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195

Letters

A Report on Radiology at Muhimbili Dar es Salaam, Tanzania

Medical

spot film capabilities

Center,

with

In December 1990, we were sent by our chairman, Carl Ravin, to assess Muhimbili Medical Centre (MMC) in Dar es Salaam, Tanzania, including the technical and equipment needs of their department, to determine whether our department could develop an outreach relationship with this facility. As might be expected of any developing country, the medical needs in Tanzania are almost overwhelming. The health care system is organized rationally into a hierarchy of progressively larger institutions, the largest of which are the four referral hospitals. With approximately 1 300 beds, MMC is the largest medical center in Tanzania,

serving

as both

the

referral

hospital

for the

es Salaam and the tertiary

hospital

large

it has an active

inpatient

outpatient

population,

region

for the country. trauma

around

In addition center

Dar

to a

and an

facility.

The entire country has only seven radiologists (five at MMC and two at another referral hospital). As a result, only two of the fourreferral hospitals and none of the 25 regional hospitals have radiologists. Of the five radiologists at MMC, three are Tanzanians. They are well trained neuroradiology

(two in Australia, fellowship

and practice

elsewhere,

The radiology technologists

and

and one has just completed

in Switzerland).

but they choose

department medical

students,

but

clinical radiology. According are performed each year; 40% are chest radiographs. Interestingly,

interpreted

could

leave

a

Tanzania

to stay in their own country. in the training of its greatest commitment of to the official count, 60,000 90% are on outpatients, and only about 5% of the films

at MMC participates

time involves examinations

are “officially”

All

by the radiologists.

All the films are screened

by a radiologist, but a report is dictated only when requested by the referring physician. Obviously, the amount of work that each radiologist

can do is a limiting factor.

The equipment and working environment at MMC would make any modern radiologist cringe. A significant problem in the entire country is the absence of stable voltage. This makes working with electronic equipment difficult and adds to the stress on that equipment. The radiographic rooms have no air conditioning. The main hospital has

one RF unit with a table that does not tilt and equipment films

and

fluoroscopy

that

often

chest unit (cassette type) and

is broken.

two

basic

The

radiographic

hospital units

for spot has an old for extrem-

ity work. For high technology, it has a small linear-array sonographic unit that produces substandard images because of the variations in voltage. To give an example of the working conditions, we witnessed a

thoracic myelogram

performed

on a table that did not tilt, and without

Burkitt

and fluoroscopy.

lymphoma

who

had

The patient

a neurologic

was a 10-year-old

block

in the

thoracic

region. The radiologist punctured the cisterna magna and injected contrast material (nonionic, water soluble). The patient then was

elevated

with pillows. After a few minutes,

plain anteroposterior

and

lateral films of the thoracic region were obtained without knowledge of the level of blockage. Despite these difficulties, it was determined that the tumor was in the midthoracic region. In addition to these difficult working conditions, the intellectual resources of the medical center are also inadequate. Neither the MMC library nor the radiology department has any recent journals or textbooks. The most current issues of AJA and Radio!ogy are from 1983. Why do these conditions exist? Unfortunately, as with many countries, Tanzania has an acute lack of hard currency. With few items to export and broad-based needs, it has little money for health care. What little money it has for this area of service is spent wisely for immunization programs and other basic needs. As a result, almost no funds are available for radiology. Obviously, the needs are great, and we left Tanzania with a strong sense that those of us who have many resources should reach out and give to those who have fewer. What should we do? First, with Dr. Berk’s help, AJR will be sent complimentary to the department at MMC to help them keep up with the rapidly changing field of radiology. We also will be sending them a subscription to Radio!ogy as a gesture from our department. Even though they will be unable to apply much of what they read, current journals will alleviate their sense of isolation from the world. Their most important pressing need is radiographic equipment-and

not

just

expensive,

large

units.

None

of the

wards

have simple view boxes. The cassettes are outdated and lead to excessive techniques (these are hard on the old equipment and result in excessive doses of radiation to the patient). Accessory items such

as bright lights and lead markers

are also in short supply.

Last,

important basic radiographic equipment is needed to upgrade the rapidly deteriorating units currently in place. In closing, we encourage the readers of AJA to assess their own resources to determine if radiographic equipment, especially older analog units, could be donated to MMC to upgrade the center’s department. This would include even small items such as cassettes, view

boxes,

and

lead

markers.

Those

interested

in

donating

can

contact Mark Baker (91 9-681 -271 1 , ext. 5238) at Duke University. By working together, we should be able to help raise the level of health care at MMC and in Tanzania. Mark E. Baker Frederick R. Porter Duke

University

Medica!

Durham,

NC

Center 27710

LETTERS

196

On Teaching

Radiology

in Developing

the U. S. Food and Drug Administration is illegal to reuse these devices. procedure,

Countries

I have just returned from Kathmandu, Nepal, where I was a visiting professor in the Department of Radiology, Tyruban University, Colloge of Medicine, for 3 weeks. From 9 am. to noon each day, I

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critiqued

chair, and Dr. Shrestha,

enthusiastically,

occasionally

saying,

senior “We just

lecturer, don’t

catheters for barium enemas such as MMI, Inc., Southfield,

were

for the residents,

they

were

attended

January

and

February,

I was

(residents), seven radiologists.” Kenyatta teaching hospital.

“teaching National

My mornings ancient

a visiting

mammography

machine

in the

and trying to get an

to work

properly.

After-

noons were spent with the residents in small group discussions. Lectures were given in the evenings, with attendance by all the radiologists of Nairobi as a result of Chairperson Dr. J. K. Kitonyi’s promotion.

In both these locations, I was in the only academic department in the nation. The equipment was minimal and old. Obtaining repairs was difficult. Nuclear imaging and CT were not available. Nairobi did not have sonography

because

their

sonographic

machine

was

bro-

academic departments was first rate. The radiologists were vibrant, enthusiastic, and well trained. They were widely read on current literature. The residents were highly motivated. The strongest impression I have of both departments is the tremendous hunger for knowledge and for information of “how it is done” in Western developed countries. I never have considered myself a good formal lecturer, but it was easy when every member of the audience was Working in a country is quite differentfrom being a tourist. My wife and I were accepted as residents in the country and learned much

about politics, culture, and religion. Although

we stayed only 3 weeks

in Nepal,

for good

stay

is desirable

Radiology

1 . Gelfand DW. Barium enemas, latex balloons, and anaphylactic AJA

support

were arranged

Foundation

to academic

radiology

It is a wonderful experience. teer for this deeply satisfying

mutual

under-

and supported

as a part of their

departments I hope task.

by the

goal of providing

of developing

countries.

radiologists

will volun-

that other

for Barium

Dr. Gelfand’s Ions, nicely

excellent

Willard

J. Howland

Canton,

OH 44708

Enemas article

[1], “Barium

Enemas,

Latex

Bal-

and Anaphylactic Reactions,” in the January issue of the AJR summarizes the subject. However, there is a mandatory cor-

rection.

Bardex catheters, Model 658 (C. R. Bard, Murray Hill, NJ), have recalled. Model 659 is still available. Each catheter costs ap-

been

proximately $23, and they should with Dr. Gelfand that resterilization

reactions.

Dr. Janower is correct in stating that the manufacturer of Bardex rectal catheters (C. R. Bard, Murray Hill, NJ) recommends that the catheters not be reused. However, it is not illegal to reuse such a device. The unfavorable aspect of reuse lies in any potential liability should reuse result in cross infection due to improper sterilization. Since I submitted the article on latex allergy [1], my colleagues and I have been using a similar rectal balloon catheter made by Akron

Catheter

and distributed

OH. This catheter

by Picker International,

is designed

The aforementioned

and recommended

catheters

not be resterilized. Although I agree of these catheters is a reasonable

both of Mayfield, for reuse.

are made of latex rubber,

as are

those made by MMI, Inc., noted by Dr. Janower, and thus they carry the risk of latex allergy. A more definitive solution is the silicon balloon-equipped enema tip recently developed by E-Z-EM, Inc., of Westbury, NY, which should be available by the time this letter and reply are published. David Bowman

Gray

Schoo!

Winston-Sa!em,

W. Gelfand of Medicine NC

27103

REFERENCE 1 . Gelfand DW. Barium AJR 1991;156:1-2

Enema

enemas,

latex

Retention

balloons,

and anaphylactic

reactions.

Catheters

A recent commentary by Dr. Gelfand [1] stated that C. R. Bard, Inc. , makes a nondisposable Bardex rubber catheter that can be

“repeatedly

cleaned,

sterilized,

and reused”

for the purposes

of

enema. Although we appreciate Dr. Gelfand’s praise and recommendation of our product, we would like to advise your readers that C. R. Bard manufactures no latex catheters that are intended for reuse or resterilization. Further, using a urinary catheter to perform a barium enema is outside the catheter’s indications, and such practices are not endorsed by our company. Bard does, however, manufacture two catheters specifically for use in performing a barium enema: the Weber and the Virden rectal catheters (catalog numbers 658 and 659, respectively; Davol, Inc., 100 Sockanossett

Catheters

!nc. 01604

1991;156:1-2

performing

Outreach

MA

REFERENCE

Barium

hanging onto every word.

a 2- to 3-month

L. Janower

Hospita!,

Worcester,

ken. No radiation therapy was available anywhere in Nepal. Despite inadequate equipment, the radiology practiced in these

standing. These visiting professorships

Vincent

Rep!y

professor

radiologists,” and 1 2 “governHospital is a 1 600-bed govern-

were spent doing arteriography

dedicated

Saint

from other

physi-

Department of Radiology at the University of Nairobi in Kenya for 8 weeks. This was a much larger academic department, with 16 registrars

are available Ml. Murray

and it

by all the staff

members, radiologists from other hospitals, many academic cians from other departments, and the technologists. Last

disagrees,

participated

see that in Ne-

pal.” For example, Paget disease never is seen. In the afternoons, I either gave prepared lectures or led small group discussions on subjects of the residents’ choice. Although the lec-

ment ment

Also, balloon manufacturers,

the five postgraduate students’ (residents’) handwritten of current cases in small group discussions. Dr. Budathoki,

reports departmental

tures

AJR:157, July 1991

a barium

Crossroad,

P.

0. Box 8500, Cranston,

RI 02920; 401-

463-7000). Both are double-lumen rubber catheters with latex balIons designed to assist in the administration and retention of a barium enema. They are supplied nonsterile and must be sterilized before use. Neither is intended for reuse or resterilization. I hope that knowledge of the availability of these products and reinforcement of the warnings against their reuse or resterilization will be helpful your readers. Frank M. Krakowski Murray

C. A. Bard, !nc. Hill, NJ 07974

LETTERS

AJR:157, July 1991

i 97

Fig.

REFERENCE 1 . Gelfand DW. Barium enemas, latex balloons, and anaphylactic

gated

reactions.

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Enemas

in Older

I read Enemas,

with interest the commentary by David Gelfand, “Barium Latex Balloons, and Anaphylactic Reactions” [1], in the

shows

don-

occupying most of common bile duct, with dilated biliary system.

AJR 1991;156:1-2

Barium

1.-ERcP filling

defect

Patients

January 1991 issue of AJR. As he suggests, the proscription against using latex balloons makes it difficult to perform barium enemas on older patients who have poor rectal tone. He recommends taping the patient’s

buttocks

to help retain

the enema.

I offer an additional alternative. I have found that a 26-French Foley catheter with a 30-mI silicone rubber balloon (Travenol Laboratories, Inc., Deer Field, IL) is useful in older patients. By using a 5 in 1 Sims Connector

(Seamless

Foley catheter bag.

Hospital

Products

can be attached

Co., WallingFord,

directly

to the tubing

CT), the

of the enema Dimitri

The Johns

Merine

Hopkins

Hospital

Baltimore,

MD

21205

REFERENCE 1 . Gelfand DW. Barium enemas, AJA 1991;156:1-2

latex balloons, and anaphylactic

that this complication occurs in 0.6% of all cholecystectomies. He suggested that resorbable suture material be used to ligate the cystic duct. However, nonresorbable suture material or metallic clips continue

to

be

used,

presumably

because

resorbable

suture

material

might allow the cystic duct to open before healing can occur. When the rapidity with which stone formation occurred in this case (3.5 months) is considered, this complication might be possible even with resorbable suture. Donald Stallard Murali Sundaram

reactions.

St. Louis

University,

Medica!

St. Louis, MO

Center

63110-0250

REFERENCE

Inadvertent

Vaginal

Filling

During

a Barium

Enema

1 . Ahlberg

While reading the letter “Detection of Inadvertent Vaginal Filling During Cystography” from Merchant et al. [1] in the February 1991 issue of AJA, I was reminded of one of my most startling moments

as a resident.

I was doing a repeat barium enema on an attractive, lady, the reason for which I can no longer rememI was seriously studying what appeared to be a very

well-coiffed,

elderly

ber. While unusual

cutoff of the the last time

“Doctor,

barium column, the they did this through

patient calmly the rectum.”

stated, I nearly

fainted! I laugh aloud every time I think of this incident, still astounded by the woman’s

stances.

incredible

poise

She is my definition

in already

compromised

of an unflappable

Sports

Hughston

circum-

lady! Sandra B. McCann

Co!umbus,

Medicine

Hospita!

GA 31995-3499

REFERENCE 1 . Merchant S, Patel V, Morparia H, Someshwar vaginal

Unusual

filling

during

Cause

We report

cystography

(letter).

of Obstructive

a case of obstructive

that was due to a foreign

R. Detection of inadvertent

AJR 1991;156:406-407

after cholecystectomy

(silk suture) in the common duct. was admitted with jaundice 3.5 months after body

A 60-year-old woman she had had cholecystectomy and sphincterotomy. CT showed a dilated biliary tree, and the results of blood chemistry tests were consistent

with

obstructive

jaundice.

An ERCP

showed

a dilated

and a 1 x 4 cm elongated filling defect in the common duct (Fig. 1). At laparotomy for exploration of the common duct, a free fragment of silk surgical suture was found covered with grumous biliary

tree

material.

Stone formation the most

common

around unusual foreign bodies has foreign

body

is silk

surgical

A. Silk ligature as a cause of choledocholithiasis Acta Chir Scand 1959;1 18:22-24

been

suture.

reported;

Ahlberg

[1]

reported nine cases of stone forming around silk suture and estimated

after cholecys-

Dissecting Intramural Hematoma of the Esophagus in Boerhaave Syndrome: CT Findings A 42-year-old alcoholic man was admitted because of tightness in the chest and substernal pain of acute onset. These symptoms had developed suddenly the day before after he drank alcohol and then vomited. Chest radiograph showed bilateral superior mediastinal and paraspinal

widening.

Contrast-enhanced

CT

scan

showed

a low-

attenuation (45 H) lesion encircling the gas-filled esophageal lumen through the entire course of the esophagus (Fig. 1). This abnormality also was found in the gastric fundus and body along the side of the lesser curvature. A high-attenuation rim of uniform thickness, presumed to be the muscular layer of the esophagus, was noted in the outer aspect of the abnormality. Esophagography with 37% Gastrografin (meglumine diatrizoate) showed marked narrowing of the entire esophageal lumen and no extravasation of contrast medium. The diagnosis was extensive intramural hematoma accompanying esoph-

ageal perforation.

Jaundice jaundice

tectomy.

Because the patient was stable, we decided to use

conservative treatment. On the patient’s fifth day in the hospital, shock suddenly developed. A CT scan showed a high-attenuation hematoma in the distal esophagus, extensive hematoma in the mediastinum, contrast medium from the previous esophagogram in the pleural space, and fluid in the lesser and greater peritoneal sac. At surgery, a deep and extensive laceration in the posterior wall of the

gastric cardia and fundus extending to the distal esophagus, empyema, and mediastinal hematoma and abscess were found. Dallemand et al. [1 ] reported two cases of intramural hematoma of the esophagus and suggested that the combination of a dissecting intramural hematoma and a perforation of the esophagus is rare. On

esophagography, a long, smooth filling defect in the mid and lower esophagus, usually on the posterior wall, is characteristic of intramural

hematoma.

An esophageal

hematoma

also

may

dissect

the

i 98

AJR:157, July 1991

LETTERS

Trilateral

:...b]

.

.

..;..

J

..

‘. .

...

.

,.

. .

.

Retinoblastoma

II

A

-

5-month-old

male

neonate

had

bilateral

leukocoria

and

inability

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to follow a light source. White reflex was present in both eyes. CT showed calcified masses in both retinas (Fig. 1 A). Both optic nerves

were normal, and no tumor spread was evident. Cranial CT showed a large enhancing mass with well-defined margins in the region of the pineal gland (Fig. 1 B). The posterior third ventricle was obliterated, and the anterior third ventricle and lateral ventricles were mildly

dilated. The right eyeball was enucleated,

and histologic

examination

confirmed the diagnosis of retinoblastoma. The patient received radiotherapy and chemotherapy. A repeat CT scan done after 2 months showed a reduction in the size of the left eye and pineal masses. The patient’s parents refused enucleation of the left eye, and he was discharged. Multicentric retinoblastomas are known to be associated with a number of extraand intracranial tumors [1 ]. Of these, pineal neoplasms are of special interest because they have been shown to be histologically

identical

to retinoblastomas

[2].

Other

pineal

neoplasms

such as pineoblastomas are rare in children, and the pineal gland of lower animals is known to have photoreceptor cells that are functionally and morphologically similar to retinal photoreceptors. On the basis of these findings, it has been suggested that the pineal neoplasm in cases of multicentric retinoblastomas is a true retinoblastoma, and the syndrome is termed trilateral retinoblastoma [3]. Eleven

cases of this rare condition Fig. 1.-Boerhaave syndrome A and B, CT scans obtained

with esophageal intramural hematoma. at admission. Scan at level of aortic arch (A) shows low-attenuation hematoma (arrows) encircling gas-filled esophageal lumen and small bilateral pleural effusions. Scan at level of distal esophagus B shows low-attenuation lesion surrounding true lumen of esophagus and higher attenuation rim (arrows), presumed muscle layer of esophagus, in outer area of hematoma. C and D, CT scans obtained 5 days after admission. Scan (C) at same level as B shows high-attenuation intramural hematoma (open arrows), contrast medium (solid arrows) from previous esophagogram in pleural space, and fluid in pentoneal space. Scan at subcarinal level (D) shows mediastinal (white solid arrows) and pleural (black arrows) abscess or hematoma, esophageal hematoma, contrast medium (arrowheads) in pleural space, and infrafissural empyema (white open arrows) with air-

have

been

examination

wall in a fashion

similar to that of an aortic dissection;

of the orbital contents

and intracranial

The occasional

occurrence

of trilateral

imperative

that CT examination

has

been

closure

reported

no extravasation showed contrast

of esophageal

rupture

in Boerhaave

[3]. In our case, the initial esophagogram of contrast material, material in the pleural

region, and pineal

intracranial

scan

so that

any

pineal

retinoblastomas

of retinoblastomas neoplasms

makes

include

present

it

a routine

are not missed.

Mandira

Mukherjee

Rajesh Gothi Shyam S. Doda Sudershan K. Aggarwal Diwan

Chand

Satpa!

Aggarwa!

!maging New

the result is an esophagus with a double lumen and extensive intramural hematoma, as in our case. In cases of dissecting hematoma, esophagography usually shows a double-barreled esophagus in which contrast medium can be seen in both the true lumen and the false lumen. In some patients, the hematoma does not communicate with the lumen and does not fill with contrast medium [2]. Spontaneous

so far [4]. Simulta-

neoplasms thus can be detected well before they become symptomatic. In the earlier cases, the pineal neoplasm may have been present initially but remained undetected until it became symptomatic.

fluid level in right major fissure.

esophageal

reported

neous detection of intracranial and orbital neoplasms and the early onset were unique features in our case. Also, CT findings were not recorded in any of the cases reported earlier. CT allows simultaneous

Research De!hi-1

Centre

10001,

India

syndrome

showed

but subsequent CT scans space. Kyung Soo Lee II Young Kim Pyo Nyun Kim and colleagues

Soonchunhyang

University Chunan,

330-100,

Hospita! Korea

REFERENCES 1 . Dallemand S, Amorosa esophagus. Gastrointest

JK, Morris DW, lyer S. Intramural hematoma of the Aadiol

1983;8:7-9

2. Shay SS, Berendson RA, Johnson LF. Esophageal hematoma: four new cases, a review, and proposed etiology. Dig Dis Sd 1981;26: 1019-1024 3. Maglinte DDT, Edwards MC. Spontaneous closure of esophageal tear in Boerhaave’s syndrome. Gastrointest Radiol 1979;4:223-225

Fig. 1.-Trilateral retinoblastoma. A, Axial CT scan through orbits

shows bilateral retinoblastoma.

Optic

nerves are not involved. B, CT scan obtained large enhancing pineal

after mass.

administration

of contrast

material

shows

a

AJR:157,

LETTERS

July 1991

REFERENCES

cardium

1 . Jakobiec FA, Tso MD, Zimmerman LE, Davis P. Retinoblastoma intracranial malignancy. Cancer 1977;39:2048-2058

2. Bader JL, Meadows

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199

AT, Zimmerman

and

despite

capture

the

and remove

relative

vigorous

LE, Bums RP, Wankun

retinoblastoma:

Michael

ectopic intracranial retinoblastoma J Paediatr OphthalmolStrabismus

of Greenfield

associated

with

bilat-

1982;19:320-325

of Tandem

Right

Mohammed A!bany

inferior

vena

man was treated

caval

filters

is a complication

filters

had migrated

for pulmonary

embolism,

mad-

3. Yakes atrium

was transferred

to our institution

for further

or myocardium

was

found.

To the best of our knowledge, only four cases of percutaneous retrieval of intracardiac migrated Greenfield filters have been reported literature,

and

no cases

of two

simultaneously

migrated

filters [3, 4]. In limited animal studies, Greenfield and Crute [5] showed that misplaced filters could be retrieved and removed up to 7 days

after insertion without

filter

Ashraf A, Shah DC. Aberrant placement of a Kimray-

in the

right

atrium:

percutaneous

retrieval.

Radiology

5. Greenfield Li, Crute SL. Surgery 198011:719-722

significant

Retrieval

of the

Greenfleld vena caval

Greenfield

vena

caval

filter.

which

management of his extensive pulmonary embolism and migrated filters. Because of his tenuous clinical status, we decided to use percutaneous retrieval rather than surgical removal. Both filters were removed readily by using the technique described by Tsai et al. [2]. Shortly after the procedure, the patient died. An autopsy showed that the cause of death was massive subacute and chronic pulmonary embolism. Careful examination of the right side of the heart showed only a 1 -mm nick of a chorda tendineae cordis. No other significant

English

filter

4. Deutsch LS. Percutaneous removal of intracardiac filter. AJR 1988:151:677-679

catheterization

in the

12208

WF. Percutaneous retrieval of Kimray-Greenfield filter from right and placement in inferior vena cava. Radiology 1988;169:849-851

days later, the patient

endocardium

Hospita! NY

U, Peyton A, Crute S. Barnes A. Greenfield vena caval later results in 156 patients. Arch Surg 1981:116:599-606

Greenfield

Ipsilateral

to the

Center

REFERENCES

recurred despite adequate anticoagulation at another institution. Via a jugular cut-down approach, a vascular surgeon released two Greenfield filters, which migrated to the patient’s right atrium (Fig. 1). Three

injury

Medica!

1988;167:423-424

situation in which two Greenfield to the patient’s right atrium.

A 67-year-old

Sarrafizadeh Allan R. Koslow

A!bany,

2. Tsai FY, Myers iv,

Atrial

reported in 7-9% of cases [1]. Several techniques have been devised to remove a migrated filter percutaneously. We recently had an unusual vertently

A. Braun

Mark B. Collins

1 . Greenfield experience:

Migration

to

G, Tully R, Esterly JA. Trilateral

eral retinoblastoma.

Percutaneous Retrieval Greenfield Filters

required

LE, et al. Bilateral retinoblastoma

with ectopic intracranial retinoblastoma: trilateral retinoblastoma. Cancer Genet Cytogenet 1982;5:203-213 3. Bader JL, Miller RW, Meadows AT, Zimmerman LE, Champion LAA, Voute PA. Tnlateral retinoblastoma. Lancet 1980;2:582-583

4. Zimmerman

instrumentation

them.

risk of injury to the heart. This case

illustrates that migrated Greenfield filters can be retrieved percutaneously from the right atrium without significant injury to the endo-

Antegrade

The catheter

Femoral

described of

the

Arteriography

for conversion

femoral

artery

of retrograde [1]

ipsilateral antegrade used this technique

femoral arteriography in patients who require

the

when

lower

extremity

visualization

also

has

to antegrade used for

been

in 45 patients. We have unilateral arteriograms of

of the

aortic

bifurcation

and

iliac arteries is not needed. The catheter has a double curve and is triangular (Cook Inc., Bloomington, IN). The common femoral artery is catheterized by using the Seldinger technique. The tip of the catheter is inserted into a visceral or renal artery, and by means of a pushing and rotational motion ofthe catheter at the groin, the triangular shape ofthe catheter is reformed. The catheter then is brought down into the common and external iliac artery with its tip facing the lateral wall. The catheter is placed in the middle of the external iliac artery for the angiogram (Fig. 1). Twenty milliliters of a medium-density contrast material is injected

at 5 mI/sec. Diagnostic The

material material

advantage

studies

of this

technique

are obtained is the

in all cases.

smaller

volume

of contrast

used in diagnostic studies. The entire bolus of contrast injected is used to opacify the vessels in the lower extremity.

Yashwant A!bert

Einstein

College

D. Patel

of Medicine

Bronx,

NY

10461

REFERENCE 1 . Patel YD. Catheter artery catheterization.

A

for conversion of retrograde AiR 1990154:179-180

to antegrade

femoral

B Fig. 1.-Percutaneous removal of intracardiac A, Lateral chest radiograph shows vertically

Greenfield B, Frontal

Greenfield filters. and horizontally oriented

filters in right atrium. chest

radiograph

Fig. 1.-Angiogram obtained

capture and removal of the second filter.

after

retrieval

of one filter shows

ter in external

iliac

shows artery

grade femoral arteriography.

cathe-

for ante-

LETTERS

200

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Nomenclature

of Veins

in the Lower

Extremity

Recently, some of our referring clinicians have been misled by the diagnosis of thrombus in the “superficial femoral vein,” thinking that the clot did not predispose to pulmonary embolism because it was in a superficial vein. This prompted us to review the nomenclature of the veins in the lower extremity. According to anatomy texts [1 , 2], the deep veins of the leg are the pop!itea! vein from the junction of the anterior and posterior tibia! veins to the adductor canal, the femora! vein from the adductor canal to the inguinal ligament, and the profunda femoris vein draining the thigh

muscles

ligament.

These

perficial great

and

veins (long)

joining

are of

the for

the

thigh

are

somewhat

saphenous

femora!

vein

named

the

just

below

accompanying

the

arteries.

variable

but

inguinal The

include

vein

1991

ening. Of the nine cases with a stenosis overestimated on Doppler sonography, two were attributed to tortuosity of the vessel and inability to see the vessel well. Of the remaining seven, only four fulfill the criterion of Bluth et al. of SVR >1 .8, and only three fulfill the criterion of PEDV >40 cm/sec for the diagnosis of a stenosis >60% in diameter. If our criteria [2] had been applied, only four of the seven

patients

would

have reached

the threshold

criterion

of SVR >2.0,

and none would have reached the threshold criterion of PEDV >50 cm/sec for a >70% area (45% in diameter) of stenosis. When the two criteria are in disagreement, a third criterion, such as PSV, may

be helpful. These data are not provided

su-

patients, as about

the

cm/sec.

by Beckett

et al. for their

but examination of their Figure 2 shows a PSV estimated 1 1 0 cm/sec by comparison with the displayed PEDV of 36

This meets neither threshold

(Bluth et al. or Robinson

et al.)

the media! and !atera! cutaneous veins, vein, the superficia! circumflex i!iac vein, vein. They lie in the subcutaneous fat,

for a stenosis >60% in diameter. Therefore, we think that few, if any, of the patients presented had duplex examinations that overestimated the degree of stenosis found at angiography.

to the deep

Second, for PSV 7O% (45% diameter) ifthe PSV was 1 .8 and seven vessels with SVR >2. For this reason, information about PSV in the series of Beckett et al. would be useful. Third, the diameter of stenosis determined on the basis of angiography may not be accurate. As stated by Bluth et al., asymmetric stenoses are assessed most reliably by determining the percentage

Therefore,

of the area that is stenotic.

we have returned

these veins in the interests and of anatomic precision.

to standard

of better

anatomic

nomenclature

communication

Eric Suburban

for

with our clinicians

Radio!ogic

L. Bressler

Consu!tants,

Riverside

Ltd.

Medica!

Minneapo!is,

the

Center

55454

MN

REFERENCES 1 . Hollinshead

WH.

Textbook

of

anatomy.

New

York:

Harper

& Row,

1962:441

2. Gray H. Anatomy,

descriptive

and

surgical.

New

York:

Bounty

Books,

diameter

of stenosis

The criteria of Bluth et al. are based on

as measured

from

the

narrowest

sonography

David

3. Abrams HL, ed. Abrams

angiography: vascular and interventional radiology, 3rd ed. Boston: Little, Brown, 1983:1879-1881 4. Foley WD, Middleton WD, Lawson TL, et al. Color Doppler ultrasound imaging of lower extremity venous disease. AJR 1989;1 52:371-376 5. Vogel P. Laing FC. Jeffrey RB Jr. Wing VW. Deep venous thrombosis of the lower extremity: US evaluation. Radiology 1987;163:747-751

Carotid Sonography Stenosis

Contralateral

to Severe

Reading West

used carotid duplex

sonography

of 23 patients

to examine

This

conclusion study,

my

is opposite colleagues

that and

drawn I found

in whom

they

the artery contralateral

by only

Robinson a weak

duplex

sonography.

AJR 1988;151

et al. [2].

conclusions

In

correlation

can be explained

:1045-1049

SM, Aufrichtig

D, Baker JD.

Carotid duplex sonography: a multicenter recommendation for standardized imaging and Doppler criteria. RadioGraphics 1988;8:487-506

Reply

between the peak systolic velocity (PSV) in the ipsilateral nonstenotic vessel compared with the area of stenosis in the contralateral vessel (r2 = .036, p = .21). This included 19 vessels with a contralateral stenosis of >9O% reduction in area or occlusion (Fig. 1 from Robinson

[2]). We think these discrepant

19603

2. Robinson ML, Sacks D, Perlmutter GS, Marinelli DL. Diagnostic criteria for

to an artery that had significant stenosis or occlusion. The authors conclude that an increase in blood-flow velocity in the internal carotid artery on the side opposite an artery with a tight stenosis or occlusion is a common source of error. that

PA

1 . Beckett WW Jr. Davis PC, Hoffman JC Jr. Duplex Doppler sonography of the carotid artery: false-positive results in an artery contralateral to an artery with marked stenosis. AJNR 1990;1 1 : 1049-1053, AJR 1990; 155:1091-1095 carotid

a series

Reading,

Sacks Hospital

REFERENCES

3. Bluth El, Stavros AT, Marich KW, Wetzner et al. [1] describe

of

in general.

1977: 61 63.

Beckett

section

the vessel, which was the measurement also used by Beckett et al. The criteria of Robinson et al. are based on calculations that determine the area of stenosis by using measurements of the reduction in diameter in two planes. If the patients presented had asymmetric stenoses, the criteria of Robinson et al. would be preferable. For these reasons, we disagree with the conclusion of Beckett et al. that use of duplex sonography to determine the degree of stenosis in the carotid artery contralateral to a severely stenotic or occluded internal carotid artery is more prone to error than is use of duplex

as

follows. First, the diagnostic duplex sonographic criteria for stenosis used by Beckett et al. may be too liberal. They used criteria published by Bluth et al. [3] but relied entirely on peak systolic velocity ratio (SVR). Bluth et al. [3] also describe criteria that include PSV, peak enddiastolic velocity (PEDV), diastolic velocity ratio, and spectral broad-

We appreciate Dr. Sacks’s interest in our work on duplex sonography [1], and we would like to address the points that he has questioned. Our criteria for grading stenoses are adapted from those of Zweibel and Dreisbach (refresher course presented at the annual meeting of the Radiological Society of North American, December 1986), as shown in Table 1 of our paper [1 ]. Although these criteria rely heavily on systolic velocity ratio (SVR), they also include real-time imaging and peak end-diastolic velocity (PEDV). The criteria of Bluth et al. [2] and Robinson et al. [3] had not been published when we did our study (January 1 987 to May 1 988). Our results might have been slightly different if we had used different duplex sonographic quanti-

fications

for our criteria. We chose to use diameter

rather than area

for

angiographic

and

duplex

sonographic

so that our measurements studies,

which

have

measurements

would correlate

achieved

accurate

better

duplex

Fig. 1.-Radiograph shows osteolytic defects in skull extending from frontal area to posterior panetal re-

of stenosis

with

many

multiple

previous

sonographic

quantifi-

cation of stenosis by using measurements of diameter. Our criteria for overestimation were that a vessel be miscatego-

gion in a bandlike

fashion.

Downloaded from www.ajronline.org by 64.204.10.110 on 11/09/15 from IP address 64.204.10.110. Copyright ARRS. For personal use only; all rights reserved

rized on the basis of duplex sonographic criteria; that is, the stenosis would be more severe according to duplex sonographic measurements than shown angiographically. We did not suggest that the degree of overestimation necessarily placed that vessel in a hemodynamically significant category. Several of the vessels for which stenosis

was

overestimated

on the

basis

of duplex

sonographic

data

would not be hemodynamically significant by any criteria. The patient shown in Figure 2 of our paper (peak systolic velocity [PSV], 112;

Multiple Osteolytic Band Pattern

SVR, 2.0; and PEDV, 36 cm/sec) meets criteria for both the 40-59% and the 60-79% categories of Bluth et al. Thus, these criteria, like all grading systems, are guidelines that must be applied patients who may not fall into a clearly defined category.

We do not use degree of spectral broadening

in real life to

for grading stenosis.

were well defined,

Our criteria as adapted from Zweibel and Dreisbach stress SVR rather than PSV. We think this is necessary because many of our patients with hypertension or aortic valve disease have elevated PSV throughout the common and internal carotid arteries. In this setting,

value for the PSV of the internal

carotid artery has less significance than the ratio of internal carotid to common carotid velocity. We are not aware of data suggesting that measurements of PSV are superior to measurements of SVR for quantification of stenosis. Robinson et aI. found that PSV, SVR, and

region.

plastic

Emory

University

Jr.

James

C. Hoffman,

Jr.

Schoo! At!anta,

GA 30322

WW Jr. Davis PC, Hoffman JC Jr. Duplex Doppler sonography of the carotid artery: false-positive results in an artery contralateral to an artery with marked stenosis. AJNR 1990; 1 1 : 1 049-1 053, AJR 1990;155: 1091-1095 duplex

SM, Aufrichtig

was

decided

drilling

the

were

complicated

to enhance

outer

table

of the

skull

was

were

AD.

[1

a period

of

skull.

performed

Multiple

small

holes

from the frontal region to the osteolytic by the

Incas

skull defects of Peru

before

].

D, Baker JD.

sonography:

King

Edward

Pare!,

3. Robinson ML, Sacks D, Perimutter GS, Mannelli DL. Diagnostic criteria for carotid duplex sonography. AJR 1988;151 : 1045-1 049 4. Powis RL. Doppler spectral broadening in normal blood flow and disease. 1983;1

After

by wound infection, the the chances of the wound’s

of the

a multicenter recommendation for standardized imaging and Doppler criteria. RadioGraphics 1988;8:487-506

Am Rev Diagn

normal.

the treatment of epilepsy or for benign intracranial hypertension (pseudotumor cerebri) [1 ]. A regular array of discrete round holes was fashioned in Turkey in an effort to promote vascularization and growth of skin grafts [1]. In our case, holes were drilled in the outer table to promote the growth of granulation tissue from the diplo#{232} so that grafting could be attempted later. Vimal H. Patel Suleman Merchant Abbas Mistry and colleagues

of Medicine

1 . Beckett

Carotid

by

at admission

which

Spontaneous healing apparently occurred in many cases of infection that complicated this ancient practice. Multiple surgical holes also have been made on one side of the cranium for

REFERENCES

2. Bluth El, Stavros AT, Marich KW, Wetzner

surgeons

Trephining

C. Davis

W. Beckett,

radiographs

the posterior parietal region. These noted on the radiograph we saw. 1 500

Patricia

of a

equal in size, and fairly evenly spaced.

were drilled in the outer table, extending

purpose. William

strikingly

treatment,

healing

Previously reported studies [3, 5] have used multiple parameters for quantification of stenosis; SVR was equally, if not more, reliable than for this

Skull

primary

PEDV were “equivalent predictors of significant disease”; PSV was preferred in that study because of the “ease of measurement” [4].

PSV

Significance

Another odd feature was their bandlike distribution from the frontal to the posterior parietal region (Fig. 1). This bandlike pattern along with the equal size and even spacing suggested an iatrogenic cause, which was confirmed. Details are as follows. A 19-year-old woman had a gross avulsion injury of the scalp as a result of having her long hair entangled in a weaving machine. The scalp was avulsed from the frontal area up to the posterior parietal

[4].

threshold

Defects:

Multiple osteolytic defects in the skull are a well-established radiologic entity. latrogenic causes for the appearance of such lesions rarely have been described. We report one more iatrogenic cause. During a routine reporting session, we saw a lateral radiograph of the skull that showed multiple small osteolytic defects. The defects

Spectral broadening is neither a necessary nor a sufficient criterion for quantification of stenosis. It is a common occurrence in the absence of stenosis and is associated with vessel branching, tortuosity, changes in vessel diameter (i.e., carotid bulb), and so forth

we think that an arbitrary

Skull

Bombay

Memorial 400

Hospital 012,

!ndia

REFERENCE

:3-8

5. Garth KE, Carroll BA, Sommer FG, Oppenheimer DA. Duplex ultrasound scanning of the carotid arteries with velocity spectrum analysis. Radiology

1 . Hodges

1983;147:823-827

Letters Letters figures

may

are published to the Editor be included.

FJ III. Pathology

diagnosis, imaging, the head and neck.

of the skull. In: Taveras JM, ed. Radiology: vol. 3. Neuroradiology and radiology of Philadelphia: Lippincott, 1986:1-21 intervention,

at the discretion of the Editor and are subject to editing. must not be more than two double-spaced, typewritten pages. Abbreviations

should

not

be used.

See

Author

Guidelines,

Material being submitted or published elsewhere should not be duplicated in letters, of letters must disclose financial associations or other possible conflicts of interest.

Letters

concerning

a paper published

in the

AJR

reply to be published in the same issue. Opinions necessarily reflect the opinions of the Editor.

will be sent to the authors expressed

in the Letters

One or two

page

AS.

and authors

of the paper for a

to the Editor

do not