion, which reaches bifurca­tion and iliac arteries tubular endoprosthesis with distal narrowing can be used, it is placed deep into iliac artery and contralateral side is closed by embolisation. Limb vascularisation is provided by femoro-femoral by by-pass. Endoprosthesis for abdominal aorta is usual­ly placed in local or spinal anaesthesia. 


Our experience 
We treated 3 patients with aortic aneurysm in our Institution, two patients with aneurysm in descendent part of thoracic aorta and one with abdominal aneurysm. In patients with thoracic aortic aneurysm the indication for treatment was a high risk for operation pro­cedure. A patient with abdominal aortic aneurysm choosed this treatment as an easier procedure after having two open heart surg­eries. In the first case, it was pseudoa­neurysm, which caused hoarseness and in the second case due to the late complication with deformation of endoprosthesis and interna! leakage (Figure 2a,b,c) after 2 treatments of percutaneous placement of endoprosthesis. 

Šurlan Met al. / Endovascular treatment of aortic aneurysm by endoprosthesis 
Results 

Treatment with endoprosthesis is successful in cases where there is no leakage into aneurysm, where there is narrowing of aneurysm or no longer growth of it. In the cases of leakage the procedure is unsuccessful, and it is also the same, if aneurysm grows, even without obvi­ous leakage. If aneurysm does not become smaller, even without leakage, we should state that aneurysm is not excluded, except if it is very calcified. In the cases where aneurysm stays the same (or grows bigger) with leakage present, there is quite a risk of its rupture. 

Complications 

Possible complications are divided by Die­trich8 into 3 groups: complications during in­troduction, local/vascular and distant/sys­temic complications. 
Complications due to introduction are cau­sed by missapproach, displacement of endoprosthesis, endoprosthesis' collapse, deformation and thrombosis. Local/vascular complications are: aneur­ysm rupture, leakage, stenosis of endopros­thesis, occlusion of renal arteries or sub­clavian artery, ileofemoral injury, embo­lism and bleeding. 




Distant/systemic complications: microem­
bolisations, multisystemic failure, renal or 
cardiac failure, myocardial infarction, 
arrhythmia, stroke or transient vascular 
disturbance. 
Endoprothesis can cause vascular distur­bance of spina! cord and so transient or per­manent paraparesis. The most frequent com­plication is leakage of blood at the site of attachment into aortic wall either above or bellow aneurysm. Leakage can be early or late. Causes of early leakage can be due to endoprosthesis or aortic wall. Endoprosthesis can bend or detach from the attachment site, its size or shape can be unsuitable or it can incompletely expand or be misplaced. 
Aortic neck can be short, too wide or cov­ered with recent thrombus or atheroma, so endoprosthesis is attached to a wounded neck. Small, fresh bleeding usually stops spontaneously in few weeks. If leakage is pre­sent after 3 months, and the patient is not coagulopath, we have to treat it. The leakage will persist if there is inflow and outflow in the aneurysm with a pressure difference. This kind of leakage does not stop spontaneously and risk of aneurysm's rupture persists. Blood flow direction in the aneurysm can flow from the upper to lower site of leakage (Figure 3a), from upper or lower to side bran­ches (Figure 3b) or from lower to side branch-


Figure 3. Schematic figure of blood flow direction in leakage into aneurysm. A) Blood flow between upper and lower leakage. B) Blood flow between upper leakage and side branches. C) Blood flow between lower leakage and side branches. D) Blood flow between arterial branches and aneurysm. 
Radio/ Oncol 2000; 34(2): 107-13. 

Šurlan Met al. / Endovascular treatment oj aortic mzeurysm by endoprosthesis 
es (lumbar, hypogastric, AMI) or between branches and aneurysm itself (Figure 3d). Persistent leakage in aneurysm without out­flow persists only if leakage is profound or outflow is not obtained. Late leakage is a complication diagnosed during follow-up of the patient without previous leakage. It is caused by displacement of endoprosthesis (Figure 2 b,c,d), deformation of parts of endo­prosthesis, progressive dilatation of aorta at the attachment site. It is the most serious complication of this kind of treatment. Diagnosis and differentiation of leakage is important for its treatment (Figure 2). 





Diagnosis of early and late complications 
Displacement, deformation, and bending of endoprosthesis is most easily diagnosed by plain film of chest and abdomen in AP and side projection. In comparison with previous films we can evaluate the present state. US, which is relatively cheap and non-invasive method, can evaluate the size of aneurysm: it can be smaller, equal, or bigger. More profo­und leakage or/and blood flow in the ane­urysm can be diagnosed by Doppler US. Small leakage and very small changes at the attach­ment site are better shown with spiral CTA, with 3 mm thick transversal slices. With spiral CTA a communication between aneurysm and side branches can be obtained, and also the changes in diameter and volume as well as the displacement of aneurysm (Figure 2a,c).9 
Alternative method is MRA. It shows pre­cise changes in aortic wall, size of aneurysm and thrombus in it.10 It enables 3 D picture in few directions. Spiral CTA is more reliable for smaller leakage. MRA is in some regards bet­ter then CTA -there is no ionisation and ne­phrotoxic contrast media. MRA is used as a method of choice in treatment of patients before endovascular placement.10 Ferro mate­rial in some endoprosthesis unables further MRA follow-up. 
Radio/ Onco/ 2000; 34(2): 107-13. 


Treatment results, discussion and conclusion 
Both our patients with thoracic aortic aneurysm have no clinical problems after 2 years and also our patient with abdominal aneurysm was without symptoms after a year. We found no changes on plain film in posi­tion or shape of endoprosthesis. We will per­form spiral CTA one year after the procedure, or even sooner in the case of clinical prob­lems or changes found on plain film. In Standford, there were 102 patients with aneurysm of descendent part of thoracic aorta of different aetiology treated between July 1992 and February 1997.12 The procedure was successfully performed in ali cases, 82% survived 35 months. 1,8 % of patients died in the period up to 35 days after the procedure. Nobody died during the procedure, 3,9 % re­mained paraplegic and 4 % suffered from par­tial thrombosis of aneurysm. These results are encouraging in comparison with operative treatment, with death rate between 12 %­17 %.14 The most experienced with abdominal aneurysm intravascular endoprosthesis treat­ment is Paradi 5 , 15, but he did not follow up the patients. In large group of 765 patients from 31 European countries the results and complications of abdominal aneurysm treat­ment with endoprosthesis are published between the period of May 1994 and No­vember 1997. 92 % were treated with bifure­ational prosthesis, only 8 % with tubular. The treatment was successful in 83 % after 3 mon­ths. 3,7 % patients died in the first 30 days. Internal leakage was diagnosed in 14 %, of those 68 % closed spontaneously. The results are comparable with operative.16 
In conclusion, we can state that treatment of aortic aneurysm with endoprosthesis in descendent part of thoracic aorta is more suc­cessful than abdominal aneurysm treatment, especially on long-terms. In some indications it is even more successful than the operative treatment and so it becomes a method of choice for thoracic descendent aortic ane­

Šurlmz M et a/. / E11dovascular lrealmenl of aorlie m1e11rys111 by ezzdoprost/zesis 
urysm. The biggest problem is attachment of endoprosthesis in abdominal aorta to the aor­tic wall between aneurysm and renal arteries, when this part is too short or weakened. 

References 
1. 
Balko A, Piasecki GJ, Shah DM, Carney WI, Hopkins RW, Jackson BT. Transfemoral placement of intraluminal polyurethane prosthesis for abdominal aortic aneurysm. J Surg Res 1986; 40: 305-9. 

2. 
Parodi JC, Palmaz JC, Barone HD. Transfemora\ intraluminal graft implantation for abdominal aor­tic aneurysms. Azm Vase Surg 1991; 5: 491-9. 

3. 
Dake MD, Miller DG, Semba CP, Mitchell RS, Walker PJ, Lindell RP. Transluminal placement of endovascular stent grafts for the treatment of descending thoracic aortic aneurysms. New E11gl J Med 1994; 331: 1729-34. 

4. 
Pavcnik D, Keller FS, Gabrijelcic T, Šurlan M. Transfemoral intraluminal stent graft implanted far thoracic aortic aneurysm. Tlzorac Cardiov Surg 1995; 43: 208-11. 

5. 
Parodi JC. Endovascular repair of abdominal aortic aneurysms and other arterial lesions. J Vase Surg 1995; 21: 549-55. 

6. 
Lammer J, Kretschemer G, Thurner S, H{Jlzenbein Th, Cejna M, Hausegger KA, Gschwendtner M, Mendel HJ, Havel M, Minar E, Ahmadi R, B{Jhming HJ, Deutsch M, Koch G, Polterauer P. Austrian multicentric registry of aortic stentgrafts (AMRAST). Cardiovasc In/er Rad 1998; 21 (Suppl 1): S92. 

7. 
Chuter TA, Risberg B, Hopkinson BR, et al. Clinical experience with a bifurcated endovascular graft far abdominal aortic aneurysm repair. J Vase Surg 1996; 24: 655-66. 


8. 
Dietrich EB. What are the key factors to achieve durable endoluminal abdominal aortic aneurysm repair. THI Peripheral Interventions for the Cardiovascular Specialist. Huston 1997, Oct 15-17. 

9. 
Balm R, Katee R, Blankensteijn JD, Mali WPTM, Eikelboom BC. CT angiography of abdominal aor­tic aneurysrns after transfernora\ endovascular aneurysrn management: diameter and volurne rneasurements. Eur J Vascular Surg 1996; 12: 182-8. 

10. 
Durharn JR, Hackworth CA, Tober JC, Srnead WL. Magnetic resonance angiography in the preopera­tive evaluation of abdominal aortic aneurysrns. Am J Surg 1993; 166: 173-8. 

11. 
Prince MR, Narasirnham DS, Stanley JC, Cho KJ. Gadolinium-enhanced rnagnetic resonance angiography of abdorninal aortic aneurysrns. J Vase Surg 1995; 21: 656-69. 

12. 
Semba CP. Endovascular grafting in the thoracic aorta. J Vase lnterv Radio/ 1998; 1 (Suppl 9): 39-41. 

13. 
Edvards RD. Complications and early success rate of endovascular repail· of abdominal aortic aneurysms. Cardiovasc In/er Rad 1998; 21 (Suppl 1): S93. 

14. 
Parodi JC. Endovascular stent graft repair of aortic aneurysms. Curr Opi11 Cardiol 1997; 12: 396-405. 

15. 
Melton LJ III, Bickerstff KL, Hollier LH, Van Peenan HJ, Lie JT, Pairolero PC, Cherry KJ, O'Fallon WM. Changing incidence of abdominal aortic aneurysms: a population based study. Am J Epidemiol 1984; 120: 379-86. 

16. 
Moreno-Cabral CE, Miller DC, Mitchell RS, Stinson EB, Oyer PE, Jamieson SW, Shurnway NE. Degenerative and artherosclerotic aneurysms of the thoracic aorta. J Thorae Cardiov Sur 1984; 88: 1020-32. 

17. 
Ernst CB. Abdorninal aortic aneurysm. New Engl J Med 1993; 328: 1167-72. 




Ultrasound-guided aspiration biopsy of subclinical regional 





metastases of head and neck carcinoma 
Alenka Višnar-Permjc1, Aleksandar Anicin2, Živa Zupancic\ Bojana Cernelc1 , Lojze Smid2, Dubravka B. Vidmar\ Milan Gorenc1 
Clinical Institute oj Radiology, University Medica/ Centre, Ljubljana, Slovenia, 2 University Department oj Otorhinolaryngology and Cervicojacial Surgery, University Medica/ Centre, Ljubljana, Slovenia 
Background. Studies concerned with the estimation oj ultrasound (US) combined with ultrasound-guided aspiration biopsy (USGAB) in the detection oj subclinical regional metastases Jrom the planocellular carci­noma oj head and neck are promising, but in Jew cases. Recently, the authors have pointed out the role oj lymph node size parameters in order to decide about the use oj USGAB. The aim oj this study was to test the reliability oj US-USGAB far the detection oj subclinical regional metastases in patients with planocel­lular head and nec/c carcinomas, including the evaluation oj lymph node size parameters. Patients and methods. 121 neck sides with no palpable metastases were examined by US in 77 patients with planocellular carcinomas oj head and neck. Depending on the results obtained, USGAB was performed on 64 neck sides. After surgery, the results oj US-USGAB were compared with histological findings oj the dissected lymph nodes. Results. The study s/10wed 77 % overall sensitivity oj US and USGAB, and 100 % specificity, while the 95% accuracy rate was reached. Negative predictive value was 94 %, and positive 100 %. The index oj trans­versal / longitudinal diarneter was the best predictor oj metastatic lymph node involvement. Conclusion. The results oj this study established that USGAB is an appropriate rnetlwd far detection the subclinical regional metastases on neck, and should be included into the routine diagnostic work up in the evaluation oj the extent oj head and necks carcinomas. 
Key words: head and neck neoplasms -pathology -ultrasonography; biopsy needle; lymphatic metastasis 
Received 15 May 2000 Accepted 30 May 2000 Correspondence to: Alenka Višnar-Perovic, Clinical 
Radiology Institute, University Medica! Centre Ljubljana, Zaloška 7, Sl-1525 Ljubljana. Phone: +386 1 143 15 30; Fax: +386 1 133 31 044; E-rnail: alenka.perovic@s5.net 

Introduction 
Planocellular carcinomas of head and neck frequently disseminate into the regional lymph nodes. Presence or absence of lymph node metastases is one of the most relevant prognostic factors, as the cure rate is 50% lower in patients with regional metastases.1 

Višnar-Perovic A ef ni./ Ultraso1111d-
g11ided aspiration biopsy 
Occult regional metastases represent a par­ticular problem in the diagnosis and treatment of the patients with planocellular head and ne­ck carcinomas, as they can be difficult to dete­ct by imaging methods. Therefore, in most cen­ters the elective treatment of neck is conside­red to be indicated when the risk of subclinical regional metastases, assessed on the basis of primary tumor site and size, exceeds 15 do 20 %.2, 3 However, treatment could be more directed and effective if the preoperative diag­nosis of lymph node condition in the clinical stage NO were comparable with histological findings of the dissected neck lymph nodes. 
The assessment of metastatic neck lymph node involvement by palpation is unreliable, as the obtained results were false negative (up to 30 %) and false positive (up to 20 %).4 Seve­ra! authors found CT more sensitive than pal­pation.5-7 Magnetic resonance with a contrast medium (MR) can detect up to 60 % of clini­cally occult metastases in the neck lymph nodes 8, and 70 % accuracy in stage NO is the result of using only ultrasonography (US).9 Nevertheless, the authors agree that the men­tioned methods, by using only morphologic criteria, cannot reliably differentiate between reactive inflammatory changes and metasta­
10 

tic involvement of the lymph nodes.8,Con­sidering recent technologic development, the diagnosis of suspicious lymph nodes can be most accurate by using high resolution ultra­sound in conjunction with guided fine -nee­dle aspiration biopsy (USGAB). With this technique, the high sensitivity of US is com­plemented by the excellent specificity of aspi­ration biopsy.11 In the available reports, the diagnosis of neck lymph node metastases in patients with planocellular head and neck carcinomas stage NO with USGAB yielded 76 % sensitivity, 100 % specificity and 89 % ac­curacy.9 These results are better than those reported for MR or CT.5-8 The importance of particular sonographic lymph node size para­meters is stili controversial. While some authors believe that the transversal lymph no­de's diameter is the most important 8, others claim that the relation between the transver­sal and the longitudinal diameter more reli­ably predicts metastatic lymph node involve­ment.12 Relevant for consideration is the reli­ability of negative US-USGAB findings. Some authors tried to solve this question by using Bayes' formula, which correlates the probabi­lity of subclinical neck metastases before and after US-USGAB procedure.13 Few studies have been carried out on the use of US and USGAB in the diagnosis of subclinical regio­nal metastases in groups of patients with pre­viously untreated planocellular carcinomas of oral cavity, pharynx and larynx where elec­tive dissection of the neck lymph nodes was foreseen as well (stage NO). Therefore we decided to test US-USGAB method in our institution by using the above mentioned cri­teria for selection of patients, also evaluating the size of lymph nodes. 
Patients and methods 
In the period from October 1995 to June 1997, there were 77 patients with previously un­treated and histologically confirmed planno­cellular carcinoma of the upper respiratory and gastrointestinal tract. The mean age of the patients was 56 years (range 37-76 yrs); there were 7 females (9 %) and 70 males (91 %). Ali these patients were planned for surgery of the primary tumor with neck dis­section. There was no evidence of palpable nodes on the neck in 61 patients (79 %). In the remaining 16 patients (21 %) the enlarged lymph nodes could be palpated only on one side of the neck. Because these patients required bilateral neck dissection, only the neck sides without palpable lymph nodes were included into this study. 
Following the clinical examinations with neck palpation performed by otorhinolaryn­gologists, each patient underwent the ultra­sonography examination of the neck using a 

Višnar-
Perovic A et al. / Wtrasozmd-guided aspiration biopsy 
linear 7.5 MHz probe of Sonolayer HR sys­tem, Toshiba SSA-270 A. USGAB was per­formed of lymph nodes with a transverse diameter exceeding 5 mm, lymph nodes with transverse vs. longitudinal diameter ratio greater than 0.40, ultrasonographically non­homogeneous lymph nodes, and in those with Doppler-US evidence of pathological vascularization. USGAB was also undertaken in borderline cases with respect to the above criteria, if three or more such lymph nodes were found in the most exposed anatomical levels. Aspiration biopsies were performed using thin needles with the inner diameter 
0.6 and 0.7 mm, produced by TIK Kobarid. Each USGAB procedure was attended by two experienced radiologists specialized in sonog­raphy. In the first study, i.e. from October 1995 to November 1996, USGAB was carried out »free hand«, whereas from June 1997 on, aspiration biopsies were carried out by means of a micro-convex probe with guidance. After fixation and staining by Giemsa, the smears were reviewed and assessed by cytopatholo­gists. 
Though in some patients USGAB was not indicated, as the lymph nodes' transversal diameter did not exceed 5 mm, and their dis­tribution and shape were inconspicuous. In other patients USGAB was performed according to criteria mentioned above, and the cytological smear could contain lymph node cells, squamous carcinoma cells, or material insufficient for a cytological diagno­sis (nondiagnostic material). In the case when the aspirate contained malignant cells, the result of US-USGAB was considered positive. When aspiration biopsy failed to detect malignant cells or when USGAB was not indicated due to inconspicuous US findings, the overall US-USGAB result was considered negative. 
After having completed the diagnostic pro­cedure, all the patients underwent surgery of the primary tumor, together with either uni­or bilateral neck dissection. Primary tumors were arranged according to the TNM classifi­cation 12 taking into account their extent, as assessed during the surgery (Table 1). In the case of negative US-USGAB findings, a selective dissection of the neck was per­formed, while a modified radical neck dissec­tion (RND) was done only in the case of pos­itive US-USGAB findings. All the dissected tissue samples were positioned and labelled. Using standard procedure, every 2 mm 4-5 µm thick slices were cut and stained with hematoxylin and eosin. The preoperative US and USGAB results were compared to the results of pathohistological evaluation, this being possible on the basis of the registered position and size of the described lymph nodes. 
The value of US-established lymph nodes' size parameters, i.e. of transversal and longi­tudinal diameter and the transversal diameter in proportion to the longitudinal diameter, was statistically evaluated by means of Student's T-test and standardized normal dis­tribution. The reliability of negative US and USGAB findings was evaluated using the curve deriving from Bayes' formula. 

Table 1. Distribution of patients by primary tumor site and stage 
Site:  Oral cavity  Oro-Pharynx  Hypo-pharynx  Larynx  Tota!  
Stage:  
T1  3  2  5  
T2  14  8  7  29  
T3  4  11  13  28  
T4  5  10  15  
Tota!  17  12  16  32  77  

Višnar-Perovic A et a/. / U/trasound-guided aspiration biopsy 
Results 

There were altogether 121 neck sides exam­ined by US, 61 of them were ipsilateral with the primary tumor. In each examined side, US imaged 1-9 lymph nodes (3 on average), their transversal diameters ranging between 2 -12 mm and the longitudinal diameters between 5 -20 mm. In 55 cases, the lymph nodes were small, measuring up to 8 mm in longitudinal diameter and up to 5 mm in transversal diameter, and were oval-shaped and nonsuspicious for malignant involve­ment. In these 55 cases (neck sides) USGAB was not indicated, and thus the test findings (that is of US and USGAB) were assessed as negative. In the remaining 66 cases USGAB was performed and max. 3 lymph nodes per test side were punctured. Individual lymph nodes were aspirated one to four times, twice on average. Cytological samples from 41 neck sides showed only lymph node tissue, while from 5 neck sides they contained nondiag­nostic material. In these cases, the test find­ings were also assessed as negative. In 20 cases, the cytological examination confirmed the presence of malignant cells. The longitu­dinal diameter of USGAB positive lymph nodes ranged between 7 and 17 mm (average 12 mm), their transversal diameter between 5 and 12 mm, while the index of transversal vs. longitudinal diameter in an individual USGAB positive lymph node ranged between 
0.45 and 0.95. In 16 cases, US-USGAB posi­tive lymph node belonged to the upper jugu­lar group (leve! II), in 3 cases to the middle jugular (leve! III), and in only one case to the submandibular (leve! I). On only one neck 
while in all others the cytologically positive sample was obtained from a single lymph node. Totally in 77 patients, there were 82 lateral neck dissections performed, 31 supraomohy­oid and 8 modified RND. Separate neck side 
Radio/ Oncol 2000; 34(2): 115-22. 
surgical specimens contained from 9 to 50 histologically examined lymph nodes. Meta­stases could be found in altogether 32 lymph nodes, taken from 26 neck sides. In each of these cases, the evidence of metastases was confirmed in 1 -3 lymph nodes with a longi­tudinal diameter 6 -20 mm (average 13 mm), and a transversal diameter 5 -12 mm. 
In all 20 cases with positive cytological USGAB findings, the diagnosis was con­firmed by the histological examination of the surgically removed lymph nodes. Out of the total of 46 negative USGAB, there were two false-negative; in both the aspirates contained lymphatic elements. None of the neck sides which yielded nondiagnostic material (aspi­rates from oval shaped lymph nodes, diame­ter 5-7 mm), showed histological evidence of metastatic involvement. Out of 55 US-based negative results, four were false negative. In all 6 false negative cases, the largest lymph nodes, assessed by pathologist, have trans­verse diameter 4 -7 mm and were invariably situated on leve! II. In one of the mentioned cases, the pathologist found a single micro­metastasis in the peripheral sinus of lymph node. Also in the remaining 5 cases focal metastatic growth in the lymph node was evi­dent. 
The estimation value of US and USGAB for detection of unpalpable regional metastases 
Table 2. Results obtained in total 121 neck sides with respect to the use of USGAB 
USGAB:  Yes  No (US only)  Tota!  
test  +  20  o  20  
test  - 44  51  95  
false - 2  4  6  

Tota! 66 

side, the two aspirates from two different lymph nodes were cytologically positive, 
Table 3. Cumulative results of US and USGAB 
obtained in 121 neck sides of 77 patients 
Results Histology + Histology-Tota! 
US, USGAB+ 20 o 20 US, USGAB-6 95 101 
Tota! 26 95 121 


Višnar-Perovic A et a/. / Ultraso1111d-g11ided aspiration biopsy 
resulting from planocellular carcinoma sho­wed 77 % sensitivity and 100 % specificity, the negative predictive value was 94 %, while the positive predictive value was 100 %. On the whole, 115 correct predictions were obtained by US -USGAB in 121 neck sides, the investi­gation's accuracy was 95 %. The results are presented in Tables 2 and 3. 
Based on the results presented in Table 3, the basic indicators of cumulative success of US and USGAB were calculated as follows: 
• 
Sensitivity: 20 / 26 = 77 % 

• 
Specificity: 95 / 95 = 100 % 

• 
Negative predictive value: 95 / 101 = 94 % 

• 
Positive predictive value: 20 / 20 = 100 % • Accuracy: 115 /121 = 95 % 


In the free-hand performed USGAB of 18 neck sides, there were two false negative results whereas in the USGAB with the use of a micro-convex probe with guidance in 48 neck sides, there was no false negative results (the difference was statistically insignificant). 
The value oj lymph node size parameters 
We evaluated the statistical significance of differences and averages between the groups of cases with and without histologically con­firmed metastases, taking into account the largest lymph node parameters as determined by US in individual neck sides (transversal diameter, longitudinal diameter and the ratio between these two). In the neck sides without metastases, the average largest transversal diameter was 5.98 mm, while in the neck si­des with metastases, it was 8,12 mm. The dif­ferences as calculated by T-test were statisti­cally highly significant (p < 0.005). When cal­culating the ratio between the transversal and the longitudinal lymph node diameters, the T­test also showed statistically significant dif­ferences (p < 0.001), the index in neck sides with metastases being 0.64, and in those without metastases, 0.47. The comparison of longitudinal diameters yielded a statistically insignificant value. In this study we also eval­
uated the statistical significance of differ­ences in the average largest US-determined size parameters in neck sides with or without cytologically confirmed metastatic involve­ment, with respect to transversal diameter, longitudinal diameter, and the ratio between the two. The ratio between the transversal and longitudinal diameter turned out to be statistically most relevant (p < 0.0001); in transversal diameter this was less (p < 0.01). There too, the longitudinal diameter turned out statistically insignificant. 
The use oj Bayes theorem in the evaluation oj US and USGAB diagnosis 
Using the formula based on Bayes theorem, the 100 % specificity and 77 % sensitivity obtained in this study, yielded the curve pre­sented in Figure l. This shows that with neg­ative US and USGAB, the probability of sub­clinical lymph node metastases is decreased from the previous 20 % to 5.4 % in the neck sites without palpable metastases. On the other hand, the 20 % and 10 % probability of subclinical neck metastases after negative US and USGAB correspond to 52 % in 33 % prob­ability without US and USGAB. 

Figure 1. Probability of subclinical Iyrnph node rnetas­tases before and after negative US-USGAB. 


Višnar-Perovic A et al. / Ultrasound-guided aspiration biopsy 



Discussion 
Reports with comparable inclusion criteria are few. The results of our study are compara­ble with those reported by Brekel and co­workers. 9 In a large number of other reports, the inclusion criteria were broader, since authors also included patients with clinically evident neck metastases, patients with previ­ous radiotherapy or patients with primary tumors which histologically did not corre­spond to planocellular carcinoma. 
Rather than in the sensitivity of the test, the clinician is interested in the reliability of its negative findings, or what is the negative predictive value (NPV). Providing this para­meter is sufficiently reliable, patients with negative findings could be spared elective neck treatment. In our study, there were alto­gether 6 false negative results, the NPV was thus 94 % (95/101). In the cases with USGAB performed, NPV was 96 % (44/46). In the Dutch study with inclusion criteria similar to 
9 
ours , the use of USGAB resulted in 82 % NPV. This difference in NPV can be partly attributable to the difference in the rate of histologically confirmed cases with subclini­cal neck metastases (21.5 % in our study vs. 40 % reported by Dutch authors). 
In neck sides with false negative results of US-USGAB, histological examination confir­med metastases exclusively in the lymph no­de level 2, originating from an extensive carci­noma of the supraglottis as primary tumor; and were at least partly due to the superposi­tion. In ali false negative cases, small metasta­tic islets were found in the lymph nodes, and in one of them situated only in a marginal sinus. As neither USGAB nor any other diag­nostic method is able to detect micrometa­stases from planocellular carcinoma, we think that even a repeated USGAB on a greater number of lymph nodes would only slightly improve the sensitivity of this method. 
Cases, for which USGAB fails to provide material for cytological diagnosis, represent a separate problem. In the study by Brekel et al.9, there were 70 USGABs performed, out of these 6 yielded nondiagnostic material. When evalu­ating the results, those cases were defined as negative. The authors claim that the results would appear to be better if such cases were excluded from the study, as it was done in a majority of similar studies, in order to reduce the number of false negative results. In Takashima's et al.12 report, such cases (7.7%) were excluded from the study, but none of the neck sides had metastatic involvement histo­logicaly confirmed. In our study, USGAB was performed on 66 neck sides, and nondiagnos­tic material was obtained in 5 cases. None of those five sides had histological evidence of metastases, and therefore the results of the present study remain practically unchanged, regardless of whether the cases with nondiag­nostic material are excluded or included as negative by US-USGAB. In none of the repor­ted studies USGAB was repeated in case of nondiagnostic material. There are controver­sial opinions whether these cases should be included or excluded from studies. We believe that in studies based on similar princip les, that the cases in which USGAB provided nondiag­nostic material should be included and defined as negative in order to obtain a more objective assessment of the usefulness of the method. 
In the available reports, the authors descri­be only »free hand« performance of USGAB for the detection of subclinical neck lymph no­de metastases. Based on our own experience, in the first part of our study, »free hand« per­formed USGAB gave 2 false negative results, while no such cases were observed when the method was upgraded by means of an addi­tional micro-convex probe with guidance. Despite the statistically insignificant differen­ce in the frequency of false negative results, we believe that the use of probe with guidance facilitates USGAB and reduces the occurrence of errors. 
Among the US parameters determining the probability of lymph node metastases, 



Višnar-Perovic A el al. / Ultraso11nd-g11ided aspiration biopsy 
particularly the relevance of size criteria has been pointed out in the last decade. While Dutch authors 8 report that the transversal lymph node diameter (minimal axial) is the most reliable size criterion for the detection of subclinical metastases, the Japanese investi­gators 12 proved that the ratio (index) between the transversal and longitudinal diameter is an even better predictive parameter. Accor­ding to the results of their investigation, there are significantly more metastatically involved lymph nodes among those with the index above 0.55. The relevance of the diameter ratio has also been confirmed by calculating the area under the ROC curve, this being sig­nificantly greater than in either transversal or longitudinal lymph node diameter (0.83 / 0.65 / 0.44). After grouping the neck sides by the presence / absence of histological and cyto­logical evidence of metastatic involvement, we obtained highly significant differences of average diameter ratio; the differences were significant in the transversal diameter, while the longitudinal diameter proved to be irrele­vant for the diagnosis of subclinical regional metastases from head and neck carcinoma. 
By improving the detection of subclinical neck metastases, it is possible to change to a certain extent the concept of elective lymph node treatment in patients with planocellular carcinoma of the upper respiratory and ali­mentary tract. Thus Brekel et al. 9, suggest that elective dissection should be omitted always when a reliable diagnostic method reduces the risk of subclinical neck metas­tases below 10-15 %, particularly in patients where the primary tumor can be removed by transoral approach, but under the condition that the patient is legible to regular follow up. The findings of our study also support the opinion that in certain cases the elective treat­ment of neck lymph nodes could be omitted on the account of better diagnosis. As evident from Bayes' curve (Figure 1) derived from our study results, the previous 33 % risk of sub­clinical metastases predicted on the basis of primary tumor site and size, was reduced to 10 % after negative US-USGAB. Better diagno­sis, improved by means of US-USGAB, would be most valuable for patients who are gene­rally not planned to undergo elective treat­ment of neck lymph nodes (initial carcinomas of the glottis, sinuso-nasal tract, skin of the head and neck), and where a therapeutic dis­section could be carried out in the case of positive findings. Likewise, a decision on the­rapeutic neck dissection could be made in the case of positive findings in the candidates for an elective procedure. In patients planned for primary radiotherapy, the use of US-USGAB will improve the detection of nonpalpable regional metastases, and the irradiation field could be adjusted with respect to the ob­tained findings. 
Conclusions 
By combining the sensitivity of US examina­tion with the specificity of US guided aspira­tion biopsy (US-USGAB) it is possible to detect a majority of subclinical regional metastases originating from planocellular car­cinoma of head and neck 
The ratio between the transversal and lon­gitudinal lymph node parameters is to be the most relevant of US size parameters to be respected in deciding to perform USGAB. US­USGAB can be recommended as the routine investigations for evaluating regional me­tastatic spread of head and neck carcinomas. 


References 
l. Spira RH, Alfonso AE, Farr NW, Strong EW. Cervical node metastases from epiderrnoid carci­noma of the oral cavity and oropharynx. A critical assessment of current staging. Am] Surg 1974; 128: 562-7. 
2. Ogura JH, Biller HF, Wette R. Elective neck dissec­tion far pharyngeal and laryngeal cancers: an eval­uation. Ann Oto/ Rhinol Laryngo/ 1971; 80: 646-51. 
Radio/ Onco/ 2000; 34(2): 115-22. 


Višnar-Perovic A et a/. / Ultrasound-guided aspiration biopsy 
3. 
Lee JG, Krause CJ. Radical neck dissection. Elec­tive, therapeutic and secondary. Arch Otolaryngol 1975; 101: 656-9. 


4. 
Ali S, Tiwari RM, Snow GB. False positive and false negative neck nodes. Head Neck S11rg 1985; 8: 78-82. 

5. 
Friedman M, Shelton VK, Mafee M, Bellity P, Grybauskas V, Skolnik E. Metastatic neck disease: evaluation by computed tomography. Arch Otolaryngol 1984; 110: 443-7. 

6. 
Mancuso AA, Harnsberger HR, Muraki AS, Stevens MH. Computed tomography of cervical and retropharyngeal lymph nodes: normal anato­my, variants of normal, and applications in staging head and neck cancer, II. Pathology. Radiology 1983; 198: 715-23. 

7. 
Stevens MH, Harnsberger HR, Mancuso AA, Davis RK, Johnson LP, Parkin JL. Computed tomography of cervical lymph nodes: staging and management of head and neck cancer. Are/z Otolaryngol 1985; 111: 735-9. 


8. 
Brekel MWM van den, Stel HV, Castelijns JA, Nauta JJ, Waal I van der, Valk J, Meyer CJ, Snow GB. Cervical lymph node metastases: assessment of radiologic criteria. Radiology 1990; 177: 379-84. 


9. 
Brekel MVM van den, Castelijns JA, Stel HV, Luth WJ, Valk J, Waal I van der, Snow GB. Ocenit metastatic neck disease: detection with ultrasound and ultrasound-guided fine needle aspiration cytology. Radiology 1991; 180: 457-61. 

10. 
Som PM. Lymph nodes of the neck. Radiologij 1987; 165: 593-600. 

11. 
Baatenburg de Jong RJ, Rongen RJ, Verwoerd CDA, Overhangen H, Lameris JS, Knegt P. Ultrasound­guided fine-needle aspiration biopsy of neck nodes. Are/z Otolaryngol Head Neck Surg 1991; 117: 402-5. 

12. 
Takashima S, Sone S, Nomura N, Tomiyama N, Kobayashi T, Nakamura H. Nonpalpable lymph nodes of the neck: assessment with US and US­guided fine-needle aspiration biopsy. J Ciin Ultrasound 1997; 25: 283-92. 

13. 
Baatenburg de Jong RJ, Knegt P, Verwoerd CDA. Reduction of the number of neck treatments in patients with head and neck cancer. Cancer 1993; 71: 2312-8. 

14. 
Takes RP, Knegt P, Manni JJ et al. Regional metas­tasis in head and neck squamous celi carcinoma: revised value of US with US-guided FNAB. Radiology 1996; 198: 819-23. 






review 

Computed tomographic angiography in intracranial vascular diseases 
Zoran Miloševic 
Clinical Radiology Instutute, University Medica/ Centre Ljubijana, Slovenia. 
Background. The development of spiral computed tomography (CT) introduced a more precise imaging of the vesse/s also with computed tomographic angiography (CTA). Because it is a minimaly invasive metlwd, it was widely accepted by radiologists and clinicians. In early 90 ties CTA also accompanied conventional angiography and magnetic resonance angiography (MRA) in imaging of intracranial vascu/ar diseases. CTA is used far the detection and evaluation of intracranial aneurysms, vascular malformations, stenoocclusive diseases of intracranial arteries and pathological changes of venous sinuses. Comparing to conventional angiography as the »gold standard«, CTA has high specificity, sensibility and diagnostic accuracy concern­ing detections of intracranial aneurysms. Regarding vascular malformations, CTA is used far diagnostics and pre and postoperative evaluation of it. CTA can show good resu/ts in imaging of venous angiomas, and so invasive conventional angiography can be avoided in this pathologi;. Stenoses and occlusions of arteries can be diagnosed and evaluated in patients with cerebral vasospasm, patients with acute stroke, and patients with chronical arterial stenoses and occ/usions. CTA is useful far the demonstration of occ/usive and stenos­ing changes of intracranial venous sinuses. Conclusion. With CTA it is possible to generate threedimensional reconstructed images which give a more accurate determination of anatomica/ relations in intracranial vascular diseases. The main disadventage of CTA in comparison to intraarterial angiography is the lower spatial resolution of CTA, but is constantly improving with the developement of better scanners and workstations, so that there are great possibilities far further developement and wider use of CTA in the diagnosis of intracranial vascular diseases. 
Key words: tomography, x-ray computed; cerebral artery diseases-diagnosis; cerebral aneurysm-diagno­sis; angiography 
Received 15 May 2000 Accepted 31 May 2000 Correspondence to: Zoran Miloševic, M.D., Clinical 
Radiology Instutute, University Medica! Centre Ljubljana, Zaloška 2, S1-1525 Ljubljana, Slovenia. Phone: +386 61 143 1530; Fax: +386 61 133 1044; E­mail: zoran.milosevic@moj.net 

Miloševic Z/ Computed tomographic angiography 
lntroduction 

Since its introduction in clinical practice in early 1970s, computed tomography has gone through a lot of important refinements and became more accurate and much faster from its beginnings till today. A progresive reduc­tion in scan times and improved spatial and contrast resolution made CT imaging a work­horse for many years. In early 1990s computed torµography has been revolutionazed by tech­nical advantages of spiral CT. Spiral CT scan­ning involves continous data aqusition throughout the volume of interest by simulta­neous moving of the patient through the 
2 

gantry while X-ray sources rotate.1,As this proces is contiuonos rather than stepwise as in conventional CT scaning, the examination tirne is reduced. Besides advantages like in­creased patients throughput and reduction of motion artifacts, the spiral CT also offers addi­tional properties which are not possible with conventional step by step CT scanning. Beca­use of short acquisition tirne, scanning can be timed with the peak opacification of arterial or venous phase, after the peripheral intra­venous application of contrast media. The resultant images (raw data) are processed with various computed rendering techniques, such as multiplanar reformatting (MPR), shaded surface display (SSD), maximum intensity projection (MIP) and volume rendering tech­nique (VRT) to generate two or three-di­mensional images of the vessels. As a result, CT angiography is performed less invasively, faster and at a lower cost than conventional intraarterial angiography.3A 
In neuroradiology, the diagnostics of cere­brovascular diseases represents one of its ma­jor fields of activity. It has progressed a lot during the last decade with the advent of MR imaging and spiral computed tomographic tehnology. CTA was increasingly used for the detection and evaluation of intracranial aneu­rysms, intracranial vascular malformations, intracranial vascular stenoses and occlusions and pathological changes on intracranial ve­nous sinuses. 
The purpose of this paper is to review the value of CTA in detection and evaluation of vascular intracranial diseases. 


Intracranial aneurysms 
Aneurysms are circumscribed dilatations of arteries that communicate directly with the vessel lumen. They may be saccular (berry) or fusiform.5 
Intracranial saccular aneurysms 
Saccular aneurysms are found in 1 % to 5,6 %.of population.5, 6 15 % to 20 % of patients have multiple aneurysms.7 Saccular aneury­sms are an important part of vascular patolo­gy, because subarachnoid haemorhage (SAH) is in 80 %-90 % caused by a rupture of a sac­cular aneurysm. In 15 % SAH may be caused by the arteriovenous malformation, and 5 % by diverse causes.8 SAH resulting from a rup­tured aneurysm of intracranial arteries car­ries a poor prognosis and the mortality in untreated patients may be as high as 45 %.8 
For many years the intraarterial cerebral angiography has been a technique of choice for the demonstration of the intracranial aneurysms, but it is invasive, expensive and has 1 % of complications, while 0,5 % of them develop permanent neurological deficits.9,10 Therefore non-invasive MRA and minimaly invasive CTA have been increasingly used over the past few years.11,1 2 Although MRA is capable of showing an accurate anatomy of intracranial vessels and vascular patology, there are some difficulties in detection and demonstraton of aneurysms with turbulent or slow blood flow.13-17 MRA is contraindicated in patients with feromagnetic elips, pacemak­ers or life-support devices.18 
CTA is insensitive to turbulent blood flow artifacts and in contrary to MRA, it can be 

Miloševic Z/ Co111puted tomogrnphic angiogrnphy 
performed in patients with ferromagnetic implants.19-21 In patients with SAH CTA de­mands little additional tirne and is easily per­formed immediately after the conventional CT.22 CTA is highly accurate, sensitive and specific as compared to DSA (gold stan­dard). 20,23-27 
Because of its minimal invasiveness, the indications for CTA in diagnostics of cerebral aneurysms are broader than for DSA and can be divided into six groups: 
l. Patients with acute SAH. The patients are usually criticaly ill and clinically unstable. On tirne diagnosis of the etiology of blee­deng is essential for planning an early surgery or other intervention. Intraarterial conventional angiography performed with­in the first 6 hours after initial bleeding is associated with an increased rebleedeng rate.28 CTA is very suitable in the acute stage after SAH because it does not require intraarterial catheterization, scaning tirne is only 50 seconds and it can be performed on the same scanner immediatly after the demonstration of SAH by conventional CT scan. 23-25,29 
2. Patients with proved history oj SAH, but with negative or indeterminate jirst angiography. In a number of patients, no underlying cause of SAH is identified despite a complete neuroradiological investigation. In the lit­erature this proportion varies between 3,8 % 30 and 46 % 31 with accepted mean of 15 %.32 The etiology of angiogram-negative SAH rernains elusive. Numerous theories have been proposed. One theory postulat­ed that SAH may be due to leakage from the lenticulostriate and thalamoperforat­ing vessels.33 Another theory suggested a venous or capillary source for the patients with perimesencephalic SAH.34 The most popular theory attributes bleeding to an aneurysm that undergoes thrombosis or is destroyed at the tirne of haemorrhage.35 CTA performed about 3 weeks later, can demonstrate partially or completely reca­nalized aneurysm. 
3. 
Patients with a suggestive but uncertain histo­ry oj SAH. In these patients, instead of in­vasive DSA as first imaging modality, CTA or MRA can often make the diagnosis.36, 37 For example, we found an aneurysm at the bifurcation of the left middle cerebral artery in a 37 years old woman who suffe­red from a sudden strong headache two weeks before and did not seek medica! help at that tirne {Figure 1). 

4. 
Patients without SAH, but with suspicious clinical signs oj an intracranial aneurysm or an aneurysm-like lesion on conventional CT images or MR images. In this group we have an example of a 68 years old woman suf­fering from paresis of the right third nerve, where we detected a large right interna! carotid artery aneurysm {Figure 2). 

5. 
Screening in »high risk population«. The exis­tence of families with a history of intracra­nial aneurysms is well recognized. In large epiderniologic studies, the prevalence of fa­milial intracranial aneurysms is higher than in general population (7% to 9%).38-44 Even in the situation of sporadic case , relatives of the patients are often worried that they may also harbor an aneurysm. In screening we use CTA as an additional or alternative method to MRA in patients with a family history of aneurysmal disease and patients with predisposing hereditary disease, such as autosomal polycystic renal disease. 


6. Follow up oj treated or non-treated aneurysms. 
Once the aneurysm is detected and clip­ped, a question may arise as to the proper placement of the clip. One potential prob­lem is to only partially clip the neck of the aneurysm and allow continued filling of the aneurysm. Another is a possible occlu­sion of vita! arteries after the improper placement. The postoperative evaluation has traditionaly been done with a conven­tional angiography.45 In a few cases we have had used CTA in order to clarify such 
Radio/ Oncol 2000; 34(2): 123-36. 

Miloševic Z/ Computed tomographic angiography 

Figure l. CT angiogram, volume rendering teclrnique, anteroposterior view, dernonstrates an aneurysm at the bifurcation of the middle cerebral artery and its relationship to the middle cerebral artery brancl1es (arrow). 

Figure 2. CT angiogram, volume rendering technique, rigl1t anterior oblique view, demonstrates a longish aneurysrn coming out from the right interna! carotid artery and spreading backwards and downwards in the area 
of tl1e third nerve (arrows). 
dilemmas. Depending on the size and ori­entation of the clip, a starshaped artifact in the immediate vicinity of the clip is seen. In most cases we have been able to demon­strate both clip and eventualy residual aneurism as well as patency of vessels de­spite this artifact (Figure 3). Inspite of this, CTA in its present form cannot replace DSA in all situations of the evaluation of the aneurysm clip placement.46 
Radio/ Oncol 2000; 34(2): 123-36. 
Finally, since CTA and DSA are in most cases complementary examinations, their combination often provides more data in the preoperative evaluation of intracranial saccu­lar aneurysms than obtained with each of them separately. CTA could be considered useful tehnique in the preoperative evaluation due to their three-dimensional representation of outer and inner vessel surfaces. The so called endovascular view of both the neck and 

Miloševic Z/ Co111puted /01110grnphic nngiogrnphy 

sack of the aneurysm can demonstrate the relationship between the aneurysm and arter­ial branches.47A8 CTA also allows the display of adjacent bone structures (Figure 4) and allow surgeons to plan a craniotomy with the best approach to the neck of the aneurysm.26 
Intracranial fusiform aneurysms 
Fusiform aneurysms are dilated and elongat­ed atherosclerotic vessels. They commonly affect the supraclinoid segment of interna! carotid artery and vertebrobasilar arteries. Mura! thrombus is common. Hemorrhage is rare.5 Surgical therapy is not possible in the majority of cases. CTA is able to clearly de­monstrate this type of aneurysm and so to avoid DSA (Figure 5). 


Figure 5. CI angiogram, volume rendering technique, posterosuperior view, demonstrates fusiformly dilated and elongated right vertebral artery and basilar artery (arrows). On the basis of this examination, it was de­cided that the patient was not an operative candidate. DSA was avioded in this case. 
Intracranial vascular malformations 
Intracranial vascular malformations are a diverse group of congenital lesions of blood vessels. These lesions are usually classified as 
Radio/ 011col 2000; 34(2): 123-36. 

Miloševic Z/ Computed tomographic angiography 
arteriovenous malformations (AVM), venous angiomas, cavernous angiomas and capilary teleangiectasias.5 
Intracranial arteriovenous malformations 
Patologically, the AVMs show clusters of ab­normal arteries and veins. The vessel walls are typically thickened and contain elastin and smooth muscle. AVMs are subdivided into pial AVMs, dura! AVMs and dura! arteri­ovenous fistulas. 
Pia/ AVMs consist of an plexus of arterial feeders, nidus and dilated draining veins. Be­cause there is no intervening capillars, blood shunts directly from arteries to veins. These vessels are patological and are prone to rup­ture. The risk of hemorrhage is 2 % to 4 % per year. For each episode of hemorrhage there is a 29 % chance of death and 23 % chance of long term morbidity.49 The therapy of AVMs can be surgical, radiosurgical or endovascular. 
A pre-therapeutical neuroradiological eval­uation requires a diversity of anatomical and hemodynamic information. From the mor­phological point of view, neuroradiological studies identify feeding arteries and draining veins and evaluate angioarchitecture of the nidus. From hemodynamic point of view, flow velocities in the different vascular com­partments shoud be evaluated. Conventional angiography still represents the gold standard for evaluating feeding arteries, draining veins and the angioarhitecture of the nidus. It is also mandatory for hemodinamic evaluation of AVMs. The experience in the last few years showed that MRA and CTA can be useful in the diagnostics of AVMs.50-52 
CTA can have important role in the follow­ing situations: 
l. Detection of AVM. CTA can be useful in a diagnosis, excluding or confirming the presence of AVM in a sugestive clinical context. 
2. Pre-therapeutical evaluation of AVM. In con­junction with conventional angiography, conventional MR and CT images, CTA can be used to obtain three-dimensional ima­ges of AVM. Reconstructed three-dimen­sional CTA images can be viewed from any perspective which can be used for an exact localisation of feeding arteries, nidus and draining veins (Figure 6). 

Figure 6. CT angiog:ram, volume rendering technique, anteroposterior view, shows pial arteriovenous malfor­rnation of the right hemisphere. Two rnain feeding: arteries (arrows), nidus (arrowheads) and draining vein (open arrow) are well dernonstrated. 
3. Post-therapeutical evaluation of AVM. The analysis of AVM reduction after the treat­ment can be performed with CTA images. This technique offers a suitable method for a minimally invasive and reproducible fol­low up. 
In dura/ AVMs and dura/ arteriovenous fistu­las neither CTA nor conventional MR or MRA can substitute or complement a conventional angiography in a diagnosis and pre-treatment evaluation. 2z53,54 

Miloševic Z/ Co111p11ted to111ogrnpfiic nngiogrnpfiy 
Venous angiomas 
Venous angiomas are congenital anomalies of the intracranial venous drainage. They repre­sent anatomic variants resulting from the arrested embryological venous development causing the persistence of primitive medulary veins.55 They are described as a local network of small, medulary veins, resembling so called caput medusae, which converge cen­trally into a large transmedullary vein that courses toward the cortical surface or the 
57 
deep venous system.56, Venous angiomas are most common incidenta! vascular malfar­mations detected radiologically and at autop­sy.58 They are also designed »developmental venous anomalies« to emphasize their fre­quency and their benign nature. Usually they cause no symptoms but may rarely be associ­ated with headache, seizure, or facal neuro­
58 59 
logic deficit , and even more rarely with acute symtomatic hemorrhage.60 In most cases a surgical therapy is not necessary or possible.58-60 
Today the technique of choice in the neu­roradiological diagnosis of venous angiomas is MRA and conventional MRI with the administration of gadolinium. A stellate app­earence on MR is said to be patognomonic of venous angiomas.61 Only in rare circumstan­ces, when the diagnosis is not certain, a con­ventional angiography needs to be per­farmed. With the conventional angiography, a venous phase abnormality characterized by multiple dilated medulary veins converging on a larger trancortical vein, giving a »caput medusa« appearance is diagnostic.58-61 
Instead the conven tional angiography, CTA can also be used.62 CTA demonstrates findings characteristic far venous angiomas: small vascular structures in deep white mat­ter converging to a more dilated trancortical draining vein (Figure 7). The use of CTA in the diagnosis of venous angiomas shows good preliminary results and could obviate the need far the conventional angiography in most cases. 

Figure 7. CT angiogram, volu me rendering technique, 
anterosuperior view, shows venous angiorna in left cerebelar hemisphere (arrows). The lesion has charac­teristic »caput medusa« configuration. 
Cavernous angiomas and capillary telangiectasias 
In cavernous angiomas and capillary talen­giectasias, both conventional and non or min­imaly invasive angiographic techniques fail to reve! the majority of lesions, whereas a con­ventional MRI stili remains the technique of choice. 5 , 27 
Intracranial vascular stenoses and occlusions 
The intracranial stenotic and the occlusive vascular patology can be divided in cerebral vasospasm in patients with SAH, acute arte­rial occlusion in patients with acute ishemic stroke and chronic stenoticocclusive diasea­ses of arteries. 
Cerebral vasospasrn 
The most debilating complication of acute SAH is the cerebral vasospasm, acounting far 14 % of deaths or severe disability in patients with SAH.63 The onset of spasm occurs 4 to 11 days after hemorrhage in approximately 

Miloševic Z/ Computed tomographic angiography 
30 % of patients.64 A current therapy includes the hypervolemic and pharmacologic therapy and its efficacy is well documented.64 
A conventional angiography is one diag­nostic method for this complication, but the risk of performing this procedure in the criti­cally ill patient can limit its application. Iran­scranial Doppler sonography is noninvasive and rapidly performed, but does not provide anatomic information and is limited to a small acoustic window. 65,66 MR angiography is restricted in the evaluation of these pa­tients due to a reduced intracranial blood flow. CIA offers the potential for rapid, minimally invasive method of diagnosing and monitor­ing this complication (Figure 8).67 

Figure 8. CT angiogram, volume rendering technique, superior view, shows vasospasm of intracranial arter­ies (arrowheads) after subarachnoidal haemorhage and an anterior communicating aneurysm (arrow). 
Acute ischemic stroke. 
Strokes are a major public health problem. Stroke is the third most common cause of death since one third of the patients die and another third are rendered permanently dis­abled. 68 In Slovenia the incidence of stroke is 190,5/100000 people. Mortality in the first 30 days is 21 %.69 Ischemic infarction of brain tis­sue, because of the acute arterial occlusion, is the major causative factor. Ihe majority of infarctions are caused by thrombembolism from underlying atherosclerotic disease. 70,71 Ihe majority of stroke patients are treated conservatively. 72 Systemic intravenous or local intraarterial thrombolysis has recently shown the promise of improving the patient's outcome.73, 74 However, thrombosis must be identified and treated promptly for optimal results. Because trombolytic drugs produce intracranial hemorrhage in 6 % to 20 % of cases, the potential for salvaging the ischemic brain must be defined.74, 75 Ihe reversibility of ischemic process not only depends on the tirne after ictus, but is primarily a function of the degree of persistent collateral flow to the affected tissues. Brain without sufficient col­lateral flow will die within minutes, whereas tissue with good collateral flow will remain viable. In the latter circumstances throm­bolytic terapy can be effective. 
Patients with acute stroke are examined with unenhanced CI of the brain to exclude intracranial hemorrhage or other rare causes for stroke. CI is also useful in assessing early signs of cerebral ishemia, such as parenhimal hypodensity and focal brain swelling.76,77 But conventional CI does not show the extent of disturbed cerebral perfusion, which is deter­mined by the site of occlusion and collateral blood supply and is not capable of showing the volume of viable tissue at risk from the low perfusion, which is the target of throm­bolytic treatment.78 Recently, MRA and MR imaging with hemodynamic and diffusion weighted pulse sequences are increasingly used in patients with acute stroke. Diffusion and perfusion images are highly sensitive to early infarction and an extent of infarcted brain tissue.79, 80 
In acutely ill stroke patients CIA is more practical and faster than MR imaging and can be performed immediately after the conven­tional unenhanced CI of the brain. Because 

Miloševic Z/ Co111puted lo111ogrnphic nngiogrnphy 
of these considerations, few authors studied whether CTA is capable of showing the site of arterial occlusion, estimating collateral circu­lation, and determining the extent of severe parenhimal perfuson deficit. Preliminary results of these studies showed that CTA is safe in cases of acute stroke and can add an important diagnostic information to those obtained by the conventional CT and may provide a rational basis for optimal treat­
s1 s2 
ments of patients with an acute stroke_7s,, 
Chronic stenoocclusive diseases 
Chronic stenoocclusive diseases of intra­cranial arteries are most commonly caused by 
83 
atherosclerosis,5,less often by nonathero­matous causes, like fibromuscular dysplasia, vasculitides and idiopathic progressive arteri­
84 
opathy (moyamoya).5, Stenoocclusive dis­eases of intracranial arteries impeares the blood supply of the brain and increase the possibility of an ischaemic stroke. Early diag­nosis and treatment of these pathologies has an important role in the stroke prevention. 
In nonatherosclerotic stenoocclusive dis­eases a conventional angiography still plays a primary role, due to mainly changes on arter­ies of the second and the third order.84 Spatial resolution of MRA and CTA is too low for pre­cise imaging of these arteries, which measure less than 1 mm in diameter.SS 

Because atherosclerosis affects mostly lar­ger intracranial arteries, like interna! carotid artery, middle cerebral artery, basilar and ver­tebral arteries, useful and reliable diagnostic method is MRA86, 87 and nowadays also CTA.88 CTA most reliably demonstrates calci­fications in atherosclerotic lesion, which can have an important impact concerning further therapy (Figure 9). 
Venous sinus compression and trombosis 
The external compression of venous sinuses can cause their narrowing or obstruction. It is most commonly caused by the tumor or bone fragn1ent with the impression fracture. Sinus thrombosis is a partial or complete ob­struction of sinus lumen due to intraluminal clot and usually affects superior sagital sinus, then transversal, sigmoid and cavernous si­
5 
nus. Thrombosis can spread into cortical veins, straight sinus and interna! cerebral veins. The interruption of venous outflow can cause local or diffuse cerbral edema and cor­tical venous infarcions, which are often haemorrhagical. 89 
In the past, the prognosis in patients with venous thrombosis has been poor, with the mortality rate between 30% and 80%, but has been irnproved in the later years by the effec­tive systemic heparin anticoagulation, fibri­
91 
nolytic therapy and anti-edema therapy.9 0,The availability of a successful treatment has increased the need for the prornpt and accu­rate diagnosis. 
Besides conventional angiography, conven­
93 94 
tional CT,92 MR and MRA91, ,have increa­sed the ability to detect this condition. The conventional contrast enhanced CT has low sensibilitiy in the diagnosis of dura! sinus thrombosis.95 MRA, the present examination of the choice for evaluation of dura! sinuses, is limited by rnotion artifacts and the patient's contraindications.92 Recently developed CTA with another name CT venography offers grea-
Rndiol Oncol 2000; 34(2): 123-36. 

Miloševic Z/ Computed tomogrnphic angiography 

ter sensitivity and specificity than a routine contrast-enhanced CT in the diagnosis of dural sinus thrombosis.92,96 On CT venography, dural sinus thrombosis is seen as the absence of opacification of the affected dural sinus on the reconstructed images (Figure 10) and as a filling defect in the dural sinus on the source images.92,96 Also, in cases of external venous compresion, CTA can reliably demonstrate venous sinuses and cortical veins, important for the preoperative planning (Figure 11). 
Conclusion 

CTA is the youngest angiografic imaging modality which has been quickly accepted especially for the detection and evaluation of intracranial saccular aneurysms, so far most­ly diagnosed by the conventional intraarterial angiography. 
An important part of CTA are post-pro­cessing techniques. Because threedimension­al reconstructions of intracranial vessels offer anatomical imaging in the similar way as per­cepted with human vision, we can better understand the morphology of pathological 

(b) clearly demonstrates parasagittal meningeoma (arrows) and its relationship to the superior sagittal sinus (arrowhead) and cortical veins, which is impor­tant in preoperative planing. 
proceses and its relations to surrounding structures. 
Minimaly invasivenes of CTA represents an important advantage to conventional intra­arterial angiography. The main disadvantage of CTA, has been and in some regard still is a lover spatial resolution compared to conven­tional angiography. Inspite of this, the bal­ance between advantages and limitations still supports CTA in many clinical issuses. 

Miloševic Z/ Co111puted tomographic nngiogrnphy 
A quick development of spiral CT scanners and image processing software enables fur­ther developement and improvement of CTA. A recent innovation of CT scanners with mul­tiple detectors makes scanning of larger vol­umes with higher spatial resolution possible. Further improvement represent new software with volume rendering techniques and fast workstations, so that it is now possible to process larger quantity of data in much shor­ter tirne. 
In conclusion, CTA, if combined with threedimensional techniques, has excellent possibilities to become a reliable and accept­able method for the evaluation of not only intracranial saccular aneurysms, but also of most intracranial vascular diseases. 
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Ueda T, Yuh WTC, Maley JE, Quets JP, Hahn PY, Magnotta VA. Outcome of acute ischemic lesions evaluated by diffusion and perfusion MR imaging. Am J Neuroradiol 1999; 20: 983-9. 

81. 
Shrier DA, Tanaka H, Numaguchi Y, Konno S, Pate! U, Shibata D. CT angiography in the evalua­tion of acute ischemic stroke. Am J Neuroradiol 1997; 18: 1911-20. 

82. 
Kucinski T, Koch C, Grzyska U, Freitag HJ, Kramer H, Zeumer H. The predictive value of early CT and angiography far fatal hernispheric swelling in acute stroke. A111 j Neuroradiol 1998; 19: 839-46. 

83. 
Consigny PM. Advances in clinical medicine: pathogenesis of atherosclerosis. AJR 1995: 164: 553-8. 


84. Harris KG, Yuh WTC. Intracranial vasculitis. 
Neuroimaging Ciin Norih Am 1994; 4: 773-97. 
85. 
Stock KW, Radne EW, Jacob AL, Bao XS, Stein­brich W. lntracranial arteries: prospective blinded comparative study of MR angiography and OSA in 50 patients. Radiology 1995; 195: 451-6. 

86. 
Dagirrnanjian A, Ross JS, Obuchowski N, Lewin JS, Tkach JA Ruggier PM, et al. High resolution, magnetization transfer saturation, variable flip angle, tirne of flight MRA in the detection of intracranial vascular stenoses. J Compul Assisl Tomogr 1995; 19: 700-6. 

87. 
Korogi Y, Takahashi M, Nakagawa T, Mabuchi N, 


Watabe T Shiokawa Y, et al. lntracranial vascular 
stenosis and occlusion: MR angiographic findings. Am J Neuroradiol 1997; 18: 135-43. 
88. Skutta B, Furst G, Eilers J, Ferbert A, Kuhn FP. Intracranial stenoocclusive disease: Double-detec­tor helical CT angiography versus digital subtrac­tion angiography. Am J Neuroradiol 1999; 20: 791-9. 
89. Zirnmerman RD, Ernst RJ. Neuroimaging of cere­bral veins: Thrombosis. Neuroimaging Ciin Norih Am 1992; 2: 463-85. 
90. 
Johnson BA, Fram EK. Cerebral venous occlusive disease Neuroimaging Ciin Norih Am 1992; 2: 769­83. 

91. 
Medlock MD, Olivero WC, Hanigan WC, Wright 


RM, Winek SJ. Children with cerebral venous 
thrombosis diagnosed with magnetic resonance imaging and magnetic resonance angiography. Neurosurgery 1992; 31: 870-76. 
92. 
Casey SO, Alberico RA, Pate! M, Jimenez JM, Ozsvath RR, Maguire WM, et al. Cerebral CT venography. Radiologi; 1996; 198: 163-70. 

93. 
Buonanno FS, Mody DM, Bali MR, Laster DW. 


Computed cranial tomographic findings in cere­
bral sinovenous occlusion. J Com.pul Assisl Tonwgr 1978; 2: 281-90. 
94. 
Vogl TJ, Bergman C, Villringer A, Einhaupl K, Lissner J, Felix R. Dura! sinus thrombosis: value of venous MR angiography far diagnosis and fallow up. AJR 1994; 162: 1191-8. 

95. 
Mattle HP, Wentz KU, Edelman RR, Wallner B, Finn JP, Barnes P, et al. Cerebral venography with MR. Radiology 1991; 178: 453-8. 


96. Ozsvath RR, Casey SO, Lustrin ES, Alberico RA, Hassankhani A, Pate! M. Cerebral venog:raphy: comparison of CT and MR projection venography. AJR 1997; 169: 1699-707. 

rev1ew 
Computed tomographic angiography of body vasculature 
Tomaž Kunst, Pavle Berden 
Clinical Radiology Institute, University Medica/ Centre, Ljubljana, Slovenia 
Background. The introduction oj helical CT scanners in cornbination with sirnultaneous opacification oj vessels with contrast medium allows the demonstration oj vessels within the chosen vohnne oj interest. This exarnination is called CT angiography. Being a minimally invasive method, it has been quic/cly acctept­ed in the spectrurn oj vessel-irnaging modalities, as far example: Doppler ultrasound, magnetic resonance angiography, transesophageal ultrasound etc. In the field oj cardiovascular radiologij, it has been used to dernonstrate patlwlogiJ oj ascending and descending aorta, like the aneurysms, dissection, traumatic rupture ar congenital anomalies. It is also very useful in pre-and postoperative follow -up in the aortic stent-graft insertion, a method which has recently become popu/ar. Also the CT angiography has greatly influenced the preoperative calculations and has clearly demonstrated the postoperative anatomical changes as well as com­plications (i.e. peristental leakage). 
Conclusions. In this context, it is comparable to intraarterial angiography and even offers some advantages over the latter. The only draw-back being som.ewhat lower spatial resolution and longer processing time, but with the advent oj a new, so called multi-slice scanners and powerful workstations, these draw-bac/cs will be minimized. 
Key words: tomography scanners, X-ray computed; aortic disease -ultrasonography -radiography 
Introduction 
The advent of spiral (helical) CT has made a great revolution at the performance of body CT and has enabled the development of CT angiography (CTA). It is minimally invasive investigation method of vascular system and 
Received 15 May 2000 
Accepted 30 May 2000 
Correspondence to: Tomaž Kunst, M.O., Clinical Radiology Institute, University Medica) Centre Ljubljana, Zaloška 7, SI-1525 Ljubljana, Slovenia. Phone: +3861131 31 23 (38-34); Fax: +386 1133 31 044 
can in many cases replace a conventional angiography. In CTA, there is a volume of data obtained rapidly with virtually no respi­ratory misregistration at peak vascular opaci­fication following peripheral injection of con­trast. The appropriate timing ensures that either venous or arterial tree is perceived and multiple overlapping slices can be obtained in order to generate two-and three-dimensional reconstructions with no increase in radiation dose to the patient. When performed as a dedicated study, CTA is faster, less invasive and (should be) cheaper than conventional angiography, with a reduced radiation dose. 

Kunst Tet ni./ Computed tomographic nngiogrnphy oj body vnsculnture 
However, there is no significant contrast sav­ing and spatial resolution is somewhat limit­ed to the vessel diameter of 1-2 mm. 
The technique must be meticulous if good­quality angiograms are to be obtained. The variables that can be altered are collimation ("beam width"), table speed, contrast volume and flow rate and reconstruction index, which are all set according to the volume of interest and suspected diagnosis. From this data, two -and three dimensional images can be generated, like multi-planar reconstruc­tions (MPR), maximurn-intensity projections (MIP), shaded surface display (SSD) and vol­urne rendering tecnique (VRT). 
Main indications for CTA of aorta and its branches are aneurysms and dissections of thoracic aorta, suspected blunt trauma or tho­racic rupture; pulmonary embolism; in abdominal aorta, the diagnosis of aneurysrns, dissections, rupture, and suspected patholo­gy in renal or visceral arteries as well as pelvi­cal arteries. It is very useful to perforrn CTA at first and afterwards surgical or interven­tional procedures on aorta and its branches. 
Thoracic aorta 
Conventional CT has an established role in detection of aortic aneurysms and dissec­tions. CTA has the advantage of thinner colli­mation and of more axial slices obtained dur­ing the peak vessel opacification.1 Entire aorta can be imaged on a single spiral and excellent multiplanar reformats can also be obtained. It can actually demonstrate the size, 

the extent and the quality of the wall of Figure lb. The same patient with "right posterior aneurysm as well as the thickness of intimal oblique" view. flap in the case of dissection (Figurel). Trne 
and false lumen can be identified and fol­suspected aortic rupture, although the rate of lowed, so the origin of the vessels from trne technically suboptimal results may limit its or false lumen or the extension of the dissec­usefulness.2 Also, the determination and dif­tion into the branches can be determined ferrential diagnosis of congenital anornalies is accurately. Some authors prefer the use of made (Figure 2). In our institution, we found CTA over conventional CT and catheter aor­CTA of a great benefit in preoperative treat­tography in cases of blunt chest trauma or ment planning and postoperative follow-up at 
Radio/ Oncol 2000; 34(2): 137-43. 



Kunst T el ni./ Co111p11ted /0111ogrnpliic nngiogmpliy of body vnsculnlure 




Figure 2b. Tluee-dimensional reconstruction showing a right aortic arch with mirror imaging of aortic branches. 
the percutaneously or sugically inserted aor­tic endoprostheses (Figure 3). 
Complex anatomy and the extent and the course of intima! flap can be determined by multiplanar reformats (MPR) or SSD and 
4 
VRT, respectively.3, In order to cover the entire thoracic aorta, it is used a collimation of 3mm, table speed of 4,5 mm/s (pitch 1,5), the volume of contrast is set to 140 ml with the infusion rate of 3 ml/s. In cases when the entire aorta is to be imaged it is used a 5mm 
Figure 3b. Reduction of the aneurysm after the inser­tion of additional endoprosthesis. 
collimator with a pitch of 1,5-2. lf renal arter­ies are to be assessed precisely, two spirals are made, one for thoracic and the other for abdominal aorta. 
Pulmonary circulation 
With CTA it is possible to identify reliably the emboli in central and segmenta! arteries, but not in the vessels below the fourth division (subsegmental arteries) (Figure 4).5 Therefore, 

Kunst Tet al. / Computed tomogrnphic nngiography of body vasculature 



Figure 4c. Multiplanar reconstruction of left pul­monary artery, demonstrating a massive thrombus (arrows). 
we scan the patient from the top of aortic arch down to the domes of diaphragm. Ideally, it is used a 3 mm slice with a pitch of 1,5, allowing the scanning time of 20 -25 sec., but patients usually cannot hold the respiration so long, so we have to use the 5 mm slice and the pitch of 1-1,5, so that the scan duration of about 10 seconds is achieved. 
Reported sensitivity and specificity for the detection of pulmonary emboli are 87 and 95%, in comparison with V/Q seans where the result is 65 and 94 %. Therefore, many authors advise new protocols for highly sus­picious PE: Doppler US of the lower limbs and CTA of pulmonary arteries, which not only reliably determines emboli, but enables a very accurate differential diagnosis.6, 7 Scintigraphy and pulmonary angiography should be reserved for negative CTA with possible subsegmental emboli.8 CTA can also be used for follow-up, i.e. to determine the effectiveness of the treatment.9 
Abdominal aortoiliac disease 
Conventional CT with contrast was frequent­ly used for the assessment of abdominal aor­tic aneurysms and provided accurate infor­mation about the size of the aneurysm, thrombus formation and diameter of trne lumen.10, 11 CTA can provide all this informa­tion, as well as can accurately assess the con­comitant renal or mesenteric artery stenoses (Figure 5). It also provides useful information for abdomino-iliacal stent-graft insertion, like the necessary device length and diameter, distance of the neck of aneurysm to renal arteries, and the involvement of pelvic arter­ies.12,13 After the insertion, it is used to con­firm the success of the procedure, and for detection of the complications, like kicking of the stent and peri-stent leaks.14 
Although there exist many different proto­cols for performing abdominal and pelvic CTA, we are using the following method: after having made native seans, the collima­tion is set to 5 mm and table speed at 7,5 mm/s, enabling the scan from above the coeli­ac trunk or superior mesenteric artery down to external iliac artery in a single scan. Axial reconstruction is made at 3 mm interval, and 

Kunst Tet ni./ Computed tomographic angiogrnphy of body vasculature 


if necessary (like in suspected renal artery stenosis), the segment of "raw data" frorn superior mesenteric artery to renal arteries is reconstructed at 1,5 mm interval in order to demonstrate selectively the pathology in this region. 
Renal arteries 
Hypertension is a common condition, and up to 10 % of patients have a renovascular cause. Although not all the renal artery stenoses cause hypertension it is irnportant to diag­nose significant stenoses, that is more than 50 %.15 Presently, the gold standard for diag­nosis is arteriography, after the Doppler US and potentially scintigraphy having been per­formed. The advantage of CTA over conven­tional arteriography is the identification of the vessel wall, leading to the improved dif­ferentia tion between ostial and truncal stenoses.16 With CTA, the presence and the extent of calcination at the site of stenosis is accurately demonstrated, so that therapeutic decision for dilatation and/or primary stent insertion should be made much easier (Figure 6). 17 , 18 The additional advantage of CTA is the ability to detect possible non-renal causes of hypertension, i.e. suprarenal tumors etc.18 
This technique is of great importance. 
Usually, it is used a 2 mm slice with a table speed of 3 mm and the axial images recon­structed at 1-1,5 mm interval. Besides axial images, maximum intensity projection (MIP) is very useful to differentiate between calcifi-


e 6. Subtotal stenosis of left renaJ artery is well demonstrated (arrow), as well as doubled right renal arteries. 
Figur

Kunst Tet al. / Computed tomographie angiography oj body vasculature 
cation and contrast-filled lumen, and SSD for the morphological assessment. MPRs are made for the measurements, and after the therapeutical procedures, the same imaging protocol is used for comparison. 
Other indications 
CTA has proven to be superior to convention­al CT in the cases of preoperative assessment of live renal donors19 20 evaluation of mesen­
, 
, 
teric ischaemia21 portal vein and hepatic 
, 
artery thrombosis, but these application fields have been stili in the experimental phases. 
Conclusion 
The CTA technique offers several advantages over conventional arteriography. Although other noninvasive modalities are gaining pop­ularity, CTA is in many cases the definite method of the vessel pathology diagnosis and differential diagnosis. Although MR angiogra­phy is being established in this field, and has many advantages over CTA, like the lack of radiation exposure and there is no iodinated contrast material needed, CTA will continue to be the forefront of noninvasive vascular imaging due to its availability, relatively low cost and effectiveness in diagnosis and treat­ment planning. 
Reference s 
1. Balm R, Eikelboom BC, van Leeuwen MS, Noordzij 
J. Spiral CI angiography of the aorta. Eur] Vase Surg 1994; 8: 544-51. 
2. 
Gavant ML, Flick P, Menke P, Gold RE. CI aortog­raphy of thoracic aortic ruptme. Am j Roentgenol 1996; 166: 955-61. 

3. 
Quint LE, Francis IR, Williams DM, Bass JC, Shea MJ, Frayer DL et al. Evaluation of thoracic aortic disease with the use of helical CI and multiplanar reconstructions: comparison with surgical find­ings. Radiologi; 1996; 201: 37-41. 


Radio/ Oncol 2000; 34(2): 137-43. 
4. 
Zeman RK, Berman PM, Silverman PM, Davros WJ, Cooper C, Kladakis AO et al. Diagnosis of aor­tic dissection: value of helical CI with multiplanar reformation nad three-dimensional rendering. A,n J Roentgenol 1995; 164: 1375-80. 

5. 
Remy Jardin M, Remy J, Deschildre F, Artaud D, Beregi JP, Hossein Foucher C et al. Diagnosis of pulmonary embolism with spiral CI: comparison with pulmonary angiography and scintigraphy. Radiology 1996; 200: 600-706. 

6. 
Goodman LR, Lipchik RJ. Diagnosis of acute pul­monary embolism: time for a new approach. Radiology 1996; 199: 25-7. 

7. 
Mayo JR, Remy Jardin M, MLller NL, Remy J, Worsley DF, Hossein Foucher C et al. Pulmonary ernbolism: prospective comparison of spiral CI with ventilation-perfusion scintigraphy. Radiology 1997; 205: 447-52. 

8. 
Cross JJ, Kemp PM, Walsh CG, Flower CD, Dixon AK. A randomized tria! of spiral CI and ventila­tion-perfusion scintigraphy for the diagnosis of pulmonary embolus. Ciin Radiol 1998; 53: 177-82. 

9. 
Remy Jardin M, Louvegny S, Remy J, Artaud D, Deschildre F, Bauchart JJ et al. Acute central thromboembolic disease: posttherapeutic follow­up with spiral CI angiography. Radiology 1997; 203:173-80. 

10. 
Simoni G, Perrone R, Cittadini G Jr, De Caro G, Baiardi A, Civalleri D. Helical CI for the study of abdominal aortic aneurysm in patients undergo­ing conventional surgical repair. Eur J Vase Endovase Surg 1996; 12: 354-8. 

11. 
Van Hoe L, Baert AL, Gryspeerdt S, Marchal G, Lacroix H, Wilms G et al. Supra-and juxtarenal aneurysms of the abdominal aorta: preoperative assessment with thin-section spiral CI. Radiology 1996; 198: 443-8. 

12. 
Moritz JD, Rotermund S, Keating DP, Oestmann JW. Tnfrarenal abdominal aortic aneurysms: impli­cations of CI evaluation of size and configuration for placement of endovascular aortic grafts. Radiology 1996; 198: 463-6. 

13. 
White RA, Donayre CE, Walot !, Kopchok GE, Wilson EP, Buwalda R et al. Preliminary clinical outcome and imaging criterion far endovascular prosthesis development in high-risk patients who have aortoiliac and traumatic arterial lesions. J Vase Surg 1996, 24: 556-69. 

14. 
Dorffner R, Ihurnher S, Youssefzadeh S, Winkelbauer F, Hl)lzenbein I, Polterauer P et al. Spiral CI angiography in the assessment of abdominal aortic aneurysms after stent grafting: 




Kunst T ef ni./ Computed tomogmphic mzgiography of body vnsculnture 
value of maximum intensity projections] Comput Assisf Tomogr 1997, 21: 472-7. 
15. 
Mitty HA, S ha piro RS, Parsons RB, Silberzweig JE. Renovascular hypertension. Radio/ Ciin Nart/z Am 1996; 34: 1017-36. 

16. 
Galanski M, Prokop M, Chavan A, Schaefer CM, Jandeleit K, Nischelsky JE. Rena! arterial stenosis: helical CT angiography. Rndialogy 1993; 189: 185­92. 

17. 
Rubin GD, Dake MD, Napel S, Jeffrey RB Jr, McDonnell CH, Sommer FG et al. Spiral CT of renal artery stenosis: comparison of three-dimen­sional rendering technique. Radiolog11 1994; 190: 181-9. 

18. 
Beregi JP, Elkohen M, Deklunder G, Artaud D, Coullet JM, Wattinne L. Helical CT angiography compared with arteriography in the detection or renal artery stenosis. Am J Roentgeno/ 1996; 167: 495-501. 



19. 
Cochran ST, Krasny RM, Danovitch GM, Rajfer J, Barbaric ZM, Wilkinson A et al. Helical CT angiog­raphy for examination of living renal donors. Am J Roentgenol 1997; 168: 1569-73. 

20. 
Platt JF, Ellis JH, Korobkin M, Reige K. Helical CT evaluation of potential kidney donors: findings in 154 subjects. Am J Roenfgeno/ 1997; 169: 1325-30. 

21. 
Rubin GD, Dake MD, Napel SA, McDonnell CH, Jeffrey RB Jr. Three-dimensional CT angiography of the splanchnic vasculature. Rndiology 1993; 189(P): 229. 

22. 
Freund M, Wesner F, Reibe F, Ei11de L, Hutzel­mann A, Heller M. Spiral CT angiography for pre­operative planning in patients with epigastric tumors: comparison with arteriography. J Comp Assist Tomogr 1996; 20: 786-91. 

23. 
Kaneko K, Honda H, Hayashi T, Fukuya T, Ro T, Irie H et al. Helical CT evaluation of arterial inva­sion in pancreatic tumors: comparison with angiography. Abdom Imagi11g 1997; 22: 204-7. 



Magnetic resonance arthrography of the glenohumeral joint 
Vladimir Jevtic, Anton Praprotnik 
Clinical Radiology Institute, University Medica/ Centre, Ljubljana, Slovenia 
Background. The purpose of this study was to estimate the value of native magnetic resonance imaging (MRI) and direct gadopentate (Gd-DTPA) magnetic resonance artrography (MRA) in diagnosing posttrau­matic pathological changes of the glenohumeral joint. Patients and methods. In 27 consecutive patients with clinically significant trauma in whom native MRI of the glenohumeral joint was not diagnostically conclusive direct MRA with paramagnetic contrast agent was accomplished. Following intraarticular injection of Gd-DTPA diluted in saline (concentration 0.2 mnzol/l) T1 W spin echo (SE) and gradient echo (GE) images were pe1formed. Diagnostic results of native MRI and MRA were compared. Results. MRA revealed 5 rotator cuff lesions, 7 labral lesions, 4 osteochondral injuries and a /oose body which were not definitely proved by native MRI. Ali the pathological findings of MRA were confirmed operatively ar arthroscopically. Conclusion. Direct MRA with Gd-DTPA showed to be a more sensitive technique far the demonstration of clinically significant inh·aarticular posttraumatic changes than noncontrast MRI. 
Key words: magnetic resonance imaging; shoulder joint -injuries; rotator cuff 
Introduction 
Owing to multiplanar imaging capabilities, to superb contrast and to high spatial resolution MRI is able to demonstrate noninvasively joint anatomy. Consequently, this modality has become the method of choice for joint imag­ing. However, MRI diagnosis of different intraarticular pathologic conditions in ana­tomically complex joints, such as the gleno-
Received 15 May 2000 Accepted 30 May 2000 
Correspondence to: Prof. Vladimir Jevtic, M.D., Ph.D., Clinical Radiology Institute, University Medica! Cen­tre Ljubljana, Zaloška 7, SI-152 5 Ljubljana, Slovenia. Phone: +386 1143 15 30; Fax: +386 1 13 3 31 044 
humeral joint, may be difficult. Therefore sev­era! techniques of MRA were evaluated. These include intraarticular use of saline or Gd­DTPA (direct arthrography) and the intrave­nous application of Gd-DTPA (indirect arthro­graphy). An important advantage of direct ar­thrography is the joint capsule distension which enables the better visualisation of intra­articular anatomic structures especially in tight joints. According to some authors MRA of the shoulder joint may provide some infor­mation of diagnostic importance about the labrum, the joint capsule and the rotator cuff which are not possible without the use of Gd­DTPA.1-5 Vast majority of centres still use non­contrast MRI as a routine diagnostic method. 

Jevtic Vel ni. / Mag11etic resonance artlzrograplzy 
The purpose of this study was to estimate the value of native MRI and direct Gd-DTPA MRA in diagnosing posttraumatic pathologi­cal changes of the glenohumeral joint and eventually to include MRA in a routine diag­nostic work up. 
Patients and methods 

On the basis of history and physical exami­nation the clinical diagnosis of rotator cuff tears (n=18) and the lesions of the labum and the capsule (n=9) was made following signifi­cant trauma. In ali of these patients native MRI was performed 0.5 -2 months following trauma. Magnetic resonance images were obtained using dedicated shoulder coil on 1.5 T scanner (Magnetom SP 63, Siemens, Erlangen, Germany). ASE sequence with Tl­weighted (TR 450 ms, TE 15 ms), PD-weight­ed (TR 1900 ms, TE 20 ms) and T2-weighted (TR 1900 ms, TE 80 ms) images was per­formed using angled coronal plane, followed by a GE Tl-weighted FISP 2D images (TR 40 ms, TE 10 ms, flip angle 40°) in an axial plane. In ali the patients the MRI diagnosis was inconclusive (3 possible rotator cuff lesions, 2 suspect labral lesions and 2 possi­ble osteochondral injuries). Due to persisting clinical symptoms MRA was indicated and accomplished 0,5 -1 months after the first examination. The joint was punctured under f!uoroscopic control using local anaesthesia. The proper position of the needle was con­trolled with 1-2 ml of non-ionic iodinated contrast material (Ultravist, Schering, Ger­many) and 10-15 ml of 2 mmol/1 Gd-DTPA 1wlution in saline (Magnevist, Schering, Germany) was then injected until the capsule became distended. After the injection passive and active movements of the shoulder joint were carried out for severa! minutes to achieve the uniform distribution of Gd-DTPA solution. Coronal oblique and axial 5 mm thick consecutive slices were obtained using a SE Tl-wieghted images (TR 450 ms, TE 15 ms), a GE FISP 2D images (TR 40 ms, TE 10 ms, flip angle 40°). A field of view was 16 cm with data acquisition matrix of 256 x 256. (MRA has been approved by the Republic's Ethics Committee). 
The images were analysed in a qualitative fashion and the diagnostic results of native MRI and MRA were compared. 
Results 

Out of 27 cases MRI revealed equivocal pathological findings in 7 patients (26%). A diagnosis of possible full thickness rotator cuff lesion was made in 3 cases, of suspect labral injury in 2 cases and of osteochondral lesions in 2 cases. In the remainder of 21 (78 %) patients no pathological findings could be demonstrated (Tablel). 
MRA confirmed rotator cuff lesions in ali 3 cases with equivocal findings on MRI and proved 2 additional tears. In 3 of these patients the diagnosis of complete (Figure 1) and in 2 cases of partial rotator cuff rupture was made (Figure 2). Typical Bankart lesions were demonstrated in 7 patients using MRA, 2 of these were the cases with suspect labral lesions on native MRI (Figure 3). In patients with labral injuries 3 osteochondral (Sach ­Hill) lesions of the posterolateral aspect of the humeral heads were revealed. MRA showed a loose body within the joint (Figure 4) which was not seen on native MRI (Tablel). In ali the patients pathological MRA findings were con­firmed by the operative procedure or the shoulder artroscopy. 
Discussion 

MRI replaced the conventional arthrography in most institutions and has become a method of choice for depicting the posttraumatic joint pathological changes. Using different imaging 
Jevtic Vet al. / Magnetic resonance artlzrography 
Table l. MRI and MRA findings 
Diagnostic modality  MRI  MRA  
Diagnosis  possible  definite  possible  definite  
N  %  n  %  n  %  n  %  
normal findings  20  74  8  30  
pathological findings  7  26  19  70  
rotator cuff lesions  3  11  5  19  
labral lesions  2  7,5  7  26  
osteochondral lesions  2  7,5  3  11  
loose bodies  o  1  3  
frozen shoulder  o  3  11  


Figure l. MRA, T1 W spin echo image in an oblique coronal plane. Complete rotator cuff rupture is demonstrated with accumulation of paramagnetic contrast agent at the insertion of the m. supraspinatus terdon (big arrow heads). Leakage of contrast material into the subacromial-subdeltoid bursa is also revealed (small arrow heads). 
protocols intra and paraarticular soft tissue other anatomically tight joints, including structures can be demonstrated noninvasively glenohumeral, were not so good. In an with high contrast and spatial resolution in attempt to increase the diagnostic accuracy of various planes. It has been proved that MRI MRI severa! MRA methods were evaluated shows high sensitivity and specificity for changing noninvasive native MRI in an inva­diagnosing the most of the clinically relevant sive diagnostic procedure. The best results pathological changes of the knee joint. were achieved by the intraarticular applica­Unfortunately the diagnostic results in some tion of gadopentate diluted in saline.1-5 
Jevtic Vet ni./ Mag11etic resonance arlhrography 
Figure 2. MRA, TI W spin echo image in an oblique coronal plane. Partial rotator cuff rupture. Small defect of the m. supraspinatus tendon is filled with paramagnetic contrast material (arrow head). 
In our study native MRI revealed equivocal pathological changes only in 7 joints (26 %) out of 27 patients with significant clinical symptoms. In none of these MRI diagnosis was definite. There was a number of cases (n=20; 74 %) with normal findings in which the clinical symptoms could not be explained by MRI. On the other hand MRA proved to be much more accurate and revealed definite, clinically relevant pathological changes in 19 (70 %) of the shoulder joints resulting in an operative procedure which confirmed the MRA diagnosis. 
Although the diagnostic results of MRA were much better than that of MRI in 8 (30 %) out of 27 cases with normal MRA findings clinical symptoms could not be substantiated by imaging features. It may be postulated that at least some of minor posttraumatic changes were spontaneously resolved in a period of severa! months following the initial trauma before MRA was accomplished, while some of them affected extraarticular anatomic structures not shown by MRA. 
In ali 3 cases with MRI diagnosis of possi­ble full thickness rotator cuff tear MRA clear­ly demonstrated typical pathological find­ings, and proved 2 additional partial lesions not shown by MRI. MRI diagnosis was main­ly based on T2-weighted SE images which re­vealed high signal intensity synovial fluid within the tendon of the supraspinatus mus­cle and an effusion within the subacromial -subdeltoid bursae. Using MRA in cases with complete tear the defect as well as the quality of neighbouring ends of the tendon were 
Figure 4. MRA, TI W spin echo image in an oblique coronal plane. Low signal intensity loose body is shown (arrow) surrounded by high signal intensity contrast material. 


Jevtic Veta/./ Magnetic resonance artlzrography 

Figure 3. MRA, Tl W gradient echo image in an axial plane. Bankart lesion is clearly demonstrated surrounded by high signal intensity solution of Gd-DTPA due to excellent capsular distension. 
clearly outlined by the high signal intensity contrast agents on Tl-weighted SE images (Figure 1). Leaking of the contrast agent into the subacromial and subdeltoid bursae was also demonstrated. In two joints with partial tear a small defect of the tendon was filled with high signal intensity gadopentate (Figu­re 2). There are severa! reasons for the superi­or diagnostic results of MRA. Firstiy, the joint capsuie distension resulted in better filling of the thorn tendon and in ieaking of contrast agent out of the joint cavity.3A,6 Secondly, higher contrast resoiution was achieved with the solution of gadopentate in comparison to synovial fiuid in native MRI.1,2 , 7 Thirdly, the spatial resoiution on Tl-weighted SE images in MRA was higher than on T2-weighted 
9 
images which were diagnostic in MRI.8,
Even greater differences between both examinations were documented in labral lesions. Only 2 possible labral lesions were shown by MRI, mainly using GE Tl-weighted FISP 2D images. MRA proved each of these iesions and confirmed additional 5 Bankart iesions. Capsular distension with contrast accumulation within the capsulolabral lesi­ons was the main reason for the better demonstration with MRA (Figure 3). MRI reveaied 2 Sach-Hill lesions as high signal intensity areas on T2-weighted SE images and iow signal intensity on Tl-weighted SE ima­ges. The diagnosis of 3 osteochondral lesions with MRA was mainly based on the contrast accumulation within the defect of the hume­ral head. 
Low signal intensity ioose body represent­ing corticai bone fragment was clearly demonstrated within a distended joint due to the surrounding high signal intensity gado­pentate only using MRA (Figure 4). 
In 3 cases the diminished capacity of the joint cavity with reduced bursae and the same 

Jevtic Vet al. / Magnetic resonance arlhrography 
leakage of the contrast agent out of the gleno­humeral joint indicated the frozen shoulder. Native MRI was not able to demonstrate these typical findings 
There were no cases with pathological MRI findings which were not confirmed by MRA. 
No adverse reactions to contrast agents or a complication due to intraarticular injection could be registrated. 
In conclusion, in this study MRA proved to be more accurate than native MRI in diagnos­ing clinically relevant posttraumatic intraar­ticular changes of the glenohumeral joint. The results indicate that MRA may be used as a safe and reliable routine diagnostic proce­dure. 
References 

1. 
Zanetti M, Hodler J. Contrast media in MR artrog­raphy of the glenohumeral joint: intra-articular gadopentetate vs saline; preliminary results. Eur Radio/ 1997; 35: 498-502. 

2. 
Kopka L, Funke M, Fischer U, Keating D, Oestmann J, Grabbe E. MR arthrography of the shoulder with gadopentetate dimeglumine: influ­ence of concentration, iodinated contrast material, and tirne on signal intensity. AJR 1994; 163: 621-3. 


3. 
Vahlensieck M, Peterfy CG, Wischer T, Sommer T, Lang P, Schlippert U, et al. Indirect MR Arthro­graphy: Optimisation and clinical applications. Radiology 1996; 200: 249-54. 

4. 
Helgason JW, Chandnani VP, Yu JS. MR Arthro­graphy: A review of current technique and appli­cations. AJR 1997; 168: 1473-80. 

5. 
Palmer WE, Caslowitz PL, Chew FS. MR Arthro­graphy of the shoulder: Normal intraarticular structures and common abnormalities. AJR 1995; 164: 141-6. 

6. 
Flannigan B, Kursunoglu-Brahme S, Snyder S, Karzel R, Del Pizzo W, Resnick D, MR Arthro­graphy of the shoulder: comparison with conven­tional MR imaging. AJR 1990; 155: 829-32. 

7. 
Hodler J, Kusunoglu-Brahme S, Snyder SJ, Cervilla V, Karzel RP, Schweitzer ME, et al. Rotator cuff disease: assessment with MR arthrography versus standard MR imaging in 36 patients with arthro­scopic confirmation. Radiology 1992; 182: 431-6. 

8. 
Palmer WE, Brown JH, Rosenthal DI. Rotator cuff: evaluation with fat-suppressed MR arthrography. Radiology 1993; 188: 683-7. 

9. 
Palmer WE, Brown JH, Rosenthal DI. Labral-liga­mentous complex of the shoulder: evaluation with MR arthrography. Radiology 1994; 190: 645-51. 

10. 
Chandnani VP, Yeager TD, DeBerardino T, Christensen K, Gagliardi JA, Heitz DR,et al. Glenoid labral tears: prospective evaluation with MR imaging, MR arthrography, and CT arthrogra­phy. Am J Roentgenol 1993; 161: 1229-35. 




review 

Magnetic resonance of cardiac tumors and masses 
Pavel Berden 
Clinical Institute oj Radiology, University Medica[ Center, Ljubljana, Slovenia 


Cardiac tumors are rare and should be differentiated from nontumoral cardiac masses because of different therapeutic approach. For this purpose, spin-echo (SE) technique and gradient-echo (GE) technique are used in magnetic resonance imaging (MR). The first provides anatomic evaluation of the heart and tissue char­acterization, while the second provides dynamic information on the blood flow and heart contraction. Cardiac rnyxoma is differentiated from thrombus by paramagnetic contrast agent administration. Their rnobility is evaluated with GE technique. Lipomas and subacute hemorrhage have the same, high signal intensity on Tl-weighted spin-echo image, therefore, the Jat suppression technique is appropriate to recog­nize them. MR is used in evaluating the response of the malignant tumor to chemotherapy. GE MR is use­ful to differentiate between the thrombus and slow-flowing blood; the adminisfration of gadolinium helps to distinguish the thrombus fronz the tum01: In patients suspected of having a cardiac tumor, echocardiog­raphy is the first method of choice. MR is used to confinn the findings oj echocardiography, to determine precisely the tumor location, extent, and its tissue characterization, to follow up patients under treatment, and to detect early tumor recurrence. 
Key words: heart neoplasms; magnetic resonance imaging 
Introduction 
Cardiac turnors are rather rare entities. Because of their rarity and the nonspecific syrnptornatology, their diagnosis rnay be de­layed. Cardiac surgery is still the preferred therapeutic approach far cardiac turnors. Nonturnoral cardiac masses are rnuch more 
Received 15 May 2000 Accepted 30 May 2000 
Correspondence to: Pavel Berden, M.D., Clinical Radiology Institute, University Medica! Centre Ljubljana, Zaloška 7, S1-1525 Ljubljana. Phone: +3861 5408 400; Fax: +386 1 133 31 044; E-mail: pave l. berden@mf. uni-lj .si 
frequent than true cardiac turnors and usual­ly require medica! treatment or no treatrnent at all.1 Thus, accurate differentiation between the two conditions is highly irnportant. The diagnosis of cardiac turnors and rnasses was very difficult before the availability of tran­sthoracic (TTE) and transesophageal echo­cardiography (TEE), cornputed tornography (CT), and magnetic resonance irnaging (MR). With the advent of modem irnaging tech­niques abnorrnal masses are much more easi­ly and frequently detected. As normal cardiac structures may be interpreted as abnorrnal by inexperienced people, precise knowledge of the normal cardiac anatorny and its variants 

Berden P / Magnetic resonance of cardiac twnors and masses 
is required. We wish to highlight the role of MR in the detection and differentiation of car­diac masses to stress the diversity of cardiac tumors, nontumoral masses, and normal vari­ants, and to present our experience with MR in evaluating cardiac masses. 
MR techniques of imaging cardiac tumors and masses 
MR is one of the preferred imaging modalities in the evaluation of the patients with suspect­ed cardiac masses. 
Two types of ECG-triggered sequences are used for the evaluation of suspected cardiac masses with MR. The first is the spin-echo (SE) technique (dark blood), the second is the gradient-echo (GE) technique (bright blood). 
The SE sequence can be Tl-or T2-weighted. It provides excellent anatomic evaluation of the heart. The differentiation between benign and malignant neoplasms based on the pat­tern of signal intensity is still not possible, although a combination of Tl-and T2-weight­ed measurements allows better description of the composition of cardiac masses. 
Most soft tissue tumors have relaxation times shorter than fluid, and produce a rela­tively low signal on Tl-weighted images and a relatively high signal on T2-weighted images. 2 Cystic fluid (pericardial cyst) has a very low signal on Tl-weighted images and a very high signal on T2-weighted images. The masses with lipomatous composition (lipomas) have a relatively high signal on Tl-weighted se­quences and an intermediate signal on T2­weighted sequences. Fat suppression tech­niques selectively saturate the signal coming from the fat and can be used to prove the fatty composition of cardiac masses. Calcifications and mature fibrotic tissue have few mobile protons, resulting in low signal in both Tl­and T2-weighted MR, while subacute and chronic hemorrhage shows a high signal intensity in both sequences.3 
Many tumors have similar signal intensity as normal myocardium and the distinction between them is difficult.4 Paramagnetic con­trast agents, such as gadoliniumdiethylene triamine penta-acetic acid (Gd-DTPA), may be administered to improve discrimination. Gd-DTPA usually accumulates in the vascu­larized tissues or in tissues that contain high­er proportion of interstitial space. Necrotic or cystic areas of a tumor do not accumulate contrast medium. This may help in the differ­ential diagnosis or valuation of the efficacy of nonsurgical treatment on the follow-up. Acute and subacute thrombus does not have vascularization and therefore cannot be enhanced by Gd-DTPA, which may help to differentiate them from tumor. Chronic thrombi can rarely be enhanced after the administration of contrast medium.5 
Gradient-echo MR is generally applied as a single-slice multiphase sequence. Images are obtained at different tirne points during the cardiac cycle in a single tomographic section. These images can be looked in a cine mode providing dynamic information on the blood flow and heart contraction (cine MR). It does not provide real-tirne imaging, but it is a very useful technique to evaluate the mobility of cardiac masses and to differentiate slow flow from thrombus. 
Normal cardiac anatomy and variants 
Severa! normal intracardiac structures can mimic pathologic masses. 
False chordae ar false tendons are sometimes found as normal variants in left ventricle. They are linear structures attached at both ends to the endomyocardium and are usually detected accidentally. 
The moderator band is a thin muscular band extending from the midinterventricular sep­tum and is attached to the free wall of the right ventricle near the base of the anterior papillary muscle. It may become very promi-

Berden P / Magnetic resonance oj cnrdiac t11111ors and 111nsses 
nent and may be mistaken for the right ven­tricular thrombus or tumor. It is unique for the right ventricle, which can be very helpful in differentiating the right from the left ven­tricle in congenital heart malformations. 
Nodular thickening of the posterior right atrial wall corresponds to the crista terminalis. It is a prominent muscular ridge that extends along the posteriolateral wall of the right atri­um between the orifices of the superior and inferior venae cavae. These structures have a similar signal intensity as myocardial tissue and should not be mistaken for neoplasm or thrombosis. 
Primary cardiac tumors 
Primary cardiac tumors of the heart and peri­cardium are extremely rare. They can be an incidenta! finding on chest radiography or cardiovascular diagnostic test. Clinical find­ings (flow disturbance, thromboembolisrn, arrhythmias, etc.) are deterrnined primarily by the anatomic location of the tumor. Seventy-five percent of the prirnary tumors are benign. Nearly half the benign tumors are myxomas and predominate in adults, where­as rhabdomyomas predominate in children. 
Benign cardiac tumors 
Cardiac myxoma (Figure 1) is an intracavitary neoplasm that can occur anywhere in the heart. Seventy-five percent of myxomas occur in the left atrium, and, usually, have a pedun­culated attachment to the atrial septum near the fossa ovalis. Systemic embolism occurs in 20 % to 25 % of patients with myxomas. 
The signal characteristics of myxomas on MR depend on the tumor composition. The areas of low signal intensity correspond with calcification (30% of myxomas) or deposition of hemosiderin; the areas of high signal cor­respond with subacute intratumoral hemor­rhage.6 The surface of the tumor is often cove­red by thrombus. Myxomas are highly vascu­lar showing significant enhancement after the administration of paramagnetic contrast agents (Gd-DTPA); the enhancernent can be of a homogeneous or heterogeneous pattern. The areas of enhancement correspond with histologic tumor cells, while unenhanced regions reflect necrosis. Myxornas have a low 


Figure l. Left atrial myxoma. Tl-weighted axial SE images before (a) and after (b) the administration of Gd-DTPA. There is a well-defined inhomogeneous mass in the left atrium attached to the posterior wall. The tumor demon­strates an inhornogeneous enhancernent pattern after contrast administration with no enhancement in the medial part. This part has very low signal on the precontrast irnage, which corresponds with calcification. c Coronal GE image: the myxorna appears strongly hypointense, surrounded by the bright intracavitary blood. 
Berden P / Magnetic resonance of cardiac tumors and ,nasses 
signal intensity on cine MR; this technique may be used to detect atrioventricular tumor entrapment. 
The differential diagnosis of myxoma includes other benign and malignant primary tumors, metastatic tumors, organized atrial thrombi, valvular vegetations and normal variants that may mimic cardiac masses. 
Cardiac lipomas are benign tumors of encapsulated mature adipose cells and repre­sent approximately 10 % of all cardiac neo­plasms. They can be intracavitary, intramy­ocardial, or intrapericardial, and are most fre­quently located in the left ventricle and right atrium. Lipomas are usually asymptomatic and in most cases require no treatment. MR shows the nature, size and location of the tumor. The differential diagnosis includes su­bacu te hemorrhage because both entities have a high signal intensity on Tl-weighted MR. Fat suppression techniques can differen­tiate fatty tissue from subacute hemorrhage. T2-weighted MR is useful, too, because lipo­mas have an intermadiate signal intensity on T2, whereas subacute hemorrhage has a high signal intensity. 
Rhabdomyoma represents 75 % of ali prima­ry cardiac tumors in early childhood and may regress spontaneously by the age of 2 years. They are frequently multiple, involve both atria and ventricles, and can have an intra­cavitary location. Differential diagnosis inclu­des fibromas, which are infrequently multiple or located in the atria. A most important dif­ferential feature is the association of rhab­domyomas with tuberous sclerosis. Cardiac rhabdomyomas have a median to high signal intensity on Tl-weighted MR and an interme­diate signal intensity on T2-weighted images. The postcontrast enhancement of the tumor is similar to the surrounding myocardium.7 
Malignant cardiac tumors 
Primary malignant cardiac tumors consist of sarcomas, lymphomas, and mesotheliomas. 
Soft tissue sarcomas are the most common malignant neoplasms of the heart, pericardi­um, and great vessels.8 Among them, angio­sarcoma and rhabdomyosarcoma are the most frequent. Occasionally, other rare primary sarcomas like liposarcomas, fibrosarcomas, leiomyosarcomas, etc. are found. Liposarco­mas are usually diffuse and involve the right ventricle. The signal intensity is lower than that of fat on Tl-weighted images. Leiomyo­sarcomas (Figure 2) predominate in the mus­cular arteries and great veins. When located in the inferior or superior vena cava, they may directly involve the right atrium. 
Angiosarcoma. One-third of primary malig­nant cardiac tumors in adults are angiosarco­mas. This highly aggressive malignant tumor can develop from the endothelium of the lym­phatics, (lymphangiosarcoma), or blood ves­sels (hemangiosarcoma). Most cardiac angio­sarcomas occur in the right atrium as single or multiple nodules infiltrating the myocardi­um and pericardium. The pericardial sac is filled with the blood. On MR, the angiosarco­mas are usually seen as heterogeneous mass­es with characteristic mosaic pattern of increased and median signal intensity on Tl­weighted images. The high signal areas result from intratumoral hemorrhage. T2-weighted images or gadolinium administration usually better delineate the tumor from the normal myocardium. 
Rhabdomyosarcoma is the second most fre­quent primary malignant tumor of the heart and occurs anywhere in the heart. In about 40 % of the cases, the pericardium is involved by direct extension from the myocardium. On Tl-weighted image, rhabdomyosarcoma appears as homogeneous mass, isointense or minimally hyperintense to the muscle. On T2­weighted images, the tumor is hyperintense to muscle. MR is used in evaluating the response of the tumor to chemotherapy. 

Berden P / Mngnetic resonance of cnrdinc tw11ors nnd 111nsses 

Figure 2. Leiomyosarcoma of the inferior vena cava extending to the right atrium. Tl-weighted axial SE images before (a and c) and after (band d) the administration of Gd-DTPA. The tumor almost completely fills the right atrium, bulges to the right ventricle and blocks VCI. Extensive enhancernent after contrast administration (b and d); it is clear that the mass in VC! is not a thrombus but a tumor. e -GE in sagital plane. A rnass of interrnediate signal intensity sunounded by the bright intracavitary blood. We perforrned transjugular biopsy to deterrnine the 
tumor nature. 
Secondary cardiac tumors 

Secondary tumors of the heart are approxi­mately 30 times more frequent than primary tumors. Tumors originating in the lung, medi­astinum, or breast can directly invade the pericardium or the heart. The most common tumors that metastasize (Figure 3) to the heart are of bronchial and breast origin, fol­lowed by melanomas, lymphomas (Figure 4), and leukemia. 
Intracaval extension can occur in adreno­cortical, hepatocellular, renal-cell and some other carcinomas. It can cause caval obstruc­tion, extension of the tumor thrombus to the heart causing atrial occlusion, and tumor embolization. Accurate identification is essential to plan treatment and MR can show the extension of an intracaval tumor throm­bus. The differentiation between the tumor component and the accompanying bland thrombus is stili difficult. Gadolinium admin­istration is helpful because the contrast usu­ally accumulates in the tumor and, to lesser extent, in an old organized thrombus. Lyrn­phornas can spread to the heart via the lym­phatic vessels. 
Berden P / Magnetic resonance oj cardiac tumors and 111.asses 

Figure 3. Metastatic seminoma to the right ventricle. Tl-weighted axial SE images before (a) and after (b) the administration of Gd-DTPA. The right ventricle is almost completely filled with the tumor-thrombus, that can not be differentiated frorn the anterior ventricular wall (tumor ingrowth). On operation, anterior wall was invaded and the tumor could not be excised completely. 

Figure 4. High-grade mediastinal lymphoma diffusely infiltrating the heart. Tl-weighted SE images in a -axial, b ­coronal, c -LAO plane. The lymphomatous tissue surrounds the ascendning aorta, pulrnonary arteries and veins. There is a narrowing of the right pulmonary artery and left atrium due to a tumoral thickening of the atrial wall. 
Berden P / Magnetic reso11a11ce oj cardiac tumors and 111asses 
Nontumoral cardiac masses and mimics 
Cardiac thrombi 
Cardiac thrombi are much more frequent than cardiac tumors and usually occur in patients with regional or global wall motion abnormalities (atrial fibrillation, myocardial infarction, dilated cardiomyopathy). Thrombi are mostly found in the atria. The left atrial thrombi are generally attached to the posteri­or left atrial wall by a broad base. The right atrial thrombi are found in patients with gen­erally poor condition often associated with central venous catheter. Ventricular thrombi are rare in patients with normal cardiac func­tion.9 
The cardiac thrombi usually have higher signal intensity than the normal myocardium on SE MR. Differentiation between thrombus and slow-flow may be difficult on SE, because of the increased MR signal produced by slow­flowing blood. On gradient-echo (GE), the thrombus always shows a lower signal inten­sity than does the flowing blood4, but is iso­to hyperintense compared with myocardium. That is why the differentiation between thrombus and myocardium on GE is more dif­ficult. The thrombus and the signal intensity change according to its age and degree of organization (loss of water, condensation of paramagnetic iron complexes, calcifications). 
The majority of thrombi are immobile. If they are pedunculated and mobile, it may be difficult to distinguish them from a myxoma. Gadolinium administration is helpful beca­use myxomas are highly vascular showing sig­nificant enhancement after paramagnetic contrast agents administration. Therefore, GE MR is useful to differentiate between the thrombus and slow-flowing blood, whereas gadolinium administration is helpful to dis­tinguish the thrombus from the tumor. 
Lipomatous hypertrophy 
Lipomatous hypertrophy of the atrial septum is not a trne neoplasm. It is a hypertrophy of preexisting fat and not infrequently associat­ed with increased epicardial fat.1° The fat accumulates within the interatrial septum, usually in front of the fossa ovalis. The typical appearance is high signal intensity on Tl­weighted MR. The differential diagnosis includes lipoma, liposarcoma, and nonacute hematoma. Liposarcoma has a lower signal intensity and inhomogeneity. Fat suppression techniques can be used to differentiate lipo­matous hypertrophy of the atrial septum from nonlipomatous tumors and conditions. 
Conclusions 
With the new cardiac imaging modalities such as echocardiography, CT, and MR, nor­mal anatomic heart structures can be very well recognized and differentiated from pathologic structures. 
In patients suspected of having a cardiac tumor, echocardiography is the first method of choice. MR is used to confirm the findings of echocardiography, to determine precisely the tumor location, extent, and its tissue char­acterization, to follow up of patients under treatment, and to detect early tumor recur­rence. 
Major advantages of this technique are the excellent spatial resolution, large field of view, natura! contrast between the flowing blood and the surrounding heart walls or tumor masses, multiplanar imaging capabili­ty, and use of paramagnetic contrast agents for better visualisation of the tumor borders. The large field of view is a clear advantage over echocardiography, while the multiplanar imaging capability without radiation is a clear advantage over CT. On the other hand, MR lacks the ability for real-tirne imaging though it may become clinically available in the near future. 

Berden P / Magnetic resonance of cardiac t1111wrs and masses 
With MR, cardiac masses can be very accu­rately depicted or ruled out. MR can be help­ful in tissue characterization; however, the differentiation between tumor and nontu­moral conditions, or between benign and malignant tumors, is often not possible with­out histology. 
References 
l. Hartnell GG. Great vessels of the chest. In:Bogaert J, Duerinckx AJ, Rademakers FE, eds. Magnetic res­onance of the heart and great vessels. Berlin: Springer; 1999. p.245-62. 

2. 
Gamsu G, Starck D, Webb WR, Moore EH, Sheldon PE. Magnetic resonance of benign medi­astinal masses. Radiology 1984; 151: 709-13. 


3. 
Mitchell DG, Burk DL, Vinitski S, Rifkin MD. The biophysical basis of tissue contrast in extracranial MR imaging. Am J Roentgenol 1987; 149: 831-7. 

4. 
Funari M, Fujita N, Peck WW, Higgins CB. Cardiac tumors: assessment with Gd-DTPA enhanced MR imaging. J Comput Assist Tomogr 1991; 15: 953-8. 



5. Johnson DE, Vacek J, Gollub SB, Wilson DB, Dunn 
M. Comparison of gated cardiac magnetic reso­nance imaging and two-dimensional echocardiog­raphy for the evaluation of right ventricular throm­bi: a case report with autopsy correlation. Cathet Cardiovasc Diagn 1988; 14: 266-8. 
6. 
Menegus MA, Greenberg MA, Spindola-Franco H, Fayemi A. Magnetic resonance imaging of suspect­ed atrial tumors. Am Heart J 1992; 123: 1260-8. 

7. 
Semelka RC, Shoenut JP, Wilson ME, Pellch AE, Patton JN. Cardiac masses: signal intensity fea­tures on spin-echo, gradient-echo, gadolinium enhanced spin-echo and Turbo FLASH images. J Magn Reson Imaging 1992; 2: 415-20. 

8. 
Burke AP, Cowan D, Virmani R. Primary sarcomas of the heart. Cancer 1992; 69: 387-95. 

9. 
Chin WW, Van Tosh A, Hecht SR, Berger M. Left ventricular thrombus with normal left ventricular function in ulcerative colitis. Am Heart J 1988; 116: 562-3. 

10. 
Meany JFM, Kazerooni EA, Jamadar DA, Korobkin 


M. CI apperance of lipomatous hypertrophy of the interatrial septum. Arn J Roentgenol 1997; 168: 1081-4. 



rev1ew 

Magnetic resonance of the thoracic aortic disease 
Pavel Berden 
Clinical Institute of Radiologij, University Medica/ Center, Ljubljana, Slovenia 
Conventional ECG gated spin-echo (SE) magnetic resonance imaging (MR) and magnetic resonance angiog­raphy (MRA) are excellent methods far diagnosing thoracic aortic disease. SE image provides a good spatial resolution far defining aortic anatomy and relationships to adjacent tissues. MRA shows flow but temporal resolution is inferior to conventional MR images. Contrast-enhanced 3D (three-dimensional) MRA is very accurate far defining thoracic aortic anatomy and is particularly good for defining branch vessel abnorma­lity. The sensitivity and specificity for diagnosing aortic dissection are the highest in comparison to other modalities (echocardiography, CT angiography) and range from 95 % to 100 % and 94 % to 100 %, respec­tively. MR can define clearly the full diameter of aortic aneurysm and also shows the amount of thrombi within it and its craniocaudal extent. A combination of SE and cine MRA is usually necessary. The same sequence with contrast enhancement provides all the required information on the congenital abnormalities of the aorta. MR is very reliable in congenital aortic abnormalities, aortic aneurysm and aortic dissection in hemodynamically stable patients. It should be used far all chronic thoracic aortic disease and postsurgical follow-up. Unstable patients that need intensive hemodynamic monitoring are unsuitable far MR. 


Key words: aortic disease; aorta, thoracis; magnetic resonance angiography 
Introduction 
Examination of the thoracic aorta was one of the first uses of conventional ECG gated spin­echo magnetic resonance imaging (SE MR) and remains the fundamental imaging method in diagnosing the thoracic aortic dis­ease. MR provides, non-invasively, the infor­mation on anatomy, function, and blood flow with no exposure to ionising radiation. It has become increasingly useful for evaluating suspected aortic dissection, aneurysm, and congenital anomaly. We present our experi­ence with MR technique in evaluating the pathologic conditions of the thoracic aorta. 
MR aortic imaging techniques 
Magnetic resonance (MR) 
Conventional ECG-gated SE is in many respects the reference standard for thoracic aortic MR imaging. It provides a good spatial 
Received 15 May 2000 Accepted 30 May 2000 Correspondence to: Pavel Berden, M.D., Clinical 
Radiology Institute, University Medica! Centre Ljubljana, Zaloška 7, SI-1525 Ljubljana. Phone: +386 1 5408 400; Fax: +386 1 133 31 044; E-mail: pavel.berden@mf.uni-lj.si 

Berden P / Magnetic resonance oj the thoracic aortic disease 
resolution for defining an aortic anatomy and relationships to adjacent tissues. However, it can be tirne consuming, and complicated 3D anatomy may be difficult to represent.1 Arte­facts related to slow flow or flow within the imaging plane may mimic thrombus, and, unfortunately, the conventional SE is suscep­tible to respiratory artefacts. 
Breath-hold imaging methods are fast, but may lack the spatial resolution required for making confident anatomical diagnosis. Techniques, such as HASTE and turbo­FLASH, may provide adequate information in some cases. Most turbo-FLASH sequences without gadolinium enhancement do not have adequate signal-to-noise ratios and spa­tial resolution in the chest. With contrast enhancement, the turbo-FLASH technique is relevant for diagnosing aneurysms and dis­sections. 2 
Magnetic resonance angiography (MRA) 
Non-breath-hold time-of-flight MRA -cine MRA is useful for the assessment of some lesions -coarctation, flow abnormalities (identifying trne and false lumens in the pa­tients with aortic dissection). Image quality can be improved in most patients by reducing respiratory artefacts with breath-hold cine MRA, although temporal resolution is slightly inferior to conventional non-breath-hold cine MRA. 
Contrast-enhanced 3D MRA is very accu­rate for defining thoracic aortic anatomy and particularly good for branch vessel abnormal­ity. 3 3D image processing is easier due to the high signal provided by vascular contrast enhancement. Very short TR and TE are nec­essary. Timing the injection is very important for proper enhancement and to prevent aortic anatomy being obscured by adjacent veins. Contrast enhancement is useful for defining the abnormalities that may be obscured or mimicked by a slow or turbulent flow. 
Pathology of the thoracic aorta on MR 
Dissection 
MR is suitable for the patients with chronic dissection or in postoperative evaluation.2 It can be used also in acute dissection if the patients are hemodynamically stable. MR can image intramural hemorrhage, intima! tears, stagnant blood flow versus thrombosis and periaortic blood (Figure 1). 
With SE sequences, errors can occur rela­ted to slow flow mimicking thrombus, chemi­cal shift artefacts, respiratory artefacts, signal from adjacent veins (superior vena cava), etc. The use of MRA and contrast-enhanced MRA has largely improved the MR accuracy. The sensitivity for diagnosing aortic dissection ranges in different studies from 95 to 100 % and is the highest compared to other modali­ties (86 to 100 % for transesophageal echocar­diography (TEE), and 94 to 100 % for CIA). The same is trne for the specificity -94 to 100 % for MRA, 67 to 94 % for TEE and 87 to 100 % for CTA.4, 5 
MR is probably the most reliable method for detecting postoperative complications such as anastomotic aneurysms, further dila­tation, and extension of false lumens into branch vessels. It is the best way for routinely following the patients with chronic or pro­gressive aortic abnormalities, such as patients with Marfan syndrome. 
Aortic ulceration and intramural hematoma 
Aortic ulcers are seen as focal outpouchings from the lumen of the aorta and frequently progress to aneurysm. Ulcers are typically found in the descending or abdominal aorta and may be filled with thrombus. Increased signal from ulcers on Tl-and T2-weighted images can mimic an intramural hematoma or thrombosed false lumen in aortic dissection.6 
The intramural hematoma is characterised by a localised thickening of the aortic wall due to hematoma formation without an inti-

Berden P / Magnetic resonance oj the t/10racic nortic disease 

e l. Aortic dissection type A. a -Axial SE image showing a near circular intima! flap in the descending aorta. b -Axial SE image in LAO plane. Intima! flap is seen as thin structure of increased signal intensity passing across the ascending aorta, through the aortic arch, into the descending aorta. c -corresponding angiography confirms MR findings showing flow in both lumens. 
Figur
mal tear or a double lumen. It can precede classic aortic dissection. An acute intramural hematoma may be overseen on Tl images due to the isodense appearance of the blood and aortic wall; a high signal intensity on T2 ima­ges might be helpful. 
Occasionally, the chemical shift artefact from the surface of the luminal thrombus may simulate a dissection. The differentiation between the slow flow in a false lumen and thrombus can be made using cine or contrast­enhanced MRA (Figure 2). The differentiation of the intramural hematoma from true aortic dissection is important as the <listal (type B) hematoma may resolve without surgical treat­ment, while the proximal (type A) hematoma usually progresses to dissection and requires surgical trea tment. 6 


2. Aortic dissection type B. a -Axial SE image in the thoraco­abdominal region shows an increa­sed aortic diameter, signal-void cen­trally (flowing blood) and increased signal around it (slow, turbulent flow or tlu-ombosed false lumen). b-GE at the same leve! shows inter­mediate signal parietally corre­sponding to thrombosed lumen. 
Figure 

Berden P / Mngnetic resonance of the thorncic nortic disease 
Aortic aneurysm 
MR can define clearly the full diameter of aor­tic aneurysm and also shows the amount of thrombi within it and its craniocaudal extent (Figure 3). Many thoracic aneurysms extend into the abdomen and, hence, the ability to image the entire aorta is important. The rela­tionship of the aneurysm to the major branch arteries, particularly the head and neck ves­sels, is essential when planning the surgical approach. MR can define the branch vessel anatomy and congenital variations. In ascending aortic aneurysm, the assessment of aortic valve morphology, aortic regurgitation, and relationship of aneurysmal disease to the coronary arteries are required. To provide all this information, a combination of imaging protocols is usually necessary. The combina-

Figure 3. Aortic pseudoaneurysm. SE images in axial, coronal, sagi tal and LAO plane (a-d) show round mass of dif­ferent signal intensity attached to the dorsal wall of the proximal descending aorta. Various signal intensity corre­sponds to the thrombus of different age. Aortic ulceration is seen distally on d. e -Corresponding aortography con­firms srnall outpouching-most of the pseudoaneurysrn is filled with thrornbus. 
Berden P / Mag11etic resonance oj the thoracic aortic disease 
tion of SE and cine MRA will show the size of the aneurysm (SE), branch vessel involve­ment and aortic regurgitation (MRA). The contrast-enhanced 3D MRA is excellent to define branch vessel anatomy, but the unen­hanced SE sequence may also be required to define more precisely the true diameter of the thrombosed part of the aneurysm. 7 
Congenital abnormalities oj the aorta 
MR with MRA usually provides all the infor­mation required about aortic anatomy, its relationships to adjacent structures, and bra­nch vessel anatomy, and is as accurate as angiography.8 
Conclusion 
The advantages of MR for vascular diagnosis are well known and include non-invasiveness, wide field of view, multiplanar imaging, and the ability to show complicated 3D relation­ships which is not always possible with con­ventional angiography. Similar information may be acquired using echocardiography and CT angiography. Transthoracic echocardio­graphes, TTE and TEE, are widely available and are the usual initial methods for investi­gating aortic disease. Large parts of the aorta are obscured by the overlying lung or bone and are inaccessible to echocardiography. The high specificity of MR, its non-invasive nature and the ability to image the aorta below the diaphragm are major advantages over TEE. 
CTA and MRA are extremely accurate in evaluating the thoracic aorta. CTA uses large volumes of iodinated (more toxic) contrast medium, and inflow dilution effects may mimic or obscure the disease; nevertheless, it has no potential to assess aortic regurgitation. The branch vessel anatomy may be obscured by calcifications in the vessel wall. 
In many instances, no contrast medium needs to be given with aortic MRA and com­plicated 3D anatomy can be evaluated non­invasively. When branch vessel anatomy is unclear, the contrast-enhanced 3D MRA allows accurate definition of branch vessel anatomy. The accuracy of this combined approach using MR has limited the use of aor­tography mainly to those patients who are ineligible for MR (metal implants, pace-ma­kers, claustrophobia). In addition to defining the aortic anatomy, a simultaneous imaging of intracardiac abnormalities (including valve lesions and congenital abnormalities) and complications of aortic diseases (hemoperi­cardium, left ventricular dysfunction, valvu­lar regurgitation) is possible during the same examination. 
MR has also some limitation in evaluating aortic diseases. The patients with acute tho­racic aortic dissection are medica! emergen­cies and may be unstable. The need for inten­sive hemodynamic monitoring makes them unsuitable for MR. The same problems arise in traumatic aortic rupture. CTA and TEE are more appropriate in these circumstances. 
MR is very reliable in congenital aortic abnormalities, aortic aneurysm and aortic dis­section in hemodynamically stable patients. It should be used for all chronic thoracic aortic diseases and postsurgical follow-up. 
References 
1. 
Hartnell GG. Great vessels of the chest. In:Bogaert J, Duerinckx AJ, Radernakers FE, eds. Mag11etic res­onmzce of tlze lzeart mzd great vessels. Berlin: Springer; 1999. p.245-62. 

2. 
Loubeyre P, Delignette A, Bonefoy L, Douek P, Arniel M, Reve! D. Magnetic resonance irnaging evaluation of the ascending aorta after graft inclu­sion surgery: cornparison between an ultrafast contrast-enhancernent MR sequence and conven­tional cine-MRI. J Magn Reson Imaging 1996; 6: 478­83. 

3. 
Hartnell GG, Cohen MC, Meier RA, Finn JP. Magnetic resonance angiography dernonstration of congenital heart disease in adults. Cli11 Radio/ 1996; 51: 851-7. 



Berden P / Magnetic resonance of the thoracic aortic disease 
4. 
Sommer BW, Fehske W, Holznecht N, Smekal AV, Keller E, Lutterbey G et al. Aortic dissection: a comparative study of diagnosis with spiral CT, multiplanar transesophageal echocardiography, and MR imaging. Radiology 1996; 199: 347-52. 

5. 
Laissy JP, Blanc F, Soyer P, Assayag P, Sibert A, Tebboune D et al. Thoracic aortic dissection: diag­nosis with transesophageal echocardiography ver­sus MR imaging. Radiolgtj 1995; 194: 331-6. 

6. 
Murray JG, Manisali M, Flamm SD, VanDyke CW, Lieber ML, Lytle BW et al. Intramural hematoma of the thoracic aorta: MR image findings and their prognostic implications. Radiology 1997; 204: 349­55. 


7. 
Krinsky GA, Rofsky NM, DeCorato DR, Weinreb JC, Earls JP, Flyer MA et al. Thoracic aorta: gadolin­ium enhanced three-dimensional MR angiography with conventional MR imaging. Radiology 1997; 202: 183-93. 

8. 
White RD, Higgins CB. Magnetic resonance imag­ing of thoracic vascular disease. J Thorac Imaging 1989; 4: 34-50. 




Hydrocolonic sonography in the detection of large bowel disease 
Dubravka Vidmar 
Clinical Radiology Institute, University Medica/ Centre Ljubljana, Slovenia 


Background. The presence oj fluid in the bowel lumen improves the sonographic visualisation oj the gas­trointestinal tract, thus permitting earlier and more accurate detection oj pathological changes. Hydrocolonic sonography (HS) is a method oj examining the colon after it has been cleaned and filled with water. Patients and methods. We have evaluated the method in a group oj 56 patients by comparing its results with the findings oj colonoscopy, double-contrast barium enema ar surgery. Results. HS had an overall accuracy oj 86 %, a sensitivity oj 81 %, a specificity oj 92 %, a positive predic­tive value oj 91 % and a negative predictive value oj 82 %. Conclusions. The technique is not suitable far examining the rectum, but apart from that it is comparable in usefulness to double-contrast barium enema. The main limitation oj HS is that it requires a lot oj experi­ence and skill on the part oj the sonologist, which affects its acceptability far diagnostic evaluation oj the colon. 
Key words: colonic diseaes-ultrasonography; colonic neoplasms-ultrasonography; hydrocolonic ultra­sonography; polyps 
Introduction 
Ultrasonic examination of the abdomen is a widely used diagnostic method, which usually represents the first step in the evaluation of various abdominal symptoms. In examining the bowel, we are hampered by the physical limitation of the technique, based on the fact that the difference in acoustic impedance 
Received 17 May 2000 Accepted 1 June 2000 
Correspondence to: Dubravka Vidmar, M.D., Clinical Radiology Institute, University Medica! Centre Ljubljana, Zaloška 7, Sl-1525 Ljubljana, Slovenia. 
between solid tissue and gas is so great that almost the entire emitted ultrasound wave returns to the transducer, producing an arte­fact instead of a useful image. Therefore, the examination of the gastrointestinal tract see­med impossible at first. However, a solution was suggested already in the seventies by Lutz and Rettenmaier with the description of the »pathological cocarde«; they noticed that a much better visualisation of the gastrointesti­nal tract was obtained if pathological changes were present in its wall.1, 2 The criteria of a pathologically altered bowel wall are: thicken­ing, loss of compressibility, changes in luminal width and peristaltic activity, absence of 

Vidmar D / Hydrocolonic sonogrnphy 
colonic haustration, altered blood supply and changes in surrounding tissues related to the diseased bowel. The terms used in the litera­ture for a pathological alteration of the bowel wall are a pathological target when seen in the transverse view and a pseudokidney when seen in the longitudinal view. However, imag­ing of a pathologically altered bowel wall also has its limitations. It is possible only in advanced disease and not at the stage of minor incipient changes. Moreover, intraluminal masses are not displayed, and the posterior wall is not clearly visible. Finally, a pathologi­cal target is not a specific sign and it can be false positive. A further step towards ultra­sonographic assessment of the gastrointesti­nal tract was made in the late seventies by Fleischer who noted that the image was signif­icantly improved if at least 90 % of the bowel lumen was filled with fluid; this allowed him to distinguish between the small and the large intestine as well as between the intestine and other abdominal structures.3 A more detailed visualisation of the gastrointestinall tract was not possible because of the inadequate resolu­tion of the compound scanners used at the tirne. In the mid-eighties, after the appearance of high resolution scanners providing real­tirne images, this idea was revived, developed further and tested clinically by Limberg who named his method of examining the colon hydrocolonic sonography.4 We have tested the method in a group of 56 patients and now report the results of our evaluation. 
Patients and methods 

Patients 
A total of 56 patients (37 women and 19 men, average age 61.3 years) gave their consent for the examination. They shared a history sug­gestive of colonic disease. Two patients with a history of a malignant tumour of the colon treated by resection required evaluation of the anastomosis. 
Methods 
Hydrocolonic sonography (HS) is a method of examining the colon after it has been cleaned and filled with water to improve the visualisa­tion. The success of HS depends to a large extent on the preparation of the colon, accom­plished with a diet and use of laxatives accord­ing to different schemes. Our patients did not ingest any solid food a day before the exami­nation. In the afternoon on the preceding day, they took a laxative (Coloclens) with a double quantity of water. Early in the morning on the day of the examination, they drank three litres of an electrolyte solution (Golytely). Directly before the examination, they received an intravenous injection of 0.5 to 1 ml of glu­cagon at a concentration of 1 mg/ml (Gluca­Gen, Hypo Kit) to relax the bowel. The colon was then filled with 1000 to 1500 ml of water at body temperature, instilled with the use of an enema delivery system (Nicholas Kolon­Diagnostic-System), usually employed for bar­ium enemas. During the instillation of water, the patients changed position to achieve opti­mal filling of all segments of the colon. The filling of the colon with water was observed with a low-frequency transducer (3.75 MHz). It was terminated when the caecum and ileo­caecal valve came into view. Then we started examining carefully the colon segment by seg­ment with the low-frequency transducer to evaluate the position of the bowel loops, the width of the bowel lumen etc. If a pathological change was noted, we tried to analyse more accurately the structure of the colonic wall using a high-frequency transducer (7.5 MHz). The examination was performed on the patient lying supine and in both lateral posi­tions. In some younger patients, the rectum and sigmoid were examined also in the upright position. For demonstrating the flex­ures, a lateral intercostal route was usually chosen. The duration of the examination was limited by the action of the relaxant to about 15 minutes. After emptying the water from the colon, the patients immediately under-

Vidmar O/ Hydrocolonic sonograplzy 
went colonoscopy (CS). If CS was not feasible, the sonographic findings were compared with the results of surgery or double-contrast ba­rium enema. The patients gave a written in­formed consent for the examination. After­wards they were asked to describe their toler­ance for HS as compared to CS or barium enema. The ultrasonic examinations were per­formed with Toschiba ultrasonography units (SSA-270A and lOOA), using 3.75 and 7.5 MHz transducers. 
The sonographic diagnosis was based on the following criteria: a constant thickening of the colonic wall, changes in the luminal width of the colon and the sonographic strne­ture of its wall (the quantity of echoes and presence of the normal layers), evidence of intraluminal masses fixed to the wall, loss of haustration and changes in pericolonic tis­sues. The HS findings were compared with the results of CS, double-contrast barium ene­ma or surgery. With the use of statistical ana­lysis the accuracy, sensitivity, specificity and the positive (PPV) and negative predictive value (NPV) of the method were assessed. 
Results 
Feasibility 
In three female patients of advanced age (average 80.3 years), HS could not be per­formed because they were unable to retain the instilled water, and so they were excluded from the series. CS could not be carried out in eight of the 56 patients because of poor gen­eral status (two patients) or intolerance for the procedure (six patients). Three of the eight patients were the previously mentioned women who were excluded from the study. In the remaining five patients, the results of HS were in four cases compared with surgical findings and in one case with double-contrast barium enema. 

Figure l. Normal colon descendens as displayed by hydrocolonic sonography. Five layers differing in echogenicity can be seen within the colon wall. 
Normal Jindings 
In 29 patients who all subsequently under­went CS, the HS result was interpreted as normal. HS missed six polyps (four < 7 mm in diameter in the sigmoid and two = 7 mm in­volving the sigmoid and rectum) in four patients, and one rectal tumour located at a depth of 10 cm. It identified correctly faecal material in patients with inadequate bowel preparation and even the remnants of an undigested pill in a patient's caecum. This 


Vidmar O/ Hydroco/011ic sonography 
group included the two patients with a histo­ry of colonic resection who both had a normal anastomosis. 
Tumours 
In 17 patients, HS demonstrated tumours, of which 65 % were located in the left colon. In four of the 17 patients, the finding was con­firmed at surgery, CS having proved impossi­ble. The remaining 13 patients underwent CS, which was complete only in three; in the other 10 patients, the bowel was displayed only to the level of the tumour stricture, impassable for the colonoscope. CS con­firmed 12 of the 13 tumours and missed one involving the colon and rectum. This patient was later subjected to a double-contrast bari­um enema, which confirmed the result of HS. The HS findings were accurate in all 17 patients. In six of the 17 patients (35 %), the tumour was visible also on conventional abdominal sonography. 
Polyps 
HS detected polyps in four patients, who all subsequently underwent CS. Two polyps (one of 5 mm in diameter located in the sigmoid, and the other of 20 mm in the transverse 
Figure 3. Colonic carcinoma (rectosigma): concentric thickening of the wall and narrowing of the lumen. 
colon) were confirmed on CS, while two (one of 7 mm in the transverse colon, and the other of 17 mm in the caecum) were not. 
Diverticulosis 
HS detected two cases of diverticulosis; one was confirmed by CS and the other by dou­ble-contrast barium enema. 
Figure 4. Colonic carcinoma (hepatic flexure): intralu­minal mass. 
Crohn's disease 
In a patient with known Crohn's disease, HS, performed in the course of preoperative preparations, disclosed three strictures, locat­ed under the splenic flexure, at the transition from the transverse colon to the splenic flex­ure, and at the transition from the caecum to the terminal ileum, which were all confirmed at surgery. None was visible on CS, as this had to be terminated in the descending colon because of pain. 

Vidmar O/ Hydrocolonic sonography 
Figure 5. Colonic carcinoma (coecum): eccentric thick­ening of the wall. Missed on colonoscopy. 
Statistical results 
The calculated accuracy of HS was 86 %, sen­sitivity 81 %, specificity 92 %, PPV 91 % and NPV 82%. 
Tolerance far HS 
The examination was well tolerated. The patients experienced no pain, only some dis­comfort due to the retention of water. They evaluated both CS and double-contrast bari­um enema as painful because of the insuffla­tion of air. 
Discussion 
Two basic facts vita! to the understanding of ultrasonic evaluation of the gastrointestinal tract are that good visualisation is possible if the wall of the gastrointestinal tract is patho­logically altered and if at least 90 % of the lumen is filled with fluid.1-3 In the seventies, attempts to display pathological changes of 
Figure 6. Small colonic polyp (7 mm); the structure of the colon wall remains intact. 
the colon after it had been filled with water were limited by the technical shortcomings of 
6 
the compound scanners used at the time.5,When these limitations were overcome, Lim­berg developed hydrocolonic sonography, with which he was able to display the colon from the rectosigmoid border to the caecum 
7
in 97 % of patients.4, -15 La ter on several au­thors reported that they could not demon­strate the flexures16-18 or even the greater part of the colon with HS.19 We had no such diffi­culties, provided that the instillation of water did not pose a problem. We also confirmed the experience of those authors who found it impossible to adequately visualise the rectum by HS,8,11 -4,16, 19,20 as we missed a rectal tumour and a 7 mm rectal polyp. We excep­tionally managed to display the rectum in young and slim patients, and we even diag­nosed a rectal tumour in the form of an intra­luminal mass. 
The main aim of investigations of the colon is an early detection of cancer. Colonic cancer has a high incidence in the developed world. In Slovenia, the survival of these patients is below the European average, mainly on account of late detection.21 The value of HS must be analysed by comparing this method with conventional ultrasound, double-con-

Vidmar D / Hydrocolonic s011ography 
trast barium enema and CS. Of the 17 tu­mours correctly diagnosed by HS, six (35%) were seen also on conventional ultrasonogra­phy. This compares well with data from the lit­erature12,22 , suggesting that HS is able to detect two thirds more tumours than conven­tional ultrasonography. On HS, a tumour is seen as a stenosed segment of bowel with associated concentric or eccentric incom­pressible thickening of the wall or as an intra­luminal mass. Of special interest in our series is the case of the patient with a caecal tumour, which was missed on CS but confirmed on double-contrast barium enema and at surgery. We also managed to demonstrate a rectal tumour located at a depth of 8 cm; to our knowledge the detection of tumours in a sim­ilar location by HS has not been reported in the literature. HS thus showed a sensitivity of 100 % and a specificity of 100 % for the diag­nosis of cancer of the colon excluding the rec­tum. Similar results have been reported by several authors_l0,11,23,24 In other studies, how­ever, the method was less successful.16,17,19 In comparing HS with CS, we must bear in mind that the colonoscopist does not reach the cae­cum in 10 % 25 to 30 % 26 or, according to some reports, even up to 45 % 10,16 of cases. Con­sequently, about 10 % of colonic tumours are missed on CS.16 So, in case of disagreement between the radiological and endoscopic results, it is advisable to carry out further investigations rather than rely on the result of CS,27 which may be inaccurate, as illustrated by the missed caecal tumour in one of our patients. Moreover, CS in our series was able to display the colon beyond a tumour stenosis in only three cases, whereas HS managed to do so in as many as 15 cases. An undisputed advantage of CS is the possibility of biopsy. Except in one case (the rectal tumour missed by CS), a comparison with double-contrast barium enema was not performed for two rea­sons: first, because contrast studies cannot be done after HS as the residual water would interfere with contrast coating the mucosa, 
and second, because most authors use CS as the gold standard. In comparing HS with dou­ble-contrast barium enema, which has been shown to have a sensitivity of 95-98 % for the detection of colorectal cancer28, we must con­sider also the missed rectal tumour. If this is taken into account, the sensitivity of HS in our patients was 94.5 %. As a representative of cross-section imaging techniques, HS, in con­trast to CS and barium enema, can display the bowel in cross-section with all its layers and adjacent tissues, which makes it suitable for cancer staging. In other studies, HS permitted accurate assessment of the T-stage for 86-97 % of evaluated tumours13,16,22,23 and the N-stage for 35 % 16 to 50 % 22 of tumours. In our pa­tients, we were mostly able to distinguishing the normal wall layers with the low frequency transducer, but we rarely managed to use the high frequency transducer because of poor depth penetration, and we were unable to assess reliably the T-stage of tumours or to display the adjacent lymph nodes. 
Since most colorectal cancers develop from neoplastic polyps/adenomas, an early detection of these lesions constitutes an important preventive measure. A polyp is not visible on conventional ultrasonography, but on HS it can be seen as a solid moderately echogenic mass, which is fixed to the bowel wall and can thus be distinguished from fae­cal material. We managed to demonstrate two polyps, and rule out their infiltration into lower layers. Two masses that met all mor­phological criteria of polyps on HS were not confirmed on CS, but we were unable to fol­low the previously mentioned advice of Laufer and Thoeni17 because the patients did not consent to double-contrast barium ene­ma. Using HS, we overlooked six polyps, four of them less than 5 mm in diameter and two of 7 mm. The number of polyps was too small to be statistically representative, but the results are comparable to data for small series.17 In large series, Limberg diagnosed polyps of more than 7 mm with a sensitivity 

Vidmnr O/ /-/ydroco/011ic s011ogmpl11J 
of 91 % and a specificity of 100 %, and polyps of less than 7 mm with a sensitivity of 25 % and a specificity of 97 %. The detection of polyps smaller than 7 mm is thought to be of minor clinical importance, since the likeli­hood of colorectal cancer in patients with small polyps is the same as in the population at large.10 An interesting comparison of HS and double-contrast barium enema was made by Candia and co-workers who found HS to be less sensitive (80 % vs. 92 %) but more spe­cific (100% vs. 92.8%).24 CS gives false nega­tive results in 15 % of cases, yet its advantage over HS and barium enema lies in the possi­bility of removing the polyps found. 
We diagnosed two cases of diverticula, appearing as small luminal protrusions filled with gas and faecal material and therefore highly echogenic. A successful detection of diverticula by HS has been reported only by Limberg.29 In the patient with known Crohn's disease, HS correctly identified three areas of stenosis. The result was confirmed at surgery, CS having failed because of pain. On HS, the affected segments of the gut wall were appre­ciably thickened and moderately echogenic (scarring associated with chronic inflamma­tion). The normal wall architecture and haus­trations were not visible. We had no cases of ulcerative colitis. Limberg found HS to be sig­nificantly more sensitive than conventional ultrasound for the diagnosis of Crohn's dis­ease (96 % vs. 71 %) and ulcerative colitis (91 % vs. 62 %). He also found HS to be highly spe­cific for both conditions (100 % for Crohn's disease and 98 % for ulcerative colitis). Using HS, he managed to distinguish between the two conditions in 93 % of cases.4, 7-9,13-15 
We were able to compare the overall sensi­tivity (81 %) and specificity (92 %) of HS in our patients with the data from another study, where a sensitivity of 67 % and a specificity of 96 % were obtained.17 The feasibility of HS in our patients was comparable to that observed 
171930 
by severa! other authors16,,,and inferior to the results reported by Limberg whose 
patients had no problems with the instillation and retention of water.8, 13-15 VVith the excep­tion of a study where a patient experienced two vasovagal episodes and another devel­oped diaphoresis,19 no authors have encoun­tered any complications using HS, which agrees with our experience. The average dura­tion of the examination in our patients (15 minutes) was comparable to that reported by other authors. The retention of water caused the patients some discomfort, but apart from that they evaluated the examination as pain­less, whereas CS and barium enema were both described as painful. HS is thus compa­rable in usefulness to double-contrast barium enema, over which it has the advantages of not involving ionising radiation, being better tolerated by patients, being a cross-section imaging method and being feasible in the acute stage of inflamrnation.31 Its shortcorn­ing is the inability to display adequately the rectum. It can be used in place of colonoscopy when the latter fails for subjective reasons, either on the part of the patient or the colono­scopist, or because of an objective problem, such as stenosis or acute inflammation. The main limitation of HS lies in the fact that it is technically very dernanding and can therefore be performed only by a select group of highly experienced sonologists. We believe this to be the main reason for the limited popularity of HS despite the excellent results reported by 
its users. 
Conclusions 
With HS we correctly diagnosed tumours and polyps, diverticula and stenoses in Crohn's disease, and evaluated the condition of anas­tomoses after colonic resection. No complica­tions were encountered, and the examination was well tolerated by the patients. HS is com­parable in usefulness to double-contrast bari­um enema. The main advantages of HS are the absence of ionising radiation and the 

Vidmar D / Hydrocolonic sonography 
absence of pain, while its main limitation lies in the technical demands placed on the sono­logist. 
References 
1. 
Lutz H, Rettenmaier G. Sonographic pattern of tumors of the stomach and the intestine. Proceedings of the 2nd World Congress on Ultrasound in Medicine. Amsterdam: Excerpta Medica; 1973. p 67. 

2. 
Lutz H, Petzold R. Ultrasonic patterns of space occupying lesions of the stomach and the intes­tine. Ultrasound Med Biol 1976; 2: 129-32. 

3. 
Fleischer AC, Dowling AD, Weinstein ML, James AE Jr. Sonographic patterns of distended fluid filled bowel. Radiology 1979; 133: 681-5. 

4. 
Limberg B. Diagnostik entziindlicher und tumoroser Dickdarmveriinderungen durch Kolon­sonographie. Dtsc/z med Wschr 1986; 111: 1273-6. 

5. 
Rubin C, Kurtz AB, Goldberg BB. Water enema: a new ultrasound technique in defining pelvic anatomy. J Ciin Ultrasound 1978; 6: 28. 

6. 
Jasinski R, Rubin JM, Beezhold C, Aisen A. Ultrasound examination of the colon. J Ciin Wtrasound 1981; 9: 206-8. 

7. 
Limberg B. Differentialdiagnose akut entziindlich­er dickdarmverkrankungen durch kolonsonogra­phie. Dtsch med Wschr 1987; 112: 382-5. 

8. 
Limberg B. Diagnosis of acute ulcerative colitis and colonic Crohn's disease by colonic sonogra­phy. J Ciin Wtrasound 1989; 17: 25-31. 

9. 
Limberg B. Sonographic features of colonic Crohn's disease: comparison of in vivo and in vitro studies. J Ciin Ultrasound 1990; 18: 161-6. 

10. 
Limberg B. Diagnosis of large bowel tumors by colonic sonography. Lancet 1990; 335: 144-6. 

11. 
Limberg B. Diagnosis and staging of colonic tumors by conventional abdominal sonography as compared with hydrocolonic sonography. N Engl] Med 1992; 327: 65-9. 

12. 
Limberg B. Diagnostik von kolontumoren durch hydro-kolon-sonographie. Ultraschall in Med 1992; 7: 190-3. 

13. 
Limberg B. Diagnose von Dickdarmtumoren und chronisch entziindlichen dickdarmerkrankungen 


Radio/ Onco/ 2000; 34(2): 165-73. 
durch hydrokolonsonographie. Radiologie 1993; 33: 407-411. 
14. 
Limberg B, Osswald B. Diagnose und Differen­tialdiagnose von Morbus Crohn und Colitis ulce­rosa durch Hydrokolonsonographie. Dtsch Med Wschr 1993; 118: 1181-7. 

15. 
Limberg B, Osswald B. Diagnosis and differential diagnosis of ulcerative colitis and Crohn's disease by hydrocolonic sonography. Am J Gastroenlerol 1994; 89: 1051-7. 

16. 
Duex M, Roren Th, Kuntz Chr, Richter GM, Kauffmann GW. Die kolorektale Hydrokolon­sonographie zur Diagnostik von tumorosen und entziindlichen Dickdarmerkrankungen. Ultraschall in Med 1996; 17: 266-73. 

17. 
Walter DF, Govil S, William RR, Bhargava N, Chandy G. Colonic sonography: Preliminary observation. Clinica/ Radiology 1993; 47: 200-4. 

18. 
Pochaczevsky R. Diagnosis of colonic tumors by 

hydrocolonic sonography [letter, comment]. N Engl ] Med 1992; 327: 1459. 

19. 
Chui DW, Gooding GAW, McQuaid KR, Griswold V, Grendell JH. Hydrocolonic ultrasonography in the detection of colonic polyps and tumors. N Engl J Med 1994; 331: 1685-8. 

20. 
Pompe Kirn V. Epidemiološke znacilnosti raka širokega crevesa in danke v Sloveniji. In: Repše S, editor. Kirurgija širokega crevesa in danke. Ljubljana: Klinicni center, Kirurške klinike; 1996. p. 79-85. 

21. 
Hernandez-Socorro CR, Guerra C, Hernandez­Romero J, Rey A, Lopez-Facal P, Alvarez­Santullano V. Colorectal carcinomas: diagnosis and preoperative staging by hydrocolonic sonogra­phy. Surgery 1995; 117: 609-15. 

22. 
Elewaut AE, Afschrift M. Hydrocolonic sonogra­phy: a novel screening method for he detection of colon disease? Bildgebung 1995; 62: 230-4. 

23. 
Candia C, Ciacci V, Di Segni R, Santini E. L'ecoidrocolon nello studio delle malattie del colon. Confronto con il clisma a doppio contrasto. Radio/ Med 1995; 89: 258-63. 

24. 
Brady AP, Stevenson GW, Stevenson I. Colorectal cancer overlooked at barium enema examination and colonoscopy: a continuing perceptual prob­lem. Radiologij 1994; 192: 373-8. 

25. 
Dijkstra J, Reeders WAJ, Tytgat GNJ. Idiopathic inflammatory bowel disease: Endoscopic -radio­logic correlation. Radiology 1995; 197: 369-75. 



Vidmar O/ Hydrocolo11ic s011ogrnphy 
26. Thoeni RF, Laufer l. Polyps and cancer. In: Gore RM, Levine MS, Laufer I, editors. Textbook oj gas­troi11lestinal radiology. 1 st ed. Vol l. Philadelphia: 
W. B. Saunders Company; 1994. p. 1160-99. 
27. 
Hough DM, Malone DE, Rawlinson J, Degara CJ, Moote DJ, Irvine EJ. Colon cancer detection: an algorithm using endoscopy and barium enema. Clinical Radio/ 1994; 49: 170-5. 

28. 
Limberg B. Divertikulose. In. Limberg B. So11ogra­phie des gastrointestinnltrakts. Berlin, Heidelberg: Springer Verlag; 1998; 13: 149-57. 


29. 
Nagita A, Amemoto K, Yoden A, Yamazaki T, Mino M, Miyoshi H. Ultrasonographic diagnosis of juvenile colonic polyps. J Pediatr 1994; 124: 535-40. 

30. 
Jahnel P, Drossel R. Hydrosonographie des kolons bei 52 patienten mit colitis ulcerosa. L/l/rasc/za/1 in Med 1992; 7: 190-93. 



Strictures of the male urethra: how to perform and evaluate radiourethrography and sonourethrography to avoid mistakes 
Darja Babnik Peskar, Alenka Višnar Perovic 
Clinical Institute oj Radiology, University Medica/ Centre, Ljubljana, Slovenia 
Introduction. Precise evaluation of the urethral stricture localisation, length, depth and quality of wall changes are necessary far the selection of the optimal treatment to prevent recurrences. Decision far ure­thral dilatation, interna] urethrotomy ar open surgery depends on urethroscopic, radiourethrographic-RUG, and recently, according to Me Anninch, niso sonourethrographic-SUG results. SUG adds infonnation about the depth and density of spongiofibrosis. Previously published findings of RUG /ength underesti111ation, compared to SUG and endoscopy, were responsible far inappropriate treatrnent and recurrences. In our arti­c/e, we evaluate SUG as a new imaging method in the diagnosis of uretlzral strictures and treatment plan­ning, and describe both imaging rnethods together with usual pitfalls in performance ar interpretation, pos­sible reason far incorrect length measurements, and RUG length underestimation. Patients and methods. In the period of 20 months, we evaluated SUG compared to RUG and endoscopy in 51/130 rnales with suspected urethral strictures. Results. Compared to RUG, sonography was correct in 92 % radiographycally detected strictures. Length measurements by sonography were far 22 % shorter than radiographic lengths, which cou/d be explained by radiographic magnification, as it was proved with wire measure placed on penis. Considering radiographic magnification, we did not find irnportant differences in any measurement. Opposite to previously published RUG results compared to endoscopy and SUG, radiographic length underestimation was not found. 
Conclusion. The combination of both imaging methods provides optimal information about urethral stric­ture anatomy. We cone/ude that published radiographic length underestirnation could be only a misinter­pretation. We rea/ise how important it is to avoid performance mistakes, misinterpretation, wrong compar­ison and wrong conc/usions far proper treatment planning. We advice to pe1form dynamic RUG according 
to Me Callum RW 

Key words: urethral stricture -radiography -ultrasonography 
Received 15 May 2000 Accepted 30 May 2000 Correspondence to: Darja Babnik Peskar, Clinical 
Radiology Institute, University Medica! Centre Ljubljana, Zaloška 7, SI-1525 Ljubljana. Phone: +3861 143 15 30; Fax: +386 1 133 31 044 


Babnik Peskar D et al. / Strictures of tlie 111a/e urethra 
Introduction 
Etiology, patohistology 
The urethral stricture is the result of inflam­mation and trauma, and is suspected in the patients with obstructive symptoms, recur­rent urinary tract infections, and in cases of inability to pass the catheter. Repeated instru­mentation and treatment of recidives, in­crease a risk for additional iatrogenic trauma with pressure necrosis and secondary inflam­mation, with penetration into the submucosa and underlying corpus spongiosum, resulting in subepithelial microabscesses, thrombosis and fibrosis-the urethral scar. Inelastic scar shortens the circumference, reduces the ure­thral lumen, and causes significant urodi­namic effect.1, 2 
Treatment planning 
In the absence of exposure to infections or additional iatrogenic trauma, the recurrences of strictures after treatment are believed to be the consequence of inappropriate choice of treatment.1-5 
The localisation and length of stricture are decisional, however the depth and quality of periurethral changes must be included in the treatment planning.6-10 According to recent literature, urethral dilatation and interna! ure­throtomy can be curative for short 1 cm long focal strictures, involving the epithelium alone or superficial spongiosum. For diffuse, longer and deeper strictures, reconstructive 
11 -14 
surgery is advised.1, As a first treatment choice, open surgery is indicated in severe urodynamically important strictures with deep spongiofibrosis or full-thickness-scar, for diffuse long stricture, in strictures, which extend into the membranous urethra. In penile region, tension free reanastomoses are 
12,15
limited to 2-3 cm long strictures10 , , and longer are treated with full-thickness skin or free graft or flap urethroplasty. For strictures close to the membranous urethra, posterior or transsphincter uretroplasty is necessary.11 
Imaging diagnosis of the urethral strictures 
The location and the length of stricture can be evaluated by urethroscopy or urethrography, and the depth from the appearance of the ure­thra on contrast studies, the elasticity noted at urethroscopy and the depth and density of the fibrosis evidenced during sonourethro­graphy.1,2,3,6-11 
Aim of the study 
Until recently, radiourethrography was a stan­dard technique in diagnostic imaging of ure­thral strictures in our department, where we perform 100 radiourethrographies per year. The earlier described sonourethrographic advantages without radiation risks were the reasons for the application of sonourethrogra­phy together with radiourethrograpy to gain information about: 
l. Sonouretrography as a new imaging tech­nique in urethral strictures; 
2. Radiographic length underestimation com­pared to sonography -the possible reason for inappropriate treatment decision found in previously published studies, or confir­mation of our prediction that the length underestimation could be only interpreta­tional mistake. 
Patients and methods 
In the period of 20 months, we performed subsequent radiourethrography (RUG) and sonourethrography (SUG) in 51/130 males (age 21-79 years, mean 52.7) with clinically suspected urethral strictures, according to the urodynamic studies, endoscopy, or in cases of inability to pass a catheter. The selection of patients for both subsequent imaging meth­ods during the same visit was accidental, de-

Babnik Peskar O et al. / Strictures oj the in.a/e urethra 
pending on the availability of technical facili­ties, tirne, and radiologists. 
First, we performed RUG, than SUG with­out complete disclosure of the results, and we finished both imaging methods with a radi­ographic film of voiding to avoid two installa­tions of balloon catheter or a clamp. 
1,2,11 , 
D y nami c RUG with retrograde contrast application under fluoroscopy and voiding as an integral part of the study was performed on a Siemens Siregraph D-2 by the radiologist with the assistance of the radiog­rapher. Adequate contrast application with­out additional trauma provides constant visu­alisation of the posterior urethra, the mem­branous part, bulbar conus and also sec­ondary softer strictures in the presence of pri­mary harder one. Sufficiently oblique posi­tion is necessary to avoid the superposition and not to overlook bulbar strictures (Figure 1,2,3). We slightly modified standard RUG. We did not make AP film. We prefer two dif­ferent oblique films usually with different quantity of contrast application for better length measurements and delineation of soft­er secondary strictures (Figure 3). 
The duration of radiourethrography with the aseptic installation of devices for contrast application, hence without voiding, was approximate 20 minutes with the varying voiding tirne. 
The whole urethra delineation is diagnosti­cally important for recognition of ali strictures and their precise localisation. Measurements are rnade from the films, and other observa­tions are detected also during fluoroscopy. Such measurements and technical mistakes may be re-checked from the films also later. 
In length measurements, we included tapering on both sides, "conning-down", and not only the length of a tight stricture. The degree of stricture was determined from ante­roposterior diameter of the strictured area compared to the normal luminal diameter (Figure 1,3).The strictures were classified by Devine as: mild-less than a third, moderate-a third to half, and severe -more than half of the lumen reduction. 
For objectivation of radiographic magnifi­cation in our study, we placed Lunderquist wire vessel measures or metal wires on penis in 7 patients, and analysed 10 different mea-
G 


Figure l. Radiographic urethrography(RUG)-evaluation of the stricture and measurements; a) Less contrast appli­cation, b) More contrast application, c) During voiding. B-bulbar stricture, L2-the length of the whole stricture, Ll­the length of a tight stricture, 01-normal diameter, 02-reduced lumen, m-suspected meatal stricture. 
Bnbnik Peskar Det ni./ Strictures oj the male urethra 

Figure 2. Radiographic urethrography (RUG); a,b) Correct oblique position, c) AP position with superposition of bulbar urethra. B-bulbar stricture, ž-wire rneasure. 
Q 


Figure 3. Radiographic urethrograpl1y(RUG); a) Less contrast application, b)More contrast application. L2-the length of the whole stricture, Ll-the lengtl1 of a tigth stricture, SS-secondary soft stric ture, b-baloon of the urethral catheter. 
Babnik Peskar O et ni./ Slrictures oj t/1e mnle uret/1rn 

•:-i b 
L 
L2 

l 02 ] 01 


Figure 4. Evaluation of the stricture; a) Sonographic urethrography(SUG)-transducer position b) The length and diameter, c-d) Ventral(v) and dorsal(d) spongious changes and expansion outside spongiosum. L2-The length of the whole stricture, Ll-the length of a tigth stricture, D1-normal diameter, D2-reduced diameter. 
surements, which varied depending on pati­ents' constitutions and different oblique posi­tions (Figure 2). 
Sonourethrography, according to Me Anni­nch, which was slightly modified from the first report in 1988, was performed by sonolo­gyst with the assistance of radiologist on Sie­mens Sonoline Sl-400 and Toshiba SSA-270 A with 7.5 MHz linear probe placed ventrally on penis. Transcrotally and for perineal appro­ach, we used also convex 3.75 MHz probe. 
Multiple transverse and longitudinal mea­surements with electronic caliper were made (Figure 4) during constant adequate applica­tion of saline solution, but avoiding too much transducer compression. In selected patients, additional application of sonographic con­trast Levovist was used for better delineation (Figure 5,6). The duration of sonography, when devices for contrast application were already installed at radiourethrography, ran­ged from 20 to 40 minutes. The evaluations of a stricture presence, number location and measurements were made by the sonologyst. 
Normally, 20 ml of saline solution was suf­ficient, sometimes requiring up to 40 ml. In selected patients, we used also 4 ml of sono­graphic contrast Levovist. 
Measurements and technical mistakes are usually performer-dependant, sometimes impossible to detect and correct later. 
Descriptive analyses and Wilcoxon non­parametric test were made in SPSS program for Windows. 
Results 
Six patients had normal urethra diagnosed by both imaging techniques, and others had 70 strictures by RUG and 59 by SUG. Ten sepa­rated strictures by RUG were considered as 5 

Babnik Peskar Det ni./ Strictures of the male urethra 

5. Sonographie urethrography(SUG)-longitudi­nal and tranversal seans; a) Applieation of saline solu­tion, b) Applieation of sonographie eontrast Levovist. U­urethral lumen, PD-dorsal periurethral fibrosis, KT-eor­pus eavernosus. 
Figure 
strictures by SUG, and were measured together in the same or separated anatomical region, and caused differences in number and site of strictures. Sonography really missed 6 strictures; 5 meatal and one penile (Figure 7). 
In contrast to previous reports, the radi­ogaphical lengths were 22 % longer than sono­graphical (Figure 8), and we did not find any significant differences neither in the lumen reduction (Figure 9) nor in Devine classifica­tion (Figure 10). 
Radiographic magnification present in ali measurements was proved by wire measure­ments (25 %). 
Valuable additional sonographic evalua­tions were direct delineation and measure­
6. Sonographie urethrography-measurements of strietures; a) Longitudinal sean, b) Transverse seans. L2-the whole length, Ll-the length of a tigth strieture, DI-normal diameter, D2-redueed diameter. 
Figure 
% 35  
30  
25  
20  
:;u.... 1 DI PB D SUG ¦ RUG I  CI. [I eP normal No strici.  

7. The loeation of strietures found by sonogra­phy (SUG) and radiography(RUG). B-bulbar, PB­penobulbar, P-penile, m-meatal, n-navieular, eP-entire penile, normal. 
Figure 
ments of the depth of spongiofibrosis ob­served ventrally deeper in 55. 7 % of stric ture s (Figure 4cd,5,11), and suspected outside spongiosum expansion in 31 %. 

Babnik Peskar D et ni./ Strictures of the 111a/e ure/hm 
20 
"j 

1 G 
10 1111111 
5 
o 
mm L 1 L2 15% 22% 
e 8. Mean Jength of strictures found by sonogra­phy (SUG) and radiography (RUG). The percent of radiographic magnification. Ll-the length of a tigth stricture, L2-the entire stricture length. 
Figur
mm 12 
10 8 

DRUG 6 
¦ SUG 
4 
2 
LIII 
o L 
D1 D2 
30% 26% 
9. Mean normal urethral lumen (01) and reduced lumen (02) found by sonography (SUG) and radiography (RUG). The percent of radiographic rnag­nification. 
Figure 
100 
80 
. severe 
60 
Omoderate 
40 
¦ mild 
20 
o 
l 
RUG SUG ENDOSC. 
10. Devine classification of urethral strictures by radiography (RUG), sonography (SUG), and endoscopy (endosc.). 
Figure 
Treatment decision, based on clinical sym­ptoms, imaging, surgeon routine and experi­ences, differed from the proposed by our imaging technique in 82 %; internal urethroto­my was made instead of reconstructive surgery and observed recurrence was 62 %. 
Discussion 
Until recently, the purpose of urethrography was to delineate the primary stricture and to describe the length of a tight stenosis. Such incorrect measurements could be the reason far published radiographic underestimation compared to sonography. Especially when ra­diourethrography is statically perfarmed (without fluoroscopy) or modified voiding against Zipser clamp is evaluated, as it is obvi­ous from previous reports, only a tight stric­ture is measured. We avoid static urethrogra­phy, which may contribute to the underesti­mation of length and grade and, consequently, also to inappropriate treatment decisions.7, 11 
In static urethrography, the membranous urethra is not usually visualised, and only the primary stricture is recognised. In a signifi­cant number of patients, secondary soft scars proximal to the primary stricture cannot be diagnosed in the fully distended urethra, because of paradoxical dilatation at urethrog­raphy or during voiding.11 Consequently, such an improper comparison of two differ­ent lengths, the radiographic length of a tight stricture only without tapering on both sides and the sonographically directly visible entire length of wall changes, is therefare a miscon­ception, leading to wrong conclusions (Figure 12). In such improper comparisons, we also faund similar radiographic length underesti­mation in our patients, as mentioned in pre­vious reports. SUG lengths in such wrong comparisons were far 78 % longer than RUG. 
By correct dynamic urethrography with voiding, we evaluated the whole stricture involvement and by accurate localisation of the membranous urethra also proximal stric­tures. Elongated, narrowed, irregular or asymmetric bulbar conus with presence of primary bulbar stricture (Figure 13), repre­sents its extension to membranous part and indicates transsphincter urethroplasty.11 Pro­per oblique patient's position, proper contrast application during exposure, voiding and cor-

Babnik Peskar D et a/. / Striclures oj the male urethra 


rect measurement of the stricture length, the tight stricture with "conning down" segment which illustrates its involvement in the scar, contribute to better evaluation of the stricture as well as better treatment outcome. At the same tirne, we can observe primary hard stricture with obstructive symptoms, and sec­ondary softer ones without symptoms of out­let obstruction. The latter could contract and produce obstruction after surgical treatment 
1,11 
of primary stricture alone.
Our prediction that previously published radiographic length underestimation could be only interpretation mistake is proved by our results. RUG magnification affects equally measurements of urethral lumen diameter at normal and reduced sites of the same patient, and was present in wire measurements. 
Until recently, the majority (95 %) of stric­tures were treated with one or more urethro­tomies, either blindly (Otis method) in stric­tures with wide calibre, or under direct vision (Sachse method). Reported recurrences after urethrotomy were from 15 % up to 75 % or even 92 % in selected patients.4,12,13,14 
According to the findings of a significant trend for radiographic length underestima­tion, the reported additional or better sono-

Bnbnik Pesknr O e/ ni./ Strictures of lhe ninfe 11re//1rn 

graphic evaluations of urethral strictures compared to radiourethrography, changed urethrotomy to reconstructive surgery in 16%. According to other recent reports on sonogra­phy, the treatment changed, too: 33% of stric­tures were treated by urethrotomy and 63% by reconstructive surgery. In other reports, the reconstructive surgery was also changed after sonourethrography in 37 %'15 of bulbar stric­tures with radiourethrographic intermedia te length; graft or flap urethroplasty was made instead of end-to end reconstruction. 
Adding sonographic evaluation of the stricture length, lumen reduction and classifi­cation to radiourethrography there was no need to change treatment to more reconstruc­tive surgery in our study. According to recent literature, the majority had been already indi­cated by radiographic results, based on our perfonnance, described measurements, and interpretations. Different surgeons' decisions were the result of their experience and doc­trine and is not based entirely on our imaging evalua tions. 

Babnik Peskar D et ni./ Strictures oj the male urethra 
Considering mean 22 % radiographic mag­nifica tion and longer strictures found by RUG, that are contradictory to the published results, the study did not demonstrate any difference in measurements. 
We can conclude that in everyday routine RUG is still the method of choice. We propose dynamic RUG by Me Callum. Radiation-free SUG is valuable additional method with direct visualisation of the depth and quality of spongious changes. Sonography, detecting 92 % of the strictures, may replace RUG, but in view of the sonologists-dependant mis­takes, the combination of both imaging meth­ods is optimal. 
References 

l. Devine CJ Jr. Surgery of the urethra. In: Walsh PC, Gittes RF, Perlmutter AD, Stamey TA (editors). Cnmbells urology, 5th ed. Philadelphia: WB Saunders; 1986. p.2860-3. 
2. 
Devine CJ Jr., Jordan GH. Surgery of anterior ure­thral strictures. In: Marshall FJ {editor). Operative 

urology. Philadelphia: WB Saunders; 1991. p. 307­21. 


3. 
Merkle W, Wagner W. Sonourethrngraphy of the distal male urethra -a new diagnostic procedure for urethral strictures: results of a retrospective study. j Urol 1988; 140: 1409-11. 

4. 
Merkle W, Wagner W. Risk of recurrent stricture following interna! urethrotomy. Prospective ultra­sound study of distal male urethra. Br J Urol 1990; 65: 618-20. 

5. 
Sakti D. Ultrasonographic evaluation of the ure­thral stricture disease. UrologtJ 1992; 40: 237-42. 


6. Me Anninch JW, Laing FC, Jeffrey RB Jr. Sonourethrography in the evaluation of urethral strictures: a preliminary report. J Uro/ 1988; 139: 
294-7. 
7. 
Gluck CD, Bundy AL, Fine C, Loughlin KR, Ritchie JP. Sonographic urethrogram: comparison to roentgenographic techniques in 22 patients. J Uro/ 1988; 140: 1404-8. 

8. 
Gupta S, Manibrata B, Tiwari A, Gupta RK, Kumar A, Gujral RB. Sonourethrography in the evaluation of anterior urethral strictures: Correlation with radiographic urethrng:raphy. J Ciin U/trasound 1993; 21: 231-9. 


9. Nash PA, McAnninch JW, Bruce JE, Hanks DK. Sonourethrography in the evaluation of anterior urethral strictures. J Uro/ 1995; 154: 72-6. 
10. Morey AF, McAnnich JW. Ultrasound evaluation of the male urethra for assessment of urethral stricture. J Ciin U/trasoun.d 1996; 24: 473-9. 
11. Me Callum RW. The adult male urethra: normal anatomy, pathology and method of urethrography. Rad Ciin N Amer 1979; 17: 227-44. 
12. Netto NR, Lemos GC ,Claro JFA. Interna! Urethrotomy as a complementary method after urethroplasties for posterior urethral stenosis. J Uro/ 1989; 30: 50-1. 
13. 
Hjortrup A, Sorensen C, Sanders S, Moesgaard F, Kirkegaard P. Strictures of the male urethra treat­ed by the Otis method. J Uro/ 1983; 25: 903-5. 

14. 
Gibod LB, Portz BL. Endoscopic urethrotomy: does it live up to its promises? J Uro/ 1982; 127: 

15. 
Morey AF, Me Anninch J W. Role of preoperative sonourethrography in bulbar urethral reconstruc­tion. J Uro/ 1997; 31:1376-9. 

16. 
Tanago EA. Surgical anatomy of genitourinary 


433-5. 
tract. In: Walsh PC, Gittes RF, Perlmutter AD, 6th 
Stamey TA {editol'S). Campbells urology, ed. 
Philadelphia: WB Saunders;1992: p. 50-8. 

review 

The role of sonographic evaluation of spinal canal in children 
Živa Zupancic 
Clinical Radiology Institute, University Medica/ Center Ljubljana, Slovenia 
Baclcground. Spina/ sonography is a valuable diagnostic imaging modality as it has the abi/ity to demon­strate good anatomic detail oj the spina/ canal, its contents, and the surrounding sh'uctures. The examina­tion technique, the anatomy oj the cord, the most common anomalies, and the evaluation oj the sonography compared to magnetic resonance imaging are presented. Conclusions. Spina/ sonography is recommended as the primary imaging modality far congenital anom­alies oj the lower spine in infants and as the screening modality far closed spina/ dysraphism in infants and small children. The examination technique, the anatomy oj the cord, the most common anomalies, and the evaluation oj the sonography compared to magnetic resonance imaging are presented. 
Key words: spina/ dysraphism-ultrasonography; spina/ canal-ultrasonography; child 
Introduction 
High-resolution real-tirne sonography of the spina! canal in children has been perfarmed far over fifteen years.1 It has the ability to demonstrate good anatomic detail, is nonin­vasive, easy to use, can be brought to bedside, does not require sedation, and is of low cost. The application of sonography is possible in the neonate and in children up to school age because of poor ossification of the posterior vertebral elements. It can demonstrate the spina! canal, its contents, that is the cord, the 
Received 17 May 2000 Accepted 1 June 2000 
Correspondence to: Živa Zupancic, M.D., Ph.D., Clinical Radiology Institute, University Medica! Centre Ljubljana, Zaloška 7, SI-1525 Ljubljana, Slovenia. 
cauda equina, the dura! sac and intracanalic­ular, as well as related extracanalicular mass­es. It is used to measure the spina! canal, to determine the leve! of the conus medullaris, to detect cord anomalies, and examine soft tissue abnormalities. The most common indi­cations are to determine the leve! of the conus medullaris, looking far a tethered spina! cord in infants with midline back abnormalities,1, 2 to study the spina! cord far associated malfar­mations in the newborn period in children with spina! dysraphism, such as myelomeningocele and meningocele, and to look far retethered cord after mye­lomeningocele repair. 3 
Technique of examination 
Examination is usually perfarmed with the child prane or in a lateral decubitus position 

Zupancic Ž / Sonogmplzy of spina/ canal 
with thoracolumbar spine flexed to separate the spinous processes, using a high frequency linear array transducer. Small infants can be scanned over the midline between the spin­ous processes, but in older infants and larger children it is better to scan with the transduc­er placed slightly lateral and aimed medially into the spinal canal.1 Transverse and longitu­dinal scanning of the entire spine is per­formed, preferably starting over the sacrum where the spinal canal is easily found.1 A standoff pad can be used to improve nearfield resolution. Longitudinal and transversal pic­tures are taken for documentation. 
Normal cord anatomy 

In the spinal canal the spinal cord is visu­alised as a slightly more echogenic structure than the surrounding anechoic cerebrospinal fluid, it has an echogenic dorsal and ventral surface and a central echo complex just ven­tral to the central canal (Figure 1). 
The cervical cord, as seen in the transverse plane, is oval in shape, thoracic circular and lumbar circular but larger than thoracic. The conus is tapered caudally and is well seen in the longitudinal plane. The normal cord usu­ally ends above the L-2 level, and so the tip of the conus medullaris is seen cranially to the L-31A and is central in the spinal canal. Caudally to the conus the roots of the cauda equina are visualised as echogenic strands in longitudinal plane and as echogenic dots in the transverse plane. The tip of the thecal sac often corresponds to S-2.1 To estimate the ver­tebral level of the conus on the sonogram, pal­pable landmarks are used: the tip of the low­est rib corresponds to the level of the L-2, and the same rib as followed back to the spine locates T-12, the iliac crest corresponds to the L-5.4 For the orientation it is also important to know that the cocyx in neonate is unossified and is a hypoechoic structure just <listal to the sacral segments. It should not be mistaken for a cystic lesion. 
The anterior spinal artery and epidural veins can be demonstrated using colour flow Doppler imaging. During the examination, the spinal cord and cauda equina oscillations in dorsoventral and cephalocaudal direction are observed with heart beating, breathing, 


Figure 1. Normal lumbosacral canal. Longitudinal scan: spina! cord (c) with central echo complex, conus medullaris (cm), cauda equina (c). Transverse scan: spina! cord with central echo complex (arrow). 
Zupancic Ž / Sonographt/ of spina/ canal 

crying, and moving. Oscillation can be docu­mented with M-mode sonography.1 
The tethered spina! cord 
The most common indication for sonography is to determine the vertebral leve! of the tip of conus medullaris, that is to diagnose or to rule out tethered spina! cord.1 A conus me­dullaris that terminates in the spina! canal below the superior aspect of L-3 is probably a tethered cord.1 A tethered cord is a patholog­ic fixation of the spina! cord in an abnormal caudal location, so that the cord suffers mechanical stretching, distortion and ische­mia with daily activities, growth, and devel­opment.5,6 It results in neurologic deficits as reflex changes, sensory loss, muscle wasting, power loss, and sphincter problems. The child might be normal at birth and develop deficits later. A child with an occult tethered cord can present with a lower-extremity deformity or abnormal gait.1 
There are severa! pathologic entities that can cause spina! cord tethering, the most co­mmon are leptomeningocele, intraspinal !ipo­ma, thick filum terminale, diastematomyelia, and dermal sinus. Risk factors for tethered cord are also lumbosacral skin abnormalities, anorectal malformations, presacral anomalies and lipomeningomyelocele .1 
To diagnose a tethered cord on sonography one has to 1) estimate the vertebral leve! of the tip of the conus using on the longitudinal views the sonographic landmarks, as men­tioned above (the L-2 corresponds to the leve! of the tip of the lowest rib and L-5 to the iliac crest). When one is not certain in determin­ing the vertebral leve! of the tip of the conus, a radiopaque marker can be placed on the skin at the leve! of the conus tip to take a radi­ographic film and then to determine the leve! on that film. One also 2) looks for the position of the conus within the spina! canal. The teth­ered cord is usually eccentric, more dorsal than normal. In addition, one has 3) to ob­serve for cord oscillations which are dimin­ished or absent at or above the point of tethe­ring7 (but may be normal in the newborn until tethered later1 ). 
Skin abnormalities and occult tethered spina! cord 
Midline, lumbosacral, skin abnormalities as subcutaneous lipoma, hair tuft, sinus tract, skin defect, dimple, hemangioma, skin tag or appendage, or pigmented nevi can be associ­ated with an occult spina! dysraphism (that is spina bifida occulta) and a tethered cord. Children with these abnormalities can devel­op, as they grow, foot and lower extremity de­formity, decreased sensation, scoliosis, weak­ness, abnormal gait and bladder disfunction.1 
So sonographic screening for these chil­dren was recommended in infancy8 in order to detect a tethered cord and any other asso­ciated abnormalities and to treat the children (early surgical treatment or close neuropedi­atric follow-ups). Among the above men­tioned skin abnormalities, the lumbosacral dimple has been studied for its significance most commonly.1 Lumbosacral dimples and pits are common skin abnormalities and when they are only shallow and superficial and not deep crater like or connected to a der­mal sinus (which appears as a hypoechoic band which might extend to the dural sac) they do not indicate a high risk of ocenit spina! dysraphism and there is no need to screen for a tethered cord. 9 
Lipomas 
Lipomas are subcutaneous masses of fat and fibrous tissue which may be associated with dermal sinuses, hamangioma, nevi, myelo­meningocele (Figure 2), and meningocele. They can be only superficial or are deep and extend into the spina! canal and attach to the meninges, cord, conus, or filum terminale, can tether the cord, and even grow into the 


Zupancic Ž / Sonography of spina/ ca11a/ 
Figure meningocele. Longitudinal view: cauda equina (ce), meningocele (M). 
cord (complete surgical removal is then not possible).UO On sonography they are echo­genic masses, the tethered cord is dorsal and does not oscillate freely. 
Hydromyelia, diastematomyelia 

Hydromyelia is a dilatation of the cord's cen­tral canal that can be focal or involves the entire cord and can be found with myelo­meningocele and diastematomyelia. On sono­graphy, the central echogenic lines are sepa­rated and the central canal is distended by hypoechogenic fluid. In diastematomyelia the cord is split and two hemicords with central canal in each are demonstrated on sonogra­phy. The vertebral column is nearly always abnormal, spina bifida is common. 
Myelomeningocele 

The abnormal fusion or the closure of embry­onic dorsal structures results in myelocele or myelomeningocele.11 The abnormality is visi­ble and imaging is not needed, only occasion­ally sonography is performed to distinguish a meningocele (Figure 3) from a myelomeningo­cele (in the former the sac is empty, in the lat-
Figure 3. Lumbosacral myelomeningocele. Longitudi­nal view: cauda equina (ce) with the nerve roots extending into the myelomeningocele (M). Myelome­ningocele enlarged with crying. 
ter nerve roots can be seen) (Figure 4) and to diagnose associated anomalies. For sono­graphic scanning, the sac is covered by a plas­tic wrap and scanned gently. The spinal cord is usually thinner than normal. 
After myelomeningocele repair, neurologic functions should not deteriorate. If they do, it may be caused by retethered spinal cord (inci­dence 15 %)12 due to adhesions and scarring. The cord in myelomeningocele is low and remains low after surgery, but oscillates nor­mally. When retethered, it does not oscillate normally, it is fixed to the posterior wall of the spinal canal and dense adhesions may be pre­sent.12 The oscillation of the cord is more eas­ily assessed with sonography than with MR. In myelomeningocele scanning over the cervi­cal canal and toward the foramen magnum can demonstrate echogenic tissue of the cere­bellar vermis of the Chiari II malformation. 
Sonography and magnetic resonance imaging (MR) 
With the availability of MR, the imaging modality which is the best for the demonstra-

Zupancic Ž / Smwgraplzy of spina/ ca11a/ 
Figure 4. Lumbasacral lipama assaciated with meningacele. Transverse and langitudinal views: paarly defined hiperechaic lipama (1) and hypaechaic meningacele (M). 
tion of the anatomic details of the spina! canal, spine, and surrounding soft tissues, the role of sonographic imaging had to be reevaluated. Severa! studies comparing sono­graphy and MR were conducted. Evaluating 755 children with rnyelorneningocele in a study conducted to propose a diagnostic radi­ological model to accurately evaluate the neu­rological problems in the rnyelorneningocele child3 the authors found MR to be the best modality to evaluate the posterior fossa and the total spine. At tirnes MR may not ade­quately diagnose subtle cases of tethering of the spina! cord, cord infarction, arachnoid cysts, or diastermatornyelia. In these cases, further evaluation is necessary with sonogra­phy to look at cord pulsations in cases of teth­ering, and computed tornography (CT) for other cases. In severe scoliosis MR is not ade­quate and CT is indicated. 
As spina! sonography has becorne an accepted study to screen for occult dysraph­nism in neonates and infants, it was irnpor­tant to correlate sonography and MR. The authors of a study correlating sonography and MR confirmed the role of sonography in screening and stressed that MR is most useful when sonographic findings are abnorrnal or equivocal or when the normal skeleta! rnatu­ration lirnits the sonographic visualisation of the intracanalicular contents.11 In another study of imaging of terminal rnyelorneningo­cele (in a low nurnber of patients) the authors cornpared sonography, CT, and MR and con­cluded that MR is the irnaging rnodality to diagnose and evaluate children with a rnyelo­rneningocele. 3 Important are the results of the study on diagnostic value of spina! sonogra­phy, a comparative study with MR imaging in paediatric patients.13 In 32 of 38 examina­tions sonography allowed exactly the same diagnosis as MR. In five examinations, sonog­raphy depicted the rnain abnorrnality but MR revealed additional findings. Whenever sono-


Zupa11cic Ž / Sonograplzy of spi11al cana/ 

g:raphy seans were normal, MR images also did not depict any spinal diso:rder. In all 24 examinations with abno:rmal MR findings, sonog:raphy enabled detection of the abnor­mality. 
Concluding, spina! sonog:raphy represents a valuable diagnostic tool for congenital anomalies of the lower spine in infants and small children and is recommended as the p:rimary imaging modality in those patients. 
References 

l. DiPietro MA The pediatric spina! canal. In: Rumack CM, Wilson SR, Charboneau J W, editors. Diagnoslic ultraso1111d. St. Louis: Mosby Year Book; 1998. p. 1589-615. 
2. 
Vocke AK, Ruhmann O, Lazovic D. Standardised sonographic investigation of the lumbar spine in 247 newborn. Klin Pediatr 1999; 211: 22-6. 

3. 
Byrd SE, Radkowski MA. The radiological evalua­tion of the child with a myelomeningocele. J Natl Med Assoc 1991; 83: 608-14. 

4. 
DiPietro MA. The conus medullaris: normal US findings throughout childhood. Radiology 1993; 188: 149-63. 

5. 
Reigel DH. Tethered spina! cord. Concepls Pedialr Neurosurg 1983; 4: 142-64. 


6. 
Yamada S, Zinke DE, Sanders D. Pathophysiology of the "tethered cord syndrome". J Neurosurg 1981; 54: 494-503. 

7. 
Raghavendra BN, Eipstein FJ, Pinto RS, Subra­manyam BR, Greenberg J, Mitnick JS. The tethered spina! cord: diagnosis by high -resolution real-time ultrasound. Radiology 1983; 149: 123-8. 

8. 
Hall DE, Udvarhelyi GB, Altman J. Lumbosacral skin lesions as markers of occult spina! dys­raphism. JAMA 1981; 246: 2606-8. 

9. 
Gimson PJ, Britton J, Hall DM, Hill CR. Lum­bosacral skin markers and identification of occult spina! dysraphism in neonates. Acta Paedialr 1995; 84: 208-209. 

10. 
Chapman PH. Congenital intraspinal lipoma: anatomk considerations and surgical treatment. Clzild's Brai11 1982; 9: 37-47. 

11. 
Korsvik HE, Keller MS. Sonography of occult dys­raphism in neonates and infants with MR imaging correlation. Radiograplzics 1992; 12: 297-306. 

12. 
Tamaki N, Shirataki K, Kojima N, Shouse Y, Matsumoto S. Tethered cord syndrome of delayed onset following repaiI· of myelomeningocele. J Neurosurg 1988; 69: 393-8. 

13. 
Rohrschneider WK, Forsting M, Darge K, Troger J. Diagnostic value of spina! US: comparative study with MR imaging in pediatric patients. Radiology 1996; 200: 383-8. 



Renal cell carcinoma in the ectopic kidney prospects of diagnos­ing and treatment of the carcinoma of the kidney: case report 
Erika Brencic1, Marjeta Stanovnik2, Mojca Glušic1 
1 Clinical Radiology Institute, Llniversity Medica/ Centre, Ljubljana, Slovenia 2Institute of Oncology, Ljubljana, Slovenia 
Background. An extensive use of ultrasonography and computed tomography have enormously con­tributed to the early detection of adenocarcinoma of kidney taking into consideration that they have been so far often detected by chance. In addition to provide us with an image of a tumor and contributing to dejine more easily the nature oj tumor, MRI is most helpjul in detecting the infiltrations of tumor into its sur­rounding and changes in the veins. Case report. This case report presents the patient witlz adenocarcinoma of the ectopic kidney. The ultra­sonography, computed tomography and magnetic resonance irnaging detected an abundant non-homoge­nous tumor mass in pelvis minor. Additionally to the suspected ectopia oj one of the kidneys, it was a/so suspected that tlzere was another pathological process of dijjerent etiology too. This suspicion was based on the detection oj a dijjerent tumor mass in between the intestinal /oops. Two months ajter the nonradica/ excision oj the adenocarcinoma jrom the ectopic kidney, the jol/owing changes were observed: progress oj the residual tumor in the pelvis minor and the turnor in between the intestinal loops (that was not removed during the first operation). The patient was given immunochemotherapy and /ocal radiotherapy. Conclusions. According to the availab/e data in literature, the /ocalization oj tumor in ectopic kidney is extremely mre. 
Key words: kidney neoplasms -diagnosis -ultrasonography -surgery; carcinoma, rena/ celi; tomography, computed, magnetic resonance imaging 
Received 17 May 2000 Accepted 5 June 2000 
Corespondence to: Assist. Erika Brencic, MD, Clinical Radiology Institute, University Medica! Centre Ljubljana, Zaloška 7, SI 1525 Ljubljana, Slovenia. Phone: +386 1 5408 400; Fax: +386 1 133 31 044 
Introduction 
Renal cell carcionoma (adenocarcinoma) of kidney is quite a frequent malignant tumor. It is diagnosed in 90 % of ali malignant tumors of kidney. This tumor type is characterized by different clinical and morphological proper­ties. It is considerably well radiosensitive. The only mode of treatment assuring a complete cure is surgical removal of primary tumor and solitary metastases.1 

Brencic E et al. / Rena/ cel/ carci110111a in the ectopic kidney 
Survival of patients depends on their clin­ical status at the tirne of diagnosis. The patient' s clinical status is determined by spread of disease, involving local infiltration in the surrounding tissue and the presence of distant metastases. 
The examinations, such as ultrasonogra­phy (US), computer tomography (CT) and ma­gnetic resonance (MR) have enormously con­tributed not only to obtain better possibilities of detecting malignant or benign tumors of kidneys but also to their more successful detection. 2 Each renal mas s having different density after the injection of contrast media is considered as a tumor until it's praven differ­ently. 
Adenocarcinoma of kidney is a rare malig­nancy in childhood and adolescence. At the tirne of diagnosis, one half of patients have no signs of hematorrhea; tumor is usually detect­ed by chance. 
Case report 

A 37-year-old patient was treated at the Institute for Family Planning in the year 1988, where the dysfunction of the left ectopic kid­ney accompanied by a compensatory enlarge­ment of the right kidney were observed. 
In May 1996, the patient's sperm had been taken for the in vitro fertilization. At that tirne, hematospermia was observed. The patient was therefore referred to the urolo­gist. Cytoscopic examination detected a sub­stantially enlarged median lobe of the pro­state and the wall of bladder was slightly pushed upwards to the usual location of the left ostium. The subsequent US examination confirmed the ectopia of the left pelvic kid­ney. 
By the end of 1996, the patient complained of the problems in discharge of excreta despite normal appetite and digestion. He felt a stifling pain in the lower part of abdomen. In February 1997, the patient himself palpat­ed the tumor by digital examination of rec­tum. He was immediately referred to the urologist. 
The diagnostic procedure included also US examination which detected a profuse hetero­geneous tissue of serous and solid structure, its size was 8x8.3 cm at the back of bladder on the left. These findings were the reason that we suspected a pathologically changed left ectopic kidney or left seminal vesicle. After having performed the biopsy examina­tion, the cytologic findings could not reliably define the nature of this process. The cells resembled to those of spermatogenesis. On the other hand, the suspicion of tumor could not be definitely excluded. 
CT examination discovered a non-homoge­nous tumor mass of 8x8 cm behind the uri­nary bladder (Figure la). The core of the tumor was hypodense, while the peripheral area was seen as a granular soft-tissue accu­mulation spreading towards the center. There was no infiltration of the tumor into the blad­der observed, while the tumor margins on the side of the prostate, rectal wall and internal obturator muscle were not clear. Seminal vesi­cles were not seen, while the same examina­tion detected other soft-tissue tumor masses between the loops of the jejunum (Figure lb). 
At the beginning of March 1997, the MR of the pelvis minor confirmed further growth of the tumor mass behind the bladder (Figure 2a). On T2-weighted image, the intensity of signal was different: It was hyperintensive in the core of tumor and hypointensive in its peripheral area. In the sagittal plane, the complete size of tumor mass could be seen, protruding into the wall of the urinary bladder and rectum (Figure 2b). On the Tl­weighted image, the tumor was well differen­tiated after the injection of contrast media, with hypointensive signal in its core and weak hyperintensive signal in the periphery (Figure 3). 
The MR image of the tumor was similar to the findings of CT examination. They both 

Brencic E et ni. /Rena/celi carcinonw in the ectopic kidney 

Figure l. (a) CT visualization of non-homogenous well differentiated tumor in pelvis minor: The core of tumor is hypodense, whereas the periphery is granular soft tissue. (b) Soft tissue tumor. 
Brencic E et al. /Rena/celi carcinoma in the ectopic kidney 


Figure 2. (a) MR image of tumor: On T2-weighted image, the signal in tumor core is hyperintensive, whereas in the periphery the signal is hypointensive. 
(b) Sagittal plane: The Tl-weigthed image of tumor. 
confirmed the tumor in the ectopic kidney. Another differential option of these findings was germinal tumor or malignant tumor of another etiology. 
Figure 3. Tl-weighted image of tumor: After the injec­tion of contrast medium, the signal in the tumor core is hypointensive, whereas in the periphery the signal is mildly hyperintensive. 
After the MR examination, the tumor in the pelvis minor was surgically removed. The histology findings confirmed the tissue of pri­marily papillary and partly solid clear celi car­cinoma of the kidney, grade II-III. On one spot of the tumor area, the angioinvasion of tumor tissue was observed. 
Post-operative treatment of the patient was normal. After having been discharged from the hospital to home care he was quite in a good condition. 
At the beginning of May 1997, pains in the lower part of abdomen started again. The patient complained of having complications with excretion as well as of the constant sti­fling pain in the lower part of abdomen. The US examination at the end of May discovered an echosolid and also palpable formation (size 5x5cm) in the right inferior part of abdomen (Figure 4). It was assumed that this formation was either a residuum of tumor after the operation or recurrence. 
Afterwards the patient underwent further diagnostic examinations, among them also the X-ray of thorax which findings were with­in limits. The cytoscopic findings detected that the trigone and orifice of bladder and 

Brencic E et ni. / Rennl celi cnrci110111n in lhe eclopic kidney 

Figure 4. US visualization of echosolid tumor mass in pelvis minor. 
prostatic lobe were slightly elevated. The mu­cous membrane of trigone was edematous. The digital examination of rectum detected a smooth and resilient formation pressing against it. 
Another CT scan discovered two different kinds of masses; one was abundant solid tumor mass in between the loops of small intestine and colon, and the other granular solid tumor mass near the pelvic wall on the left and on the very place as it was the prima­ry tumor. Both tumors were not connected to each other. Nevertheless in pelvis minor it was suspected that there was a tumor infiltra­tion into the surrounding. 
The patient was admitted to the treatment at the Institute of Oncology, Ljubljana. An US guided biopsy of the tumor in pelvis was per­formed and the subsequent histology findings confirmed the recurrence of the same type of tumor, as it was the primary one, i.e. small cell carcinoma corresponding to the carcinoma of kidney. The medical team at the Institute of Oncology decided to treat the patient with combined chemoimmunotherapy. 
The patient received Paraplatin 3x750 mg, intravenously, in 3 weeks' interval, Vinblastin 4 mg, 24-hour infusion, in 2 weeks' interval, and Intron A 3.000.00, subcutaneously, 3 x / week. During the therapy, the patient suf­fered from some mild toxic effects, such as myelosuppression. 
During the treatment, severa) US examina­tions were performed and two CT seans. 
After the immunochemotherapy the clini­cal status of the patient improved. US exami­nation also confirmed the decrease and colli­quation of tumor. After a 3-month combined immunochemotherapy, the patient was re­ferred again, if possible to operate him addi­tionally. The CT scan showed the progression of disease with an extensive tumor masses in 

Brencic E et al. / Rena/ celi carcinoma in the ectopic kidney 
the abdomen. The infiltration of tumor was observed in the surrounding tissue; particu­larly suspected infiltration was that one grow­ing into the wall of rectum (Figures Sa,b). Another surgery was not possible any more, so the medical team decided for symptomatic palliative irradiation treatment. The tumor in the abdomen was pressing against the wall of rectum and for this reason the patient was obstipated. The patient received radiotherapy with TD 1800 cGy (180 cGy a day). Additio­nally to the radiotherapy, the patient received sensibilization treatment with Velbe 2mg in 24 hour infusion, 2 x / week. Despite the radiotherapy, progression could not be pre­vented. 
In January 1998, the patient's condition deteriorated. At first he suffered from rec­tovesicle fistula followed by ileus. In March 1998, a preternatural anus was made in the transversal part of colon. The patient died in April 1998, due to a rapid progression of tumor into the abdomen. 
Discussion 

Despite properly selected diagnostic method and subsequent treatment modalities, we are not always in a position to influence favorably the course of disease. 
Carcinoma of kidney has too often been detected by chance. The detection of this dis­ease has become more successful when US and CT have been applied. With further im­provement of diagnostic techniques we have had wider possibilities to detect tumors, even to determine their nature, as well as to distin­guish between the benign and malignant one. Staging of the disease may essentially affect its treatment and prognosis. Early and accu­rate diagnose detected by US and CT should be strictly based on morphological criteria. The adenocarcinoma of kidney is often seen as a solid or non-homogenous accumulation and may be lobulated and clearly demarcated. 
Necrosis or hemorrhage often occurs in the core of tumor mass. It is important to assess the density changes in the mass after the injection of contrast medium. 
CT scan is a vital diagnostic method at the detection and staging of kidney carcinoma. MR imaging is similar to CT scan, however, it is more successful in staging. It detects even­tual anomalies and their extent, the veins and the surroundings of organs are more clearly perceptible.3 CT scan cannot detect the microscopic invasion into the perirenal fatty tissue and cannot distinguish between in­flammatory changes and tumor infiltration or identify small collaterals and infiltrations into the lymphatic system.2 When defining the nature of tumor mass with an option to dis­tinguish between the adenocarcinoma of kid­ney and the mesenchymal tumor on the basis of morphological changes and densitometry of CT scan, it would be more likely suspected that adenocarcinoma dominates.4 A solitary lesion in kidney is usually the primary tumor, though the distinction between primary and secondary tumors is very complicated.5 It is possible to observe simultaneously the renal arteries and veins, parenchyma and renal pelvis system with aid of recent technical innovations using fast sequences and contrast media during MRI. MRI can therefore be per­formed on any patient irrespective of age and readiness to co-operate in the examination. 
It was suspected that our patient had an ectopic kidney. CT scan and MRI detected a large non-homogenous tumor mass in pelvis minor. Considering the images, restrictions and changes after the injection of contrast media, the CT scan and MRI diagnoses were malignant tumor of ectopic kidney. The Tl­and T2-weighted MR images showed a tumor with a typical necrosis and hemorrhage in its core. The seminal vesicles were not seen in any MR images. Therefore, it was suspected that tumor was infiltrated into the surround­ing tissue. The first CT scan did not detect another tumor which has not been removed 

Brencic E et ni. /Rena/celi carcinoma in the ectopic kidney 

Figure 5. (a) CT visualization of tumor residuum in pelvis minor. (b) CT visualization of soft-tissue tumor in between the intestinal loops. 
Brencic E et al. / Rena! celi cnrcinoma in the ectopic kidney 
during the first operation was detected in between the intestinal loops. That tumor could have had the metastatic spread into the pelvis. Another differential diagnostic option was presence of the tumor of different etiolo­gy. The histologic findings of surgically removed tumor as well as cytological biopsy of residual tumor and/or its recurrence con­firmed the adenocarcinoma of ectopic kidney. 
Another review of the images of the first CT scan and MRI did not provide us with any additional <lata. Neither renal artery nor vein of the ectopic kidney could be seen on those images. The margins between the tumor and the surrounding organs with suspected infil­trations were better seen on MR images. There was no enlargement of lymph nodes detected on any of those images. Unfortu­nately, all the subsequent CT seans after the operation and during the therapy confirmed only a rapid progression of the disease. 
A tumor localized in an ectopic kidney has been rarely reported in literature. Our case report confirms that despite current potential diagnostics, surgical treatment, choice of chemoimmunotherapy and radiotherapy it was not possible to slow down or to prevent from the progression of disease. 
References 
1. 
Wegener OH. The kidney. In:. Whole body comput­ed tomography. Boston: Blackwell Scientific Publications; 1993. p.374. 

2. 
Bechtold RE, Zagoria RJ. Imaging approach to staiging of renal celi carcinoma. Uro/ Ciin N Am 1997; 14: 507-22. 

3. 
Kreft BP, Miiller-Miny H, Sommer T, Steudel A, Vahlensieck M, Novak D, MLiller BG, Schild HH. Diagnostic value of MR imaging in comparison to CT in the detection and diferential diagnosis of renal masses: ROC analysis . Eur J Radio/ 1997; 7: 542-7. 

4. 
Dalla-Palma L, Pozzi-Mucelli R. Problematic renal masses in ultrasonography ad computed tornogra­phy. Ciin lmag 1990: 14: 83-98. 

5. 
Schubert RA, Soldner J, Steiner T, Schubert J, Kaiser WA. Bilateral renal cell carcinoma in a horseshoe kidney: preoperafive assesment with MRI and digital subtraction angiography. Eur Rndiol 1998; 8: 1694-7. 





Prof. Mira Vurnik-Žumer, M.D., Ph.D. (1916-1998) 

Professor Mira Vurnik-Žumer, a prominent radiologist and teacher of several generations of medical students and radiologists in Slovenia, died on August 8, 1998 at the age of 82 years. 
Professor Mira Vurnik-Žumer was bom in Vienna on September 28, 1916. She complet­ed her pre-university education in Ljubljana, and graduated in 1935. She pursued her study of medicine at the Faculties of Medicine in Ljubljana and in Zagreb, and graduated M.D. from the latter in April 1942. She did her pre­registration year in the Ljubljana General Hospital, and worked as a volunteer physi­cian at the Department of Interna! Medicine for two years. 
She entered the specialist training in radi­ology quite early, and in 1950 began to work at the Institute of Radiology in Ljubljana. She passed the final speciality examination in June 1954. After presenting her work on the modern classification of primary bone tumours she was appointed Teaching Assis­tant of Radiology at the Faculty of Medicine in Ljubljana on June 6, 1956. She was the first woman to occupy this position in the history of Slovene radiology. In 1965 she defended her thesis "Diagnosis of gastric carcinoma" and was advanced to the rank of Assistant Professor. In 1973 she maintained her doc­tor' s thesis entitled " Cine-and radiographic studies of the gastroesophageal region in the diagnosis of hiatus hernia in adults". The sta­tus of Associate Professor of Radiology was conferred on her one year later. Her teaching activities involved lectures, tutorials and sem­inars for medical and dental students. She was also a member of the board of examiners conducting final speciality examinations. Since 1955 she held a teaching post at the College for Radiographers Assistants in Ljubljana. 
She took an active part in numerous meet­ings of the Slovene Section of Radiology and Nuclear Medicine, as well as in many post­graduate courses of surgery, postgraduate seminars for dental surgeons, gastroenterolo­gy symposiums, the Tavcar Days postgraduate courses, Slovene-Croatian intersectional meet­ings and congresses of Yugoslav radiologists. 
In recognition of her contributions made to the field of radiology, Professor Vurnik­Žumer was elected President of the Slovene Section of Radiology and Nuclear Medicine for the periods 1956-1957 and 1962-1964. 
Her hospital appointments included a post of the supervising physician at the radiologi­cal out-patient unit of the Institute of Radio­

Prof Mira Vurnik-
Žume1; M.O., Plz.D. (19160-1998) 
logy in Ljubljana and that of the chief of the Institute's service of gastroenterologic radiol­ogy (both since 1966). In addition, she pro­vided radiological services for the Izola and Trbovlje general hospitals. 
Her chief areas of interest included radio­logical diagnosis of skull pathologies, muscu­loskeletal conditions -particularly of bone tumours, and intraabdominal pathological processes. During the second part of her career, Professor Vurnik-Žumer devoted most of her tirne and energy to the radiological diagnosis of gastroenterological diseases, paving the way for this new subspecialty. 
She introduced two important diagnostic methods -conventional tomography of the skull and hypotonic duodenography -in the routine radiological practice in Slovenia. 
Professor Vurnik-Žumer published a num­ber of papers about the above mentioned top­ics, most of them dealing with radiological diagnosis of the digestive system. 
Her lectures on the "Radiology of the Digestive System" published in 1976, were an indispensable manual for medica! undergrad­uates for many years. This text, together with contributions by other faculty teachers, served as the basis for the first textbook of radiology in the Slovene language. 
She retired in 1976. 
Professor Vurnik-Žumer will always be remembered as an outstanding teacher by many generations of medica! and dental stu­dents, radiological engineers and postgradu­ate trainees. She pioneered modem radiolog­ical diagnosis of gastroeneterologic disorders, and was one of the founders of the Ljubljana Institute of Radiology as we know it today. She has set a fine example to us all, and the outstanding contribution she made to the Slovene radiology will never be forgotten. 
Vladimir Jevtic 

Slovenian abstract 
Radio/ Oncol 2000; 34(2): 85-91. 

Defekografija: porocilo o 35 primerih 
Jamar B, Šurlan K 
Izhodišca. Namen raziskave je bil oceniti indikacije pri bolnikih, poslanih na preiskavo na Inšti­tut za radiologijo Klinicnega centra v Ljubljani od oktobra 1996 do decembra 1999. Bolniki in metode. Na Inštitut je bilo v navedenem casu napotenih na defekografijo 35 bolnikov (31 žensk in 4 moški, s povprecno starostjo 56,5 oz. 34,5 let ) s težavami pri defekaciji, ki so tra­jale od 1 meseca do 17 let. Z raznimi napotnimi diagnozami je iz proktoloških ambulant prišlo 26 bolnikov, 9 pa iz gastroenteroloških ambulant. Defekografija je funkcijska rentgenska prei­skava: bolniku napolnimo rektum z gosto barijevo pasto, ga posedemo na posebno oblikovano komodo in v stranski projekciji delamo ciljane posnetke rektoanalnega predela v raznih fazah de­fekacije. Rezultati. Rektokelo smo našli v 21 primerih, 9 v povezavi z rektorektalno intususcepcijo, 3 z rektoanalno intususcepcijo in 2 s herniacijo v ishiorektalno foso. Našli smo še prolaps (2 prime­ra), rektorektalno intususcepcijo (4), rektoanalno intususcepcijo (1) in 3 fistule. Funkcionalne motnje smo dokazali v 3 primerih in le en izvid preiskave je bil ocenjen kot normalen. Pri 11 žen­skah so se motnje defekacije zacele po ginekološki operaciji, pri 6 po porodu. Osem žensk si je za zacetek ali olajšanje defekacije moralo pomagati z roko. Zakljucki. Defekografija je preprosta rentgenska preiskava, s katero je v vecini primerov mogo­ce pokazati patološkoanatomski ali funkcijski vzrok težav z defekacijo. 
Slovenia11 abstrnct 
Radio! Oncol 2000; 34(2): 93-9. 
Trasjugularni intrahepatalni protosistemski šant (TIPS) 
Šurlan M, Jereb J 
Izhodišca. Avtorji prikazujejo indikacije in kontraindikacije za trasjugularni intrahepatalni por­
tosistemski šant, ki jih delimo na absolutne in relativne. Absolutne indikacije so sveža in ponov­
na krvavitev iz varic požiralnika in trdovratni ascites. Relativne indikacije so splenomegalija s hi­
persplenizmom, Budd-Chiariev sindrom, preprecevanje zapletov pred presaditvijo jeter in hepa­
torenalni sindrom. Absolutni kontraindikaciji sta huda okvara jeter in odpoved desnega srca, re­
lativne pa so policisticna degeneracija jeter, novotvorbe, zapora portalne vene in hujša lokalna 
ali sistemska okužba. Pred posegom dolocimo stopnjo okvare jeter, desnega srca in ledvic, nare­
dimo biokemicne in krvne preiskave s testi koagulacije ter dolocimo koncentracijo amoniaka v 
serumu in preverimo prehodnost portalne vene. Natancno je opisana izvedba posega, skrb za 
bolnika in njegovo spremljanje po posegu. Posega je uspešen v 93-100 %, smrtnost znotraj 30 dni 
zaradi transjugularnega intrahepatalnega portosistemskega šanta je 1-3 %. Krvavitev ustavimo v 
95-100%, ascites se izboljša v 87-92 % in ledvicno delovanje v 81 %, pri hipersplenizmu se trom­
bocitopenija izboljša pri 75 % in levkopenija pri 50 % bolnikov. Zapletov ob posegu je relativno 
malo, vec jih je kasneje zaradi zožitev in zapor šanta. Po dveh letih je šant prehoden pri 50 % bol­
nikov. V naši skupini 29 bolnikov, zdravljenih v obdobju štirih let, s povprecnim casom opazo­
vanja 2 leti je še živih 22 (75,9 %) bolnikov, umrlo jih je 7 (24,1 %). Šest umrlih bolnikov je imelo 
alkoholno cirozo jeter, pri dveh bolnikih pa vzrok smrti ni bil povezan s transjugularnim intra­
hepatalnim portosistemskim šantom oziroma cirozo jeter. . Zakljucki. TIPS je zlasti ucinkovita metoda za ustavljanje svežih varikoznih karvavitev. Upora­
bljamo jo pri krvavitvah, kjer nismo bili uspešni z medikamentoznim zdravljenjem ali endo­
skopsko sklerozacijo. To je tudi najbolj ucinkovita metoda za zniževanje portalnega pritiska pred 
presaditvijo jeter in znatno izboljša uspehe tahšnih presaditev. 



S/ovenian abstract 
Radio/ Onco/ 2000; 34(2): 101-6. 

Slikovna diagnostika, indikacije in meritve za premostitev anevrizme aorte z endoprotezo 
Šurlan Š, Salapura V, Kunst T 
Izhodišca. Avtorji prikazujejo slikovno diagnostiko anevrizme aort, indikacije, splošne kontrain­dikacije in meritve za izdelavo ali izbiro aortne endoproteze. Preiskava z ultrazvokom je najbolj prirocna in ekonomsko upravicena metoda za odkrivanje anevrizme aort, spremljanje asimpto­matskih anevrizem ter bolnikov po zdravljenju z operacijo ali endoprotezo. Naslednji preiskavi za prikaz anevrizme aorte sta racunalniška tomografija brez kontrastnega sredstva in z njim. Na­crt zdravljenja z endoprotezo naredimo s pomocjo digitalne substrakcijske angiografije, spiralne racunalniške tomografske angiografije in/ali magnetne resonance in angiografije. Z digitalno subtrakcijsko angiografijo dobro prikažemo svetlino anevrizme in aorte ter spremembe v njej, ve­like arterije v bližini anevrizme in stanje medenicnih arterij za izbiro pristopa. Spiralna racunal­niška tomografska angiografija in magnetnoresonancna angiografija v dvo-in trodimenzionalni reprodukciji v vec smereh nam omogocata natancno izmero velikosti anevrizme, premera aorte nad in pod anevrizmo ter presodita kakovost njene stene. Zakljucki. Indikacijski podrocji za endoprotezo sta anevrizma trebušne aorte in descedentnega dela prsne aorte. Zdravljenje z endoprotezo kot manj invazivna metoda je indicirano pri bolni­kih, pri katerih ima kirurško zdravljenje veliko zapletov in visoko smrtnost. Endoproteza je zgra­jena iz kovinske opornice in proteze. Opornica pritrdi endoprotezo na neprizadeti del aorte nad in pod anevrizmo, razpre protezo in ji daje oporo. Proteza je sinteticna tkanina dakron, ki ima za ta namen primerne lastnosti, kot so majhna podajnost, poroznost, prepustnost in razteznost. Endoprotezo uvajamo v aorto skozi kateterski dovodni sistem. Vhodno mesto je kirurško odpr­ta skupna stegnenicna ali medenicna arterija. 
Slovenian abstract 
Radio/ Oncol 2000; 34(2): 107-13. 


Premostitev anevrizme aorte z endoprotezo 
Šurlan M, Salapura V 
Aortne endoproteze delimo po obliki, mestu aplikacije in po materialu, iz katerega so zgrajene. Po obliki so tubularne ali razcepišcne. Prve uporabljamo za premošcanje anevrizem prsne aorte in redkeje trebušne aorte. Anevrizme trebušne aorte vecinoma premošcamo z razcepišcno endo­protezno. Aortne endoproteze so zgrajene iz opornega kovinskega dela in proteze. Oporni del je narejen iz nerjavecega jekla ali nitinola. Proteza je iz tkanine dakrona ali politetrafluoretilena. Oporni del pritrdi protezo na neprizadeti del aorte nad in pod anevrizmo namesto šivov. Prote­zo razpre in ji daje oporo. Natancno je opisan postopek uvajanja endoproteze in premošcanja anevrizme prsne in trebušne aorte. Prikazani so možni zapleti in natancno je opisan mehanizem notranjega pušcanja in njegovo ugotavljanje. V naši ustanovi smo z aortno endoprotezo uspešno premostili anevrizmo aorte trem bolnikom. Pri dveh v podrocju descedentnega dela prsne aorte in tretjemu v podrocju trebušne aorte, nižje od ledvic. Prvemu bolniku smo premostili psevdoa­nevrizmo, ki je povzrocala hripavost, drugemu zaradi drugega poznega zapleta z deformacijo en­doproteze z notranjim pušcanjem po dvakratnem zdravljenju z endoprotezo v tujini. Tretji bol­nik se je za endovaskularno zdravljenje z endoprotezo kot manj invazivno opcijo odlocil zaradi prestalih operacij na odprtem srcu. V zakljucku smo na osnovi naših izkušenj in obljavljenih re­zultatov poskušali oceniti vrednost metode. 
S/ove11im1 abslrnct 
Radio/ 011co/ 2000; 34(2): 115-22. 

Ultrazvocno vodena aspiracijska biopsija prikritih podrocnih zasev­
kov karcinoma glave in vratu 
Višnar-Perovic A1, Anicin A2 , Zupancic Ž1 , Cernelc B1, Šmid L2, Vidmar DB1, Gorenc M1 
Izhodišca. Študije v katerih obravnavajo kombinirano rabo ultrazvoka (UZ) in ultrazvocno vode­ne aspiracijske biopsije (UZVAB) pri ugotavljanju prikritih podrocnih zasevkov plošcatocelicne­ga karcinoma glave in vratu so obetavne, vendar maloštevilne. V novejšem casu, pri odlocanju za UZVAB, avtorji povdarjajo pomen parametrov velikosti bezgavk. Želeli smo oceniti zaneslji­vost UZ-UZVAB in parametrov velikosti bezgavk pri ugotavljanju prikritih podrocnih zasevkov plošcatocelicnega karcinoma glave in vratu. Bolniki in metode. Pri 77 bolnikih s plošcatocelicnimi karcinomi glave in vratu smo z UZ pregle­dali 121 strani vratu brez tipnih zasevkov. Glede na rezultate smo na 64 straneh vratu opravili še UZVAB. Pooperativno smo rezultate UZ-UZVAB primerjali s histološkim pregledom pri disekci­ji odstranjenih bezgavk. Rezultati. V raziskavi smo dosegli 77 % obcutljivost in 100 % specificnost za UZ in UZVAB sku­paj, medtem ko je bila natancnost 95 %. Negativna napovedna veljavnost je bila 94 %, pozitivna pa 100%. Najboljši parameter pri napovedovanju prisotnosti zasevkov v bezgavkah je bilo ra­zmerje precni/ vzdolžni premer. Zakljucki. Menimo, da je metoda UZVAB primerna za diagnostiko prikritih podrocnih zasevkov na vratu in jo kaže uvrstiti med rutinske preiskave za oceno razsežnosti karcinomov glave in vra­tu. 
Slovenian abstract 
Radio/ Oncol 2000; 34(2): 123-36. 
Racunalniško tomografska angiografija pri intrakranialnih žilnih boleznih 
Miloševic Z 
Izhodišca. Uvedba spiralnega nacina racunalniško tomografskega slikanja je omogocila natan­cnejši prikaz žilja tudi z racunalniško tomografsko angiografijo (CTA). Ker je metoda minimalno invazivna, so jo hitro sprejeli radiologi in kliniki. V zacetku devedesetih let se je tudi na podroc­ju nevroradioloških preiskav intrakranialnih žilnih bolezni CTA pridružila konvencionalni intra­arterijski angiografiji in magnetnoresonancni angiografiji (MRA). CTA uporabljamo v okviru od­krivanja in evaluacije intrakranialnih anevrizem, žilnih malformacij, stenozantnih in okluzivnih bolezni intrakranialnih arterij in patoloških procesov na venskih sinusih. Pri odkrivanju intrakra­nialnih anevrizem ima CTA v primerjavi z konvencionalno intraarterijsko angiografijo -kot zla­tim standardom -visoko obcutljivost, specificnost in diagnosticno zanesljivost. Na podrocju žil­nih malformacij je CTA uporabna pri odkrivanju in pri pred-in pooperativni evaluaciji arterio­venskih malformacij. S CTA lahko dobro prikažemo venske angiome in se tako izognemo bolj in­vazivni konvencionalni angiografiji. Stenozantne in okluzivne spremebe intrakranialnih arterij lahko odkrijemo in natancneje opredelimo pri bolnikih z vazospazmom intrakranialnih arterij, pri bolnikih, ki imajo akutno možgansko kap, in pri bolnikih s kronicnimi stenozantnimi in oklu­zivnimi spremembami intrakranialnih arterij. Zakljucki. CTA je zanesljiva metoda v diagnostiki okluzivnih in stenozantnih sprememb venskih sinusov. CT angiografiji daje dodatno vrednost možnost ustvarjanja tridimenzionalnih rekon­strukcij, ki omogocajo lažjo oceno anatomskih odnosov pri intrakranialnih žilnih boleznih. 
Slabša resolucija glede na konvencionalno angiografijo je poglavitna slabost CTA, s posodablja­njem spiralne racunalniške tomografije in delovnih postaj pa se povecuje, tako da ima CTA veli­ke možnosti razvoja in vse širše uporabe na podrocju intrakranialnih žilnih bolezni. 
Slovenian abstract 
Radio/ Oncol 2000; 34(2): 137-43. 

Racunalniškotomografska angiografija 
Kunst T, Berden P 
Izhodišca. Uporabo špiralnega CT skenerja v kombinaciji z žilnim kontrastnim medijem imenu­jemo racunalniškotomografska angiografija (CT angiografija). Ker je metoda minimalno invaziv­na, je bila hitro sprejeta v slikovno diagnostiko, podobno kot Dopplerjev ultrazvok, angiografija z magnetno resonanco, transezofagealni ultrazvok itd. Na podrocju kardiovaskularne radiologi­je CT angiografijo uporabljamo predvsem za diagnosticiranje patoloških sprememb ascendentne in descendentne aorte, kot so aneurizma, disekcija, traumatska ruptura ali kongenitalne anoma­lije. Zelo koristno jo uporabljamo tudi pred-in pooperativno kot preiskavo pri vzstavitvi žilne en­doproteze v aorto. Tako v zadnjih letih priskava mocno vpliva na predoperativne odlocitve, po posegu pa jasno kaže postoperativne anatomske spremembe in tudi zaplete. Zakljucki. CT angiografija je v tem kontekstu primerljiva z intraarterielno angiografijo in ima ce­lo nekatere prednosti. Edina pomanjkljivost je nekoliko slabša prostorska locljivost in daljši cas procesiranja, vendar lahko s posebnimi skenerji z vec žarkovnimi snopi (multi-slice skenerji) in zmogljivejšimi delovnimi postajami omenjeno pomanjkljivost mocno zmanjšamo. 
Radio/ Oncol 2000; 34(2): 145-50. 

Magnetnoresonancna artrografija ramenskega sklepa 
Jevtic V, Praprotnik A 
Izhodišca. Namen študije je bil ugotoviti vrednost nativnega slikanja z magnetno resonanco (MRI) in direktne magnetnoresonancne artrografije (MRA) s paramagnetnim kontrastnim sred­stvom (Gd-DTPA) pri diagnosticni opredelitvi posttravmatskih sprememb ramenskega sklepa. Bolniki in metode. Direktna magnetnoresonancna artrografija je bila narejena na 27 bolnikih s težjo poškodbo ramenskega sklepa, pri katerih MRI ni omogocila zanesljive diagnoze. Po intra­artikularni aplikaciji Gd-DTPA v fiziološki raztopini (koncentracija 0.2 mmol/1) je bilo narejeno slikanje s spin echo in gradient eho tehniko. Primerjali smo rezultate obeh preiskav. Rezultati. MRA je pokazala strgano rotatorno manšeto pri 5 bolnikih, lezije labruma v 7 prime­rih, 4 osteohondralne poškodbe in prosto telo v sklepu, posttravmatske spremembe, ki jih MRI ni odkrila. Vsi rezultati MRA so bili potrjeni artroskopsko ali z operativnim posegom. Zakljucki. V naši študiji se je MRA v primerjavi z MRI pokazala kot obcutljivejša tehnika za pri­kaz klinicno pomembnih posttravmatskih intraartikularnih sprememb ramenskega sklepa. 
5/ovenian abstract 
Radio/ Oncol 2000; 34(2): 151-8. 

Magnetna rezonanca tumorjev in netumorskih mas v srcu 
Berden P 
Tumorji srca so redki in jih je potrebno lociti od netumorskih mas v srcu, saj je zdravljenje razli­cno. V ta namen se pri slikanju z magnetno rezonanco (MR) uporabljata spin-echo (SE) in gradi­ent-echo (GE) tehnika. Prva omogoca prikaz anatomije srca in ugotavljanje sestave tkiva, druga nudi informacije o dinamiki -pretoku krvi in srcnih kontrakcijah. Miksom srca locimo od trom­ba s pomocjo intravenske aplikacije paramagnetnega kontrastnega sredstva. Z GE tehniko oce­njujemo njegovo premicnost. Lipom in subakutna krvavitev imata enako, visoko intenziteto si­gnala na T1-uravnoteženi sliki, zato za njuno razpoznavo uporabimo tehniko mašcobne supresi­je. MR uporabljamo za oceno reakcije malignega tumorja na kemoterapijo. GE MR je koristna pri locevanju tromba in pocasnega pretoka, intravenska aplikacija gadolinija pa za locitev tromba od tumorja. Ehokardiografija je prva metoda izbire pri bolnikih s sumom na tumor v srcu. MR upo­rabimo za potrditev ehokariografskega izvida, za natancnejšo opredelitev lokalizacije in razširje­nosti tumorja, za ugotavljanje sestave tumorskega tkiva, za spremljanje bolnikov med zdravlje­njem in za zgodnje odkrivanje morebitne ponovne tumorske rasti. 
Radio/ Oncol 2000; 34(2): 159-64. 

Magnetna resonanca pri obolenjih torakalne aorte 
Berden P 
Obicajna, z EKG vodena spin-echo (SE) magnetna rezonanca (MR) in magnetno rezonancna an­giografija (MRA) sta odlicni slikovni metodi v diagnostiki obolenj torakalne aorte. SE nudi dobro prostorsko locljivost, ki omogoca prikaz anatomije aorte in odnos do okolnih tkiv. MRA pokaže pretok, vendar je locljivost slabša od obicajne MR. 3D (tri dimenzionalna) MRA s kontrastnim sredstvom je zelo zanesljiva pri prikazu aortne anatomije, predvsem pa pri ugotavljanju nepra­vilnosti njenih vej. Obcutljivost in specificnost ugotavljanja aortne disekcije se gibljeta od 95 % do 100 % oziroma 94 % do 100 % in sta najvišji v primerjavi z drugimi slikovnimi tehnikami (ul­trazvok, CT angiografija-CTA). MR jasno pokaže celoten premer aortne anevrizme, velikost tromba v njej in njeno širitev v trebušno votlino. Obicajno je potrebna kombinacija SE in kino MRA. Enake sekvence s kontrastnim sredstvom nudijo tudi vse potrebne podatke pri prirojenih nepravilnostih aorte. MR je zelo zanesljiva pri prirojenih nepravilnostih aorte, aortnih anevri­zmah in disekcijah pri hemodinamsko stabilnih bolnikih. Uporabiti jo velja pri vseh kronicnih aortnih disekcijah in pooperativnem sledenju bolnika. Nestabilni bolniki, ki potrebujejo intenzi­ven monitoring za MR niso primerni. 
Radio/ Onco/ 2000; 34(2): 201-10. 

Slovenian abstract 
Radio/ Oncol 2000; 34(2): 165-73. 

Hidrokolonsonografija v odkrivanju bolezni širokega crevesa 
VidmarD 
Izhodišca. Tekocina v lumnu izboljša preglednost prebavne cevi do te mere, da se patološke spre­membe odkrivajo prej in bolj natancno. Diagnosticno metodo za široko crevo, ki se po predho­dnem izcišcenju retrogradno napolni z vodo, imenujemo hidrokolonsonografija (HS). Bolniki in metode. Uspešnost metode smo testirali v skupini 56 bolnikov s primerjavo izvidov HS in kolonoskopije (KS) ali irigografije ali operativnim izvidom. Rezultati. Celokupna tocnost je bila 86 %, senzitivnost 81 %, specificnost 92 %, pozitivna napove­dna vrednost (PPV) 91 % in negativna napovedna vrednost (NPV) 82 %. Zakljucki. HS je po uspešnosti primerljiva z irigografijo razen za prikaz rektuma. Omejitev pre­iskave je v tem, da je zahtevna za preiskovalca, kar vpliva na njeno sprejemljivost v diagnostiki širokega crevesa. 
Radio/ Oncol 2000; 34(2): 175-84. 

Zožitev moške secnice: Pravilna izvedba in vrednotenje radiografske in ultrazvocne uretrografije, da se izognemo napakam 
Babnik Peskar D, Perovic Višnar A 
Izhodišce. Natancna ocena mesta, dolžine, globine in sestave zožitve secnice so pogoj za pravilno odlo­citev o zravljenju, da preprecimo recidive. Odlocitev o dilataciji, interni uretrotomiji ali odprtem ki­rurškem posegu zavisi od endoskopske, radiouretrografske in v zadnjem casu tudi ultrazvocne ocene po Me Anninch-u. Dodatna informacija ultrazvoka je neposredna ocena globine in sestave spongiofibroze. V predhodnih objavah ugotovljena radiografska podcenitev dolžine, v primerjavi z ultrazvokom in endo­skopijo, je možen razlog nepravilnega izbora zdravljenja in recidivom. V prispevku smo ocenili novo ul­trazvocno diagnosticno možnost pri zožitvah secnice. Opisali smo obe slikovni metodi v diagnostiki zožitev secnice važnih za izbor zdravljenja, skupaj z obicajnimi napakami v izvedbi in vrednotenju, ki so po našem prepricanju vzrok napacnim izmeram in predhodno objavljeni radiografski pocenitvi dolžine. Bolniki in metode. V obdobju 20 mesecev smo, pri 51/130 moških s sumom na zožitev secnice, ocenili ultrazvocno uretrografijo v primerjavi z radiouretrografijo in endoskopijo. Rezultati. V primerjavi z RUG je bil ultrazvok 92-odstotno pravilen v odkrivanju zožitev. Ultrazvocno izmer­jene dolžine striktur so bile v povprecju za 22% krajše od radiografskih izmer, kar lahko razložimo z radio­grafsko povecavo, ki smo jo dokazali z merilno žico postavljeno na penis. Ob upoštevanju radiografske po­vecave, drugih bistvenih razlik v vecini meritev nismo našli. V naši primerjavi RUG, SUG in endoskopije ni­smo našli predhodno objavljene radiografske podcenitve dolžine. 
Zakljucek. Kombinacija obeh slikovnih metod nam zagotavlja optimalne podatke o anatomiji zožitve secni­ce. Iz naših rezultatov sklepamo, da je objavljena radiografska podcenitev dolžine samo napaka v oceni. Za­to poudarjamo, kako pomembna je za primerno terapijo pravilna izvedba in ocena slikovnih preiskav , da se izognemo napakam v izvedbi, vrednotenju, nepravilni primerjavi in napacnim zakljuckom. Za radioure­
trografijo priporocamo dinamicno uretrografijo po Me Callumu. 
Radio/ Oncol 2000; 34(2): 201-10. 

Slovenian abstract 
Radio/ Oncol 2000; 34(2): 185-90. 
Ultrazvocno ocenjevanje hrbtenicnega kanala pri otrocih 
Zupancic Ž 
Izhodišca. Z ultrazvokom lahko pri pregledu hrbtenicnega kanala dobro prikažemo anatomsko strukturo kanala kot tudi strukturo okoljnih tkiv. V prispevku opišem tehniko pregledovanja in podam pregled anatomije in najpogostejših prirojenih anomalij, primerjavo diagnosticnosti ul­trazvoka z magnetnoresonancnim slikanjem ter vlogo in mesto ultrazvoka pri ocenjevanju hrb­tenicnega kanala. Zakljucki. Ultrazvok priporocamo kot primarno slikovno diagnosticno metodo za ocenjevanje okultnega hrbtenicnega disrafizma pri dojenckih in majhnih otrocih. 
Radio/ Onco/ 2000; 34(2): 191-8. 
Adenokarcinom v ektopicni ledvici -možnosti diagnoze in zdravljenja tumorja ledvice: prikaz primera 
Brencic E, Stanovnik M, Glušic M 
Izhodišca. Široka uporaba ultrazvoka in racunalniške tomografije je prispevala k zgodnjemu od­krivanju tumorjev ledvic, saj vemo, da so velikokrat odkriti slucajno. Magnetna resonanca nam omogoca ne samo prikaz tumorja, odlocitev glede narave tumorske mase, temvec nam poda od­govor na vprašanje infiltracije v okolico ter prisotnosti sprememb v žilah. Prikaz primera. Prikazan je primer bolnika z adenokarcinom v ektopicni ledvici. Ultrazvocna, ra­cunalniško tomografska preiskava in magnetna resonanca so pokazale veliko, nehomogeno tu­morsko maso v mali medenici. Kljub sumu o ektopiji ene izmed ledvic se je postavila možnost prisotnosti patološkega procesa druge etiologije, zlasti, ker je bila prisotna tudi druga tumorska masa med crevesnimi vijugami. Po neradikalni operaciji adenokarcinoma v ektopicni ledvici je po dveh mesecih prišlo do povecanja ostanka tumorja v mali medenici in tumorja med vijugami crevesja, ki ni bil odstranjen pri operaciji. Bolnik je bil zdravljen s kemoimunoterapijo in lokal­nim obsevanjem. Zakljucek. Po podatkih v literaturi, ki nam je dostopna, je lokalizacije tumorja v ektopicni ledvi­ci zelo redka. Postavlja se vprašanje, ali so bile izcrpane vse diagnosticne možnosti in zdravlje­nje tumorja v ektopicni ledvici, kar je bil tudi namen prikaza tega zanimivega primera. 
Notices 
Notices submitted for publication should contain a mailing address, phone and/or Jax number and/ or e-mail oj a Contact person or department. 
Computed tomography 
July 20-23, 2000 
The "8th Annual Advanced Topics in CT Scanning: The 2000 Edition" will take place in Lake Tahoe, NV, USA. 
Contact Office of Continuing Medica! Education, John Hopkins University School of Medicine, Turner 20, 720 Rutland Avenue, Baltimore, Maryland 21205­2195, USA; or call +1 410 955 2959; or fax +1 410 955 0807; or e-mail cmenet@jhmi.edu; or see Internet http://www.med.jhu.edu/cme 
Radiotherapy 
August 18-22, 2000 
The ESTRO teaching course "Evidence-Based Ra­diation Oncology" will take place in Singapore. 
Contact ESTRO office, Av. E. Mounier, 83/4, B-1200 Brussels, Belgium; or call +32 7759340; or fax +32 2 7795494; or e-mail info@estro.be; or see Internet http://www.estro.be 
Radiotherapy 
August 26 -September 2, 2000 
The 2nd International Summer School on Experi­mental and Clinical Oncology for Medica! Students will take place in Vienna, Austria. 
Contact Prof. Dr. Huber and R. Potter; call +43 1 40400 4429; or fax +43 1 40400 4451. 
Radiotherapy 
August 27-29, 2000 The 3rd Workshop on brachytherapy in Head and Neck Cancer will take place in Kiel, Germany. E-mail kovacs@onco.uni-kiel.de 

Radiophysics 
August 27-31, 2000 
The ESTRO teaching course on "Physics for Clinical Radiotherapy" will take place in Leuven, Belgium. Contact ESTRO office, Av. E. Mounier, 83/4, B-1200 Brussels, Belgium; or call +32 7759340; or fax +32 2 
7795494; or e-mail http://www.estro.be  info@estro.be;  or  see  Internet  
September 4-8, 2000  Radiology  

The 21 st International Congress of Radiology and 20th 
Interamerican Congress of Radiology will take place in Buenos Aires, Argentina. 
Contact Executive Secretariat; Tucuman 2075, 1050 Buenos Aires, Republica Argentina; or fax +54 11 4374 6487; or e-mail info@icr2000.0rg.ar 
Pathology 
September 6-10, 2000 
The ESO postgraduate course in "Theoretical and Diagnostic Histopathology -PCTDH -(Part III), Systemic Pathology" will be offered in Alexandrou­polis, Greece. 
Contact ESO office for Balkans and Middle East, N. Pavlidis, E. Andreopoulou Medica! School, Depart­ment of Medica! Oncology, University Hospital of Ioannina, 45110 Ioannina, Greece; or call +30 651 99394 or +30 953 91083; or fax +30 651 97505 
Lung cancer 
September 11-15, 2000 
The "9th World Conference on Lung Cancer" will be offered in Tokyo, Japan. 
Contact Dr. Yoshihiro Hayata, The 9th World Conference on Lung Cancer, Tokyo Medica! College Cancer Center, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan; or fax +81 3 3342 0893 

Oncology Oncology 
September 14-16, 2000 
"2nd Sparing Treatment in Oncology" will take place in Bled, Slovenia. Contact Ms. Natalija Bah, Cankarjev dom -Cultural and Symposium Centre, Prešernova 10, SI-1000 Ljubljana; or call +386 61 1767 132; or fax +386 61 217 431; or e-mail: natalija.bah@cd-cc.si 
The International Symposium on Organ 
Myelodysplastic and marrow failure syndrornes 

September 15-17, 2000 
The ESO training course will take place in Olympia, Greece. 
Contact ESO office for Balkans and Middle East, N. Pavlidis, E. Andreopoulou Medica! School, Depart­ment of Medica! Oncology, University Hospital of Ioannina, 45110 Ioannina, Greece; or call +30 651 99394 or +30 953 91083; or fax +30 651 97505 
Radiation therapy 

September 19-23, 2000 
The 19th Annual ESTRO Meeting will take place in Istanbul, Turkey. 
Contact ESTRO office, Av. E. Mounier, 83/4, B-1200 Brussels, Belgium; or call +32 7759340; or fax +32 2 7795494; or e-mail info@estro.be; web: http:/ /www.estro.be 
Breast and colorectal cancer 


September 21-23, 2000 
The ESO training course will take place in Thessaloniki, Greece. 
Contact ESO office for Balkans and Middle East, N. Pavlidis, E. Andreopoulou Medica! School, Depart­ment of Medica! Oncology, University Hospital of Ioannina, 45110 Ioannina, Greece; or call +30 651 99394 or +30 953 91083; or fax +30 651 97505 
Breast cancer 

September 26-30, 2000 
The 2nd European Breast Cancer Conference will be held in Brussels, Belgium. 
Contact PECS Conference Unit, Av. E. Mounier, 83, B-1200 Brussels, Belgium; or call +32 7750202; or fax +32 2 7750200; or e-mail EBCC-2@fecs.be; or see Internet http:/ /www.fecs.be 
September 28-30, 2000 
The ESO training course on "Monoclonal Anti­bodies, Cytokines and Growth Factors in Oncology" will take place in Patras, Greece. 

Contact ESO office for Balkans and Middle East, N. Pavlidis, E. Andreopoulou Medica! School, Depart­ment of Medica! Oncology, University Hospital of Ioannina, 45110 Ioannina, Greece; or call +30 651 99394 or +30 953 91083; or fax +30 651 97505 
Lymphoma 

October, 2000 
The ESO postgraduate course will take place in Izmir, Turkey. 
Contact ESO office for Balkans and Middle East, N. Pavlidis, E. Andreopoulou Medica! School, Depart­ment of Medica! Oncology, University Hospital of Ioannina, 45110 Ioannina, Greece; or call +30 651 99394 or +30 953 91083; or fax +30 651 97505 
Radiation therapy 
October 2-6, 2000 
9th Capture Therapy for Cancer will take place in Osaka, Japan. E-rnail igcong@po.iijnet.or.jp 
The International Symposium on Neutron 
Oncology 
October 4-6, 2000 
The 4th National Congress of Federation of Spanish Societies of Oncology (F.E.S.E.O.) will be offered in La Caruna, Spain. 
Contact Technical Secretariat, Orzan Congres, S.L.; call +34 981 169 855; or fax +34 981 247 908 
Oncology 
October 6-7, 2000 
The ESO course on "Fatigue/Exhausting in Cancer Patients" will take place in Milan, Italy. 
Contact ESO Office, Viale Beatrice d'Este 37, 20122 Milan, Italy; or call +39 0258317850; or fax +39 0258321266: or e-mail esomi@tin.it 

Notices 213 
Surgical oncology 
October 6-7, 2000 
The ESO training course will take place in Herakleion, Greece. 
Contact ESO office for Balkans and Middle East, N. Pavlidis, E. Andreopoulou Medica! School, Depart­rnent of Medica! Oncology, University Hospital of Ioannina, 45110 Ioannina, Greece; or call +30 651 99394 or +30 953 91083; or fax +30 651 97505 
Radiation oncology 
October 8-12, 2000 
The ESTRO teaching course on "Evidence-Based Radiation Oncology: Principles and Methods" will be offered in Lleida, Spain. 
Contact ESTRO office, Av. E. Mounier, 83/4, B-1200 Brussels, Belgiurn; or call +32 7759340; or fax +32 2 7795494; or e-rnail info@estro.be; or see Internet http://www.estro.be 
Radiobiology 
October8-12, 2000 
The ESTRO teaching course on "Basic Clinical Radiobiology" will be offered in Bratislava, Slovakia. 
Contact ESTRO office, Av. E. Mounier, 83/4, B-1200 Brussels, Belgiurn; or call +32 7759340; or fax +32 2 7795494; or e-rnail info@estro.be; or see Internet http://www.estro.be 
Radiation oncology 
October 8-12, 2000 
The Joint Meeting DEGRO-OGRO-DGMP will be offered in Munchen, Gerrnany. See Internet http://www.degro.org 
Bioelectrornagnetisrn 
October8-12, 2000 
The "3rd International Conference on Bioelectro­rnagnetisrn" and "1 st Slovenian-Croatian Meeting on Biomedical Engineering" will be offered in Bled, Slovenia. 
Contact Prof. Damijan Miklavcic -president, Faculty of Electrical Engineering, University of Ljubljana, Tržaška 25, SI-1000 Ljubljana, Slovenia; or call +386 61 1768 264; or fax +386 61 1264 658; or e­mail 3rdICBEM@svarun.fe.uni-lj.si; or see Internet http://www.albatros-bled-sp.si 
Oncology 
October 12-14, 2000 
The ESO training course on "Oncology through the Ages: Historical, Philosophical and Ethical Aspects" will take place in Athens, Greece. 
Contact ESO office for Balkans and Middle East, N. Pavlidis, E. Andreopoulou Medica! School, Depart­rnent of Medica! Oncology, University Hospital of Ioannina, 45110 Ioannina, Greece; or call +30 651 99394 or +30 953 91083; or fax +30 651 97505 
Medica! oncology 
October 13-17, 2000 The ESMO Congress will take place in 
25th Hamburg, Gerrnany. Contact ESMO Congress Secretariat, Via Soldino 22, CH-6900 Lugano, Switzerland; or call +41 91 950 0181 or fax +41 91 950 0782; or e-rnail esrno@dial.eunet.ch; or see Internet http:/www.esrno.org 
Radiation therapy 
October 22-25, 2000 
ASTRO Annual meeting will be held in Boston, Massachusetts, USA. 
Contact American Society for Therapeutic Radio­logy and Oncology Office, 1891 Preston White Drive, Reston, VA 20191, USA; web site: www.astro.org 
Soft tissue sarcomas and bone tumours 
October 26-28, 2000 
The ESO training course will take place in Ankara, Turkey. 
Contact ESO office for Balkans and Middle East, N. Pavlidis, E. Andreopoulou Medica! School, Depart­ment of Medica! Oncology, University Hospital of Ioannina, 45110 Ioannina, Greece; or call +30 651 99394 or +30 953 91083; or fax +30 651 97505 
Oncology 
October 27-29, 2000 
The ESO training course on "Angiogenesis: Indications in the Prognosis and Treatment of Cancer" will take place in Alexandroupolis, Greece. 
Contact ESO office for Balkans and Middle East, N. Pavlidis, E. Andreopoulou Medica! School, Depart­ment of Medica! Oncology, University Hospital of Ioannina, 45110 Ioannina, Greece; or call +30 651 99394 or +30 953 91083; or fax +30 651 97505 


Thoracic tumours 

November, 2000 
The ESO training course will take place in Nicosia, Cyprus. 
Contact ESO office for Balkans and Middle East, N. Pavlidis, E. Andreopoulou Medica! School, Depart­ment of Medica! Oncology, University Hospital of Ioannina, 45110 Ioannina, Greece; or call +30 651 99394 or +30 953 91083; or fax +30 651 97505 
Ovarian cancer 

November 2-3, 2000 
The ESO training course will take place in Athens, Greece. 
Contact ESO office for Balkans and Middle East, N. Pavlidis, E. Andreopoulou Medica! School, Depart­ment of Medica! Oncology, University Hospital of Ioannina, 45110 Ioannina, Greece; or call +30 651 99394 or +30 953 91083; or fax +30 651 97505 
Colorectal carcinoma 


November 3-5, 2000 
The ESO training course will take place in Ankara, Turkey. 
Contact ESO office for Balkans and Middle East, N. Pavlidis, E. Andreopoulou Medica! School, Depart­ment of Medica! Oncology, University Hospital of Ioannina, 45110 Ioannina, Greece; or call +30 651 99394 or +30 953 91083; or fax +30 651 97505 
Medica! physics 

November 5-9, 2000 
EPSM 2000, The Annual Conference of Engineering and the Physical Sciences in Medicine in Australasia will be offered in Newcastle, Australia. 
E-mail phtk@cc.newcastle.edu.au 
Radiophysics 

November 9-12, 2000 
The International Workshop on Monte Carlo Treatment Planning will be offered in Stanford, USA. E-mail cma@reyes.stanford.edu; or see Internet http://www-radonc.stanford.edu/ 
Oncology 
November 10-11, 2000 
The ESO course on "Anemia and Cancer Therapy" will take place in Milan, Italy. 
Contact ESO Office, Viale Beatrice d'Este 37, 20122 Milan, Italy; or call +39 0258317850; or fax +39 0258321266: or e-mail esomi@tin.it 
Radiation oncology 
November 11-14, 2000 
10111 will be offered in Madrid, Spain. E-mail congress@nucletron.nl 
The International Brachytherapy Conference 

Paediatric oncology 
November 12-18, 2000 
The training course under the auspices of the Inter­national Society of Paediatric Oncology will be held in Chandigahr, India. 
Contact P.A. Voute, call +31 20 5665655; or fax +31 20 6912231 
Paediatric oncology 
November 16-20, 2000 
The training course under the auspices of the International Society of Paediatric Oncology will be held in Sao Paulo, Brazil. 
Contact P.A. Voute, call +31 20 5665655; or fax +31 20 6912231 
Medica! physics 
November 20-22, 2000 
The Topical Meeting on Physics and Engineering will be offered in Lisbon, Portugal. See Internet http://www.newton.itn.pt/itn/ Meetings/MeRPE/default.html 
Radiotherapy 
November 23-24, 2000 
The Kiel Teaching Course on Prostate Cancer Brachytherapy (LDR and HDR) will take place in Kiel, Germany. 
E-mail kovacs@onco.uni-kiel.de 

Notices 215 
Radiation oncology 
November 23-24, 2000 
The 11 u, SFRO Meeting be offered in Paris, France. Contact SOCFI, 14 rue Mandar, 75002 Paris, France; or call +33 1 44 882 525; or fax +33 1 40 260 444. 
Neck surgery 
November 27-29, 2000 
The ESO master course will take place in Milan, Italy. 
Contact ESO Office, Viale Beatrice d'Este 37, 20122 Milan, Italy; or call +39 0258317850; or fax +39 0258321266: or e-mail esomi@tin.it 
Organising secretariat: P. Lonati; phone +39 0257 489 490; fax + 39 0257 589 491; e-mail head&neck@ieo.it 
Pediatric oncology 
November 30 -December 2, 2000 
The ESO conference will take place in Rome, Italy. 
Contact ESO Office, Viale Beatrice d'Este 37, 20122 Milan, Italy; or call +39 0258317850; or fax +39 0258321266: or e-mail esomi@tin.it 
Oncology 
December 4-8, 2000 
The "World Assembly on Tobacco Counters Health WATCH-2000" will take place in New Delhi, India. 
Contact Vimal Arora Conference Secretariat, WATCH 2000, 509-B, Sarita Vihar, New Delhi-110044, India; or call +91 11 694 4551; or fax +91 11 694 4472; or e-mail varora@ndf.vsnl.net.in ; or see Internet http://www.watch-2000.org 
Radiation morbidity 
December 10-12, 2000 
The ESTRO workshop on radiation morbidity will be held in Brussels, Belgium. 
Contact ESTRO office, Av. E. Mounier, 83/4, B-1200 Brussels, Belgium; or call +32 7759340; or fax +32 2 7795494; or e-mail info@estro.be; or see Internet http://www.estro.be 
As a service to our readers, notices of 111eeti11gs or cours­es will be inserted free o f charge. Please sen/ infonnation to t!ze Editorial office, Radiology and Oncology, Vrazov trg 4, 51-1000 Ljubljana, Slovenia. 


FONDACIJA ''DOCENT DR. J. CHOLEWA" JE NEPROFITNO, NEINSTITUCIONALNO IN NESTRANKARSKO ZDRUŽENJE POSAMEZNIKOV, USTANOV IN ORGANIZACIJ, KI ŽELIJO MATERIALNO SPODBUJATI IN POGLABLJATI RAZISKOVALNO DEJAVNOST V ONKOLOGIJI. 
MESESNELOVA 9 
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Activity of "Dr. J. Cholewa" Foundation for Cancer Research and Education -A Report f or the First Quarter of 2000 
The activity of the Foundation in the year 1999 was finaliy assessed in the first weeks of the year 2000. It was agreed that in general it is becoming increasingly difficult to entice individuals and other business subjects to contribute to the special type of charities, as is the activity of the "Dr. J. Cholewa" Foundation. Fortunately, there are some of the donors from Slovenia and abroad who tirelessly continue to try to support it, and the members of the Foundation and its Executive and Supervisory Committees feel obliged to express their grati­tude to ali who understand the importance of its goals and activities to reach them. 
The summary of the activities of the Foundation in the year 1999 makes a complex and interesting reading. The Foundation helped to finance the Annual Conference of the lnternational Breast Cancer Study Group in Bled, Slovenia; the International Conference on Cancer in Opatija, Croatia; and the Plecnik Memorial Meeting in Ljubljana, Slovenia. Furthermore, a public invitation for research grants in the field of oncology was pub­lished in "Dnevnik" and "Vecer" daily newspapers in Slovenia, in "Radiology and Oncology" international oncology journal, published in Ljubljana, Slovenia, and in "ISIS", the journal of the Medica! Chamber of Slovenia, Ljubljana, Slovenia. Surprisingly, the response to this invitation was rather lukewarm. It is planned the invitation will be publicly issued again this year with the aim to provide grants for MSc, PhD and post-doc­toral studies. A "14th Oncological Weekend" meeting with the themes concerning lung and thyroid cancers was also organised with the help of the Foundation, and the Proceedings of this meeting were published in a spe­cial publication. In addition, severa! grants for participation on various international congresses and symposia were provided for the applicants from Ljubljana and different regions of Slovenia. 
The Foundation continued to support the regular publication of "Radiology and Oncology" international scientific journal, and the regular publication of the "Chalienge ESO Newsletter" in 1999. Both medica! jour­nals are edited, published and printed in Ljubljana, Slovenia. In the past year the Foundation also contributed support for the publication of the Slovenian Dictionary of Medica! Terminology, and far the Proceedings of two meetings organised by the Nursing Association of Slovenia, and dedicated to the problems in oncology. 
The Foundation will in the year 2000 strive to concentrate its activities to further facilitate the access to oncology research and education to as many interested individuals and institutions in the various regions of Slovenia as possible. Severa! new approaches and ways to achieve the enhancement of the knowledge in can­cer prevention and early detection ali over the country wili have to be evaluated. In addition, special attention will be given to the requests coming from the regions of Slovenia outside Ljubljana to provide grants for the participation of Slovenian oncologists and others on various educational meetings in the country and abroad. 
On behalf of the Foundation a special award was presented to Mr. Miloš Kovacic, MSc, one of its founding members and a long-time supporter of its activity. Mr. Kovacic is the director of the "KRKA" pharmaceutical company, and as such is a well known and highly respected personality in Slovenia and one of its foremost busi­ness leaders. It is safe to say that his activity in the pharmaceutical industry in Slovenia and its branches else­where represents an essential part of its success. His support and help in the functioning of the Foundation are therefore extremely valuable and should be viewed in the context of his precious tirne and high leve! day-to­day responsibilities. 
On the more sombre note, the Foundation gravely feels the loss of Dr Srecko Rainer, Professor of gynae­cology at the Medica! Faculty of the University of Ljubljana. Professor Rainer was one of the founding members of the Foundation and was always ready to help in improving the quality of its activities. His sharp mind and wit will be greatly missed. 
Andrej Plesnicar, MD 
Tomaž Benulic, MD 
Borut Štabuc, MD, PhD 


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Radiology and Oncology 
Instructions f or authors 


Editorial policy of the journal Radiologi; and Oncology is to publish original scientific pa­pers, professional papers, review articles, case reports and varia (editorials, reviews, short communications, professional infarmation, book reviews, letters, etc.) pertinent to diag­nostic and interventional radiology, computer­ized tomography, magnetic resonance, ultra­sound, nuclear medicine, radiotherapy, clinical and experimental oncology, radiobiology, radiophysics and radiation protection. The Editorial Board requires that the paper has not been published or submitted far publication elsewhere: the authors are responsible far all statements in their papers. Accepted articles become the property of the journal and there­fare cannot be published elsewhere without written permission from the editorial board. Papers concerning the work on humans, must comply with the principles of the declaration of Helsinki (1964). The approval of the ethical committee must then be stated on the manu­script. Papers with questionable justification will be rejected. 
Manuscript written in English should be submitted to the Editorial Office in triplicate (the original and two copies), including the illustrations: Radiologi; and Oncology, Institute of Oncology, Vrazov trg 4, SI-1000 Ljubljana, Slovenia; (Phone: +386 61 132 00 68, Tel./Fax: +386 61 133 74 10, E-mail: gsersa@onko-i.si). Authors are also asked to submit their manu­scripts on a 3.5" 1.44 Mb farmatted diskette. The type of computer and word-processing package should be specified (Word far Windows is preferred). 
All articles are subjected to editorial review and review by independent referee selected by the editorial board. Manuscripts which do not comply with the technical requirements stated herein will be returned to the authors far cor­rection befare peer-review. Rejected manu­scripts are generally returned to authors, how­ever, the journal cannot be held responsible far their loss. The editorial board reserves the right to ask authors to make appropriate changes in the contents as well as grammatical and stylistic corrections when necessary. The expenses of additional editorial work and requests far reprints will be charged to the authors. 
General instructions• Radiology and Onco­logy will consider manuscripts prepared accor­ding to the Vancouver Agreement (N Engl ] Med 1991; 324: 424-8, BM] 1991; 302: 6772; JAMA 1997; 277: 927-34.). Type the manuscript double spaced on one side with a 4 cm margin at the top and left hand side of the sheet. Write the paper in grammatically and stylistically correct language. Avoid abbreviations unless previously explained. The technical data should confarm to the SI system. The manu­script, including the references may not exceed 15 typewritten pages, and the number of figures and tables is limited to 4. If appro­priate, organize the text so that it includes: Introduction, Material and methods, Results and Discussion. Exceptionally, the results and discussion can be combined in a single sec­tion. Start each section on a new page, and number each page consecutively with Arabic numerals. 
Title page should include a concise and infarmative title, fallowed by the full name(s) of the author(s); the institutional affiliation of each author; the name and address of the cor­responding author (including telephone, fax and e-mail), and an abbreviated title. This should be fallowed by the abstract page, sum­marising in less than 200 words the reasons for 
the study, experimental approach, the major findings (with specific data if possible), and the principal conclusions, and providing 3-6 key words for indexing purposes. Structured abstracts are preferred. If possible, the authors are requested to submit also slovenian version of the title and abstract. The text of the report should then proceed as follows: 
Introduction should state the purpose of the article and summarize the rationale for the study or observation, citing only the essential references and stating the aim of the study. 
Material and methods should provide enough information to enable experiments to be repeated. New methods should be described in detail. Reports on human and animal subjects should include a statement that ethical approval of the study was obtained. 
Results should be presented clearly and concisely without repeating the data in the tables and figures. Emphasis should be on clear and predse presentation of results and their significance in relation to the aim of the investigation. 
Discussion should explain the results rather than simply repeating them and interpret their significance and draw conclusions. It should review the results of the study in the light of previously published work. 
Illustrations and tables must be numbered and referred to in the text, with appropriate location indicated in the text margin. Illu­strations must be labelled on the back with the author's name, figure number and orien­tation, and should be accompanied by a descriptive legend on a separate page. Line drawings should be supplied in a form suit­able for high-quality reproduction. Photo­graphs should be glossy prints of high quality with as much contrast as the subject allows. They should be cropped as close as possible to the area of interest. In photographs mask the identities of the patients. Tables should be typed double spaced, with descriptive title and, if appropriate, units of numerical mea­surements included in column heading. 

References must be numbered in the order in which they appear in the text and their cor­responding numbers quoted in the text. Authors are responsible for the accuracy of their references. References to the Abstracts and Letters to the Editor must be identified as such. Citation of papers in preparation, or sub­mitted for publication, unpublished observa­tions, and personal communications should not be included in the reference list. If essen­tial, such material may be incorporated in the appropriate place in the text. References fol­low the style of Index Medicus. All authors should be listed when their number does not exceed six; when there are seven or more authors, the first six listed are followed by "et al.". The following are some examples of refer­ences from articles, books and book chapters: 
Dent RAG, Cole P. In vitro maturation of monocytes in squamous carcinoma of the lung. Br] Cancer 1981; 43: 486-95. 
Chapman S, Nakielny R. A guide to radiolog­ical procedures. London: Bailliere Tindall; 1986. 
Evans R, Alexander P. Mechanisms of extracellular killing of nucleated mammalian cells by macrophages. In: Nelson DS, editor. Immunobiology of macrophage. New York: Academic Press; 1976. p. 45-74. 
Page proofs will be faxed to the corre­sponding author whenever possible. It is their responsibility to check the proofs carefully and fax a list of essential corrections to the edi­torial office within 48 hours of receipt. If cor­rections are not received by the stated dead­line, proof-reading will be carried out by the editors. 
Reprints: Fifty reprints are free of charge, for more contact editorial board. 
Far reprint information in North America Contact: International Reprint Corporation 968 Admiral Callaghan Lane,# 268 P.O. Box 12004, Val/ejo; CA 94590, Tei: (707) 553 92 30, Fax: (707) 552 95 24. 



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