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427
Letters
referral patterns.
The Selling of a Profession
specialty Increasingly,
economic
issues
dominate
the practice
of radiology,
often overshadowing the more stimulating intellectual challenges that attracted us to the specialty. Vexations such as turf battles, restrictions of third-party payers, and the rampant federal bureaucracy captured our attention and absorbed our energies during the decade of the eighties. Generally, radiology is weathering these trials, as it is a unified society bound to the commitment to abide by the ethical guidelines that best serve the specialty and, most importantly, our patients. As the centennial of radiology approaches, a little-publicized insidbus practice threatens the integrity of our discipline. I refer to the practice of allowing nonradiologists to interpret images and bill for or be paid for their services within radiologic facilities, an abuse that threatens the very core and foundation of the specialty. We witness fellow radiologists laying aside moral principles and medical ethics as they shamelessly sell their rights to imaging to nonradiologists. It is disheartening to see under the letterhead of a radiologist or an imaging group directed by radiologists reports generated by nonradiologists.
Such
sinister
ventures
to
which
radiologists
are
party
foretells a splintering and fragmenting of radiologic care. Although many of us left the bitter turf battles of the eighties bloodied
but resolute,
a few compromised
their
specialty
and wel-
the nonradiologist interlopers with open arms and open checkbooks. These radiologists were not coerced into such dangerous liaisons; indeed, some actively sought these arrangements.
comed
Clearly,
these
self-referral
abuses
represent
the extreme
in conflict
of interest inasmuch as the nonradiologist who perpetrates the misuse of imaging both requests and interprets the imaging study. In such practices, a spin-off of laissez-faire medicine, the goals are not improvement in the quality of imaging or better service but rather personal financial gain. These ersatz radiologists covet the crown jewels of radiology: MR and CT. The more prosaic and less well compensated plain films do not interest them; and please, paying patients only-no pro bono work. Recent Stark amendments may herald an increase in such practice patterns; the abusers cleverly attempt to bypass the sanctions of kickback regulations. The abusive arrangements, of which the patient is not aware or has been misled about, fall far short of the ideals of practice. How can organized radiology respond to such perilous intrusions? (1) Recognize that such practice patterns exist and should be discouraged. (2) Adopt more stringent ethical guidelines. The American College of Radiology should take a leadership role in this matter. (3) Let the public know of these practices and how such practices abuse
(4) Serve notice on radiologic
of radiology
pretenders
that the
is not for sale.
Congressman Stark (D, CA) sent a clear warning to all of medicine when he stated, “Physician ownership/referral arrangements represent an exploding virus which ultimately will erode the trust patients have traditionally placed in their physicians” [11. A profession is a bond, and trust is the glue that seamlessly holds the profession together and defines its nature. The professional societies in radiology seek to maintain a high level of standards and to promote excellence in imaging; as well, they foster intellectual exchange, encourage collegiality, and defend ethical practice patterns. Those who would shatter the links of that professional bond, who would sully the trust that holds them to professional standards, should make the rest of us fear for the future. Their chilling example reminds us of Gresham’s law that
the bad
Membership
drive
out the good.
in a society
of
specialists
carries
with
it an
implied
contract. Arnold Relman, in a recent Shattuck lecture, wrote, “Most of us believe we are parties to a social contract, not a business contract” [2]. In radiology, that contract, or covenant, charges us to provide quality imaging in an ethical and honest manner. That goal serves
best
the
paramount
interests
of
the
patient
and
eschews
those of the self-referring physician. When the boundaries of ethics are trespassed, it is the obligation of the other members of the specialty to condemn such transgressions and to serve notice that the interests of radiology and the patient are being poorly served. If we
are to survive
as a specialty,
the
collaboration
with
self-referring
nonradiologist physicians-in essence the selling of the professionmust cease as a viable practice option. James F. Lally Christiana
Hospita/,
Medica/
Center of Oe/aware Newark, DE 19718
REFERENCES
1 . Iglehart JK. Health policy report: Efforts to address the problem of physician self-referral. N EngI J Med 1991;325:1820-1824
2.
Relman
AS. Shattuck
lecture.
The health
care
industry:
where
is it taking
us? N Engl J Med 1991;325:854-859
Winning the Turf War It starts early, in medical school. “I’m on radiology next month. I the vacation to sit back, relax, and enjoy the friendly radiologists.” It has been 12 years since my third-year rotations, and I am still hearing the same remarks from today’s students. need
LETTERS
428
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As a radiologist in private practice (also 2 years as an assistant professor), I know radiology is no vacation, but my nonradiology colleagues do not. This hurts radiologists at the bargaining table from hospital committees to negotiations on Relative Value Schedules. It is time we stop spoon-feeding our medical students and instead give
AJR:159, August 1992
considered
as a possible
septicemia
or endocarditis.
cause
of hemoptysis
in patients Vincent
them a dose of the real world as the other specialties do. For example, night call with the emergency department resident, hours of arteri-
ography with lead apron, teaching assignments, and participation in communicating results to referring physicians would do for a start. I urge my academic colleagues to look beyond the textbooks and consider the political roots of preserving the prestige of our specialty. The Magnetic
Louis Institute
Resonance
A. Friloux III of Ar/ington
Ar/ington,
Mycotic Aneurysm of the Bronchial Cause of Hemoptysis
VA
22206
Poland’s
Vigo,
Erlangen,
Germany)
died 4 weeks
of dura
controlled
the
(Totoplast
Dura;
hemoptysis
(Fig.
later of multiple organ failure.
Bleeding from bronchial arteries is usually due to chronic pulmonary infection, pneumoconiosis, or tumor [1 2]. To our knowledge, rupture of a mycotic aneurysm of the bronchial artery in adults has not been previously reported. Angiographic features of mycotic aneurysm are ,
nonspecific,
and
congenital
aneurysms
Large Benign Fibroma
are difficult
to exclude.
of the Pleura in
A 31 -year-old man had routine chest radiography before sinus surgery. The radiographs showed a large right-sided pleural effusion (Fig. 1 A). The patient said he had had progressive exertional dyspnea for 4 years. Axial CT scans showed a large, heterogeneously enhancing soft-tissue mass and pleural effusion occupying much of the right hemithorax and absence of the right pectoralis muscle (Figs. 1 B
cartilage;
bronchoscopy no obstructing
of the right hand was noted incidentally. showed lesion
At the time of thoracotomy, After drainage of approximately circumscribed,
Grossly,
only was
absence
right
Sub-
bronchus
found.
the right lung was totally collapsed. 3 I of serosanguineous fluid, a well-
20 x 1 2 x 1 0 cm pleura-based
the adjacent
of the
mass
was
resected.
lung and chest wall were not involved.
Histo-
Rapid
Fig. 1.-Benign fibroma of pleura in a 31-year-old man with Poland’s syndrome. A, chest radiograph shows
growth of the aneurysm is associated with risk of rupture, and prompt treatment is required. Selective embolization of the bronchial arteries is simple and reliable. It results in rapid control of the hemoptysis, even in a patient whose condition is unstable [1 -3]. This case emphasizes that mycotic aneurysm of a bronchial artery should be
opacification
B
Fig. 1.-Mycotic aneurysm of bronchial artery in a 34-year-old man with hemoptysis. A, Arteriogram shows small aneurysm (arrow) on distal part of left bronchIal artery and no extravasation of contrast medium. B, Arteriogram obtained after embolization shows left bronchial artery is occluded.
of right
hemfthorax
and no mediastinal shift. B and C, contrast-enhanced cT scans show a large, heterogeneously enhancing mass in right hemithorax (B, C), absence of right pectoralis muscle(B), and right-sided pleural effusion (C).
A
A
France
Syndrome
sequent
1 B). The patient
Paris,
1 . Remy J, Arnaud A, Fardou H, Giraud R, Voisin C. Treatment of hemoptysis by embolization of bronchial arteries. Radiology 1977;122:33-37 2. Vujic I, Pyle R, Hungerford GD, Griffin CN. Angiography and therapeutic blockade in the control of hemoptysis. Radiology 1982;143:19-23 3. Rabkin J, Astavjef V. Gothman L, Grigorjev V. Transcatheter embolization in the management of pulmonary hemorrhage. Radiology 1987;163: 361-365
and 1 C). Syndactyly
Pfrimmer
Sibert
REFERENCES
dium.
fragments
Denys
Annie
H#{244}pita/Bichat 75018
severe hemoptysis occurred. Selective bronchial arteriography showed a small aneurysm (diameter, 1 7,000 examinations per year), we cannot break even
economically
of $50
at a charge
approximately
per examination-and
$45 per examination,
our cost
is
even with high volume. Ronald G. Evens
Malilnckrodt Institute of Radiology Washington University Medical Center St. Louis, MO 63110
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431
LETTERS
August 1992
AJR:159,
Dr. Evens
is mistaken
accounting
1 . Warren Burhenne Li, Hislop TG, Burhenne HJ. The British Columbia mammography screening program: evaluation of the first 15 months. AiR 2. Vogel VG, Peters GN, Evans WP, Texas Breast Screening Project Scientific Review Committee. Design and conduct of a low-cost mammography screening project: experience of the American Cancer Society, Texas division. AJR 1992;158:51-54 3. Sickles EA. Low-cost mass screening for breast cancer with mammography (commentary). AiR 1992;158:55-57
In regard
is done
to the recent
article
[1] on the British
Columbia
mam-
by independent
accountants.
during
The unit cost of $32.66
the first 15 months
has actually decreased
per examination.
Two
operation
that they might
were adopted
get exactly
what
and expanded
they paid for if a program
to a nationwide
like this
unit costs
of $26.54 in the
for the center
Lower
Mainland.
Charles North Bakersfield,
CA 93302-0119
provincial
volunteer
expenses
such
and the report
responsible
for follow-up.
We
states
do
not
that
understand
he cannot
be added
Dr.
Evens’s
even
which
is done by
as the Cancer
last
for
in all unit-cost
of the provincial add that the unit
is sent to this physician,
break
in
for the one
should
centers We should
now
each year show
and $30.24
$4.62
for promotion,
organizations
registration,
Society.
All
name on
who will then be
paragraph
economically
in which
he
though
he
even
that costs him $45. This runs contrary
to his request for defining cost with rigid science. We would also like to put Dr. North at ease, because any one of our 24 radiologist-
in seven centers can read and get his professional
1 00 screening
1 . Warren Burhenne U, Hislop TG, Burhenne HJ. The British Columbia mammography screening program: evaluation of the first 15 months. AJR
screened
in Victoria Again,
to $26.50
Columbia
women who are screened are required to give a physician’s
screeners REFERENCE
in British
but office rental is now included
amortization,
charges $50 for an examination
project.
We can now
and now amounts
centers
with more than 10,000 patients
in Surrey capital
additional
cost does not include
Consider
per examination
of our program.
woman screened
convinced that this is a truly realistic for a moment the concern about
as presented.
was
report cost accounting for 3Y2 years in the same pilot program center with mammography screening of 35,650 patients. The unit cost per
figures. Four additional mammography screening program opened last year.
breast cancer and think about undergoing a testing procedure knowing that the person who ultimately is responsible for interpreting the results will be paid slightly more than lunch at McDonald’s would cost. Persons do get what they pay for, and over a large series of screening examinations, I fear
US$32.66
amortization and $1 .08 for office rental. Cost detailed fashion by the director of finance of Cancer Agency, and annual audits are performed
mography screening program, although the concept of low-cost mammography screening certainly has merit, I am not the least bit program
that
in a
the British Columbia prevailed
1992;158:45-49
he assumes
all expenses (in U.S. dollars) such as salaries and benefits, professional fee, film cost, and equipment maintenance; $4.62 should be
added for equipment REFERENCES
when
“paid” per examination. We clearly state that this was the “cost” per patient allotted against a government grant, and the breakdown is analyzed in the Results section of our article [4]. The cost includes
mammograms
fees for
per hour, the same time that it probably
takes Dr. North to have lunch at McDonald’s. L. J. Warren Burhenne T. G. Hislop
1992;158:45-49
H. J. Burhenne University of British Vancouver, B.C., Canada
Replies We are pleased
to respond
to the concerns
of Drs.
Evens
and
North. Already in 1986, Dr. Evens [1] doubted documentation of lowcost screening mammography [2, 3] in the United States. The low cost of high-volume screening mammography depends, to some extent, on the differences between screening and diagnostic mammography. Diagnostic mammography in a radiology department is time-consuming for the radiologist: he or she must be in the department, ensure that a good history is obtained, be available to consult with the patient, review routine projections and request specialized views, mount the mammograms, and dictate a detailed report. He or she must sign the completed report and contact the referring physician in involved
cases.
Screening
mammography
while
he or she reads
the mammograms
and pushes
one of
two buttons on the computer, which generates a paragraph stating either that the mammogram is normal and the patient should return at a specified interval or that the mammograms appear to be abnormal and requesting the patient’s physician to proceed to diagnostic mammography. Two technicians have taken, during the daytime, in one room, mammograms at a rate of six to 10 patients per hour, and the patients have filled in a questionnaire. By contrast, diagnostic mammography
permits
scheduling
of no more than three patients
hour in a room with more sophisticated
equipment.
REFERENCES 1 . Evens
RG. Mammographic
cost (letter).
Radiology
screening: 1986;161 :850
how to operate
successfully
at low
2. Bird RE, McLelland R. How to initiate and operate a low-cost screening mammography center. Radiology 1986;161 :43-47 3. Sickles EA, Weber WN, Galvin HB, Ominsky SH, Sollitto RA. Mammographic screening: how to operate successfully at low cost. Radiology 1986;160:95-97
4. Warren
Burhenne
mammography 1992;15:45-49
Li, Hislop TG, Burhenne HJ. The British Columbia program: evaluation of the first 15 months. AiR
screening
in a free-standing
clinic, on the other hand, does not require the presence of a radiologist: He or she comes in the evening to read premounted films with only two views of each breast. No telephone or other interruptions occur
Columbia V5Z 1M9
per
Dr. Evens is correct that we did not define cost as an economist would [1 ]. The low cost refers to fees charged per examination, rather than cost of performing the examination. We also agree that in some instances even with high volume, it is not possible to perform screening mammography
$50. However, viable
situation
and break
even
economically
with
others [2, 3] have shown that screening provided
the
examination
can
a charge
of
is a financially
be performed
in a
nonhospital setting. The 1987 American Cancer Society Texas Breast Screening Projoct was principally designed as an activity to promote screening It greatly increased public awareness about breast and the value of early detection. Quality assurance standards
mammography.
cancer
LETTERS
432
throughout couraged
AJR:159,
August
1992
the state were markedly improved, and the project enthe development of accreditation standards by the Ameri-
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can College of Radiology. Most, if not all, of the 306 participating facilities subsidized the $50 mammogram and, like Dr. Evens, did not break even at that charge. Subsequently, however, we have seen the fees for screening mammography reduced throughout the state. Most high-volume facilities now charge $45 to $75 per examination. Victor Vogel The University of Texas, M. 0. Anderson Cancer Center Houston, TX 77030 George
Peters
W. Phil Evans Bay/or University Medical Center Oailas, TX 75246 REFERENCES
A
1 . Vogel VG, Peters GN, Evans WP, Texas Breast Screening Project Scientific Review Committee. Design and conduct of a low.cost mammography screening project: experience of the American Cancer Society, Texas dMsion. AiR 1992;158:51-54 2. Bird RE, McLelland A. How to initiate and operate a low.cost screening mammography center. Radiology 1986;161 :43-47 3. Sickles EA, Weber WN, GaMn HB, Ominsky SH, Sollitto RA. Mammographic screening: how to operate successfully at low cost. Radiology 1986;160:95-97
Gastroduodenal Intussusception Prolapsed Gastric Adenoma A 63-year-old man with a diagnosis
Due to a B
of gastric
cancer
was referred
C
to our hospital. Intermittent postprandial epigastric discomfort and weight loss had begun 6 weeks before. An upper gastrointestinal barium study performed 1 month before showed a polypoid mass in the antrum ofthe stomach (Fig. 1A). Endoscopy at admission showed a 7 x 10 cm, ulcerated, polypoid mass arising from the anterior wall of the proximal part of the antrum of the stomach. Biopsy of the mass indicated adenocarcinoma. CT scans obtained 1 month later showed a large mass in the duodenum (Figs. 1 B and 1C) and no evidence of a mass in the stomach. Oral contrast medium did not
due to prolapsed gastric adenoma. A, Radiograph shows large polypoid mass (arrows) in antrum of stomach. B and C, CT scans show large soft-tissue mass (arrows, B) in duodenum and beaklike narrowing in distal stomach (arrowheads, C). Central lowdensity area within mass (B) represents fluid in duodenal lumen.
pass beyond the duodenum during CT scanning, even when the patient was in the right lateral decubitus position. An upper gastrointestinal series was not performed at this time.
Byler disease, a progressive familial intrahepatic cholestasis syndrome, was first described in 1969 [1]. The disease is often diagnosed early in life on the basis of pruritis, hepatomegaly, and elevation of serum levels of bilirubin. Most patients die of hepatic failure in the second decade of life. In older patients with Byler disease, liver
At laparotomy,
a gastroduodenal
intussusception
caused
by a
mass in the stomach was found. The intussusception was easily reduced, although the gastric antrum and duodenal bulb were mod-
Fig.
1.-Gastroduodenal
Hepatoma
biopsies
intussusception
Complicating
often
show
Byler Disease
progression
to
biliary
cirrhosis
[1 -4].
We
de-
A subtotal gastrectomy with gastrojejunostomy was performed. The pathologic diagnosis was a sessile type of tubular adenoma of the stomach with early malignant transformation. Gastric intussusception is usually associated with benign gastric tumors such as leiomyoma, adenoma, and lipoma. CT findings in
scribe a case of Byler disease in a 29-year-old man in whom a hepatocellular carcinoma developed. The patient was being considered for orthotopic liver transplantation for treatment of Byler disease. At the time of the evaluation for liver transplantation, the patient
cases of gastroduodenal
Laboratory tests indicated that the patient had lipid-soluble hypovitaminosis, elevated levels of serum alkaline phosphatase, and markedly elevated levels of serum a-fetoprotein. Contrast-enhanced abdominal CT and MR imaging showed a low-attenuation region in the liver that was not present on a previous CT scan (Fig. 1 ). A sonographically guided percutaneous needle biopsy of the lesion was performed. Pathologic examination showed hepatoma with underlying micronodular biliary cirrhosis. The patient received an orthotopic liver transplant and had no evidence of recurrent or metastatic disease after 1 year. In 1969, Clayton et al. [1 ] described a progressive familial intra-
erately edematous.
intussusception are characteristic. The site can be seen as an abnormal targetlike mass in the
of the invagination duodenal region on CT scans. CT also may show foreshortening beaklike
narrowing
in the
distal
stomach.
be made on the basis of such findings
greater and lesser omentum. obstruction of the gastric outlet
The
correct
diagnosis
as an invagination
and can
of the
Other CT findings include signs of and
multiple
concentric
layers
within
a mass. Hyun K. Ha
Catholic
University Seoul
Kyung S. Shinn In C. Kim Yong W. Bahk Medical Co//ege 137-701,
Korea
had had vague
pain in the right upper
quadrant
for several
hepatic cholestasis syndrome in several descendants immigrant acids.
Byler
named Byler, all of whom had elevated disease
is the
second
most
common
months.
of an Amish
serum levels of bile form
of
familial
Pretoria
W. K. Andrew Eugene Marais Hospitaa/ 0002, Republic of South Africa
REFERENCE RM, Coidwell DM, Ben-Menachem V. Ligamentous compression the celiac axis: CT findings in five patients. AiR 1991;156:1101-1103
of
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1 . Patten
Reply
The median arcuate medial in a 29-year-old
Fig. 1.-Hepatocellular carcinoma ease. A, CT scan with contrast material
shows
man with Byler dis-
a peripherally
enhancing
mass
4 cm In diameter in left lobe of liver that proved to be hepatocellular carcinoma. Note also dilation of intrahepatic biliary ducts, consistent with
Byler disease. B, Corresponding
lateral
TI-weighted MR image shows area of low lobe of liver.
signal
in
of left
segment
decussate
cholestasis
that becomes
apparent
in infancy;
the first is
Alagille’s syndrome. Inheritance of the disorder is presumed to be autosomal recessive [4]. Patients characteristically have jaundice, pruritis, or hepatomegaly in the first year after birth. Laboratory tests
borders
ligament
originates
as a condensation
of the two crura of the hemidiaphragm
of the as they
toform
is a variable
the ventral border of the aortic hiatus. The ligament In most autopsy specimens, it can be seen as round, fibrous cord 1-3 mm wide; however, in others,
structure.
a well-defined
only an amorphous area of connective tissue can be detected. Similarly, the relationship of the origin of the celiac axis to the median arcuate ligament of the diaphragm is an extremely variable
one, because origin
intrahepatic
fibrous
of multiple
of the celiac
axis;
factors,
including
the height
the height and angle of
of the ligament;
and the body
habitus, sex, and age of the subject. We appreciate Dr. Andrew’s confusion
about the relationship
the median
axis
arcuate
ligament
to the celiac
as described
of
in our
[4]. Pathologic findings initially may be normal or show a giant-cell
paper [1]. We refer Dr. Andrew to an excellent 1971 clinicoanatomic analysis of this spatial relationship between the arcuate ligament of the diaphragm and the celiac artery in 75 fresh autopsy specimens [2]. In most cases, the median arcuate ligament resembles an inverted U, passing superior to the origin of the celiac axis in its midportion
hepatitis.
but extending
cirrhosis
more laterally. Yet in 36 (48%) of dissections, Lindner and Kemprud [2] found that the ligament sagged inferiorly in its midportion, passing anterior and inferior to at least part of the origin of the celiac artery, and thereby creating the potential for ligamentous compression of the artery against the aorta. Although the clinical syndrome of intes-
show elevated serum levels of bile acids, high serum levels of alkaline phosphatase,
and intermittent
elevation
of serum levels of bilirubin
Later in the course of the disease, micronodular biliary and portal hypertension may occur. Death because of hepatic failure in the second decade of life is the norm. Recently, orthotopic liver transplantation has been used to treat Byler disease. The neoplastic potential of familial intrahepatic cholestasis is not generally known. Two previous reports [3, 4] of malignant tumor in this disease have been described. Patients with Byler disease likely
have an increased risk of hepatocellularcarcinoma
developing if biliary
cirrhosis develops before they die of hepatic failure. Patients with biliary atresia, tyrosinosis, and a-i -antitrypsin deficiency have a similar risk. Frequent radiologic and laboratory examinations may make early diagnosis of complicating hepatoma possible and accelerate therapeutic intervention (transplantation) of this relatively rare complication of Byler disease. Shawn P. Quillin James A. Brink Ma//inckrodt Institute of Radiology Washington University Medical Center St. Louis, MO 63110
REFERENCES 1 . Clayton RJ, Iber FL, Ruebner BH, et al. Byler disease: fatal familial cholestasis in an Amish kindred. Am J Dis Child 1969;1 17:112-124 2. Dahms BB. Hepatoma in familial cholestatic cirrhosis of childhood. Arch Pathol Lab Med 1979;103:30-33 3. Ugarte N, Gonzales-Crussi F. Hepatoma in siblings with progressive familial cholestatic cirrhosis of childhood. Am J Clin Pathol 1981;76: 172-1 77 4. Riely CA. Familial intrahepatic cholestatic syndromes. Semin Liver Dis 1987;7:1 19-133
Ligamentous In their article,
Compression “Ligamentous
of the Celiac
Axis:
CT
Findings in Five Patients” [1], which appeared in the May 1991 issue of the AJA, Patten et al. state that the median arcuate ligament usually passes posterior and inferior to the origin of the celiac axis. This
seems
to me to be anatomically
axis is an intrathoracic structure, ligament of necessity is anterior to the origin of the celiac axis.
impossible,
unless
and inferior
tinal ischemia (median entity is controversial,
well documented
to the origin
of the celiac
arcuate ligament syndrome) related the anatomic relationship discussed
axis
to this here is
[3, 4]. R. M. Patten D. M. Coldwell
V. Ben-Menachem University
of Washington
School
of Medicine
Seattle,
WA 98195
REFERENCES
1 . Patten
RM, CoIdwell D, Ben-Menachem
the celiac axis: CT findings
in 5 patients.
V. Ligamentous AiR
1991;156:
compression 1101-1103
of
2. Lindner HH, Kemprud E. A clinicoanatomic study of the arcuate ligament of the diaphragm. Arch Surg 1971;103:600-605 3. Dunbar JD, Molnar W, Beman FF, Marable SA. Compression of the celiac trunk
and abdominal
angina.
AiR
1965;95:731-743
4. Reuter S. Accentuation of celiac compression by the median arcuate ligament of the diaphragm during deep expiration. Radiology 1971;98: 561-564
Bilateral Posttraumatic Detected with CT
Adrenal
Hemorrhage
A 26-year-old man was admitted to our hospital after being in a motor vehicle accident. Abdominal examination showed distension, rigidity, and tenderness. The patient rapidly became hemodynamically
of the Celiac Axis Compression
posterior
the celiac
which it is not. The median arcuate to the aorta and therefore superior
unstable. Exploratory bleeding
laparotomy
splenic laceration,
inal CT scans obtained of free intraabdominal
showed hemoperitoneum
and splenectomy
was performed.
and a Abdom-
24 hr after laparotomy showed a small amount fluid, hematoma of the splenic bed, and soft-
tissue contusion of the left flank. Both adrenal glands were enlarged and had an unusually high density (Fig. i). These findings were consistent with bilateral adrenal hemorrhage. The clinical course was not favorable, and 24 hr later the patient died of cardiac arrest.
434
LETTERS
Fig.
1.-Abdominal
CT
scan
shows enlarged, high-density ad-
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renal glands (arrows), infiltration of perirenal fat, and hematoma of sic bed.
AJR:i59,
amount of meniscal degeneration as do nonrunner athletes.” The study was constructed such that the only subjects were asymptomatic marathon runners who volunteered to participate. Therefore, the conclusions can relate to asymptomatic marathon runners only
to include marathon
runners in general. It is
possible, and in fact likely, that of all marathon tomatic runners make up only a small subset.
broad, more generalized
Adrenal hemorrhage in adults is uncommon and is usually associwith trauma, septicemia, or anticoagulant therapy [1 -3]. The CT findings of this condition have been well described [2, 4]: an adrenal mass with homogeneous hyperdensity and streaky infiltration of the periadrenal fatty tissue. In most cases, the lesions are unilateral, on the right side; approximately 20% of posttraumatic adrenal hemorrhages are bilateral [4]. A susceptibility to massive intraglandular bleeding
adrenal
is probably related to the complex vascular supply of the glands [1 ]. They have a rich vascular supply coming from
Each adrenal gland is drained
by a single central
trauma
that
compresses
the gland
against
the spine,
acute
increase in intraadrenal pressure due to compression of the inferior vena cava, and shearing of small vessels as a result of deceleration forces [3, 4]. In our case, hemorrhage as a result of compression of the inferior vena cava seems to be the most likely explanation for hemorrhage in the right adrenal gland, because blunt trauma occurred to the left side only. Detection
trauma
of bilateral
has important
condition amenable clinical manifestations
adrenal
hemorrhage
clinical implications.
in a patient
with
severe
This is a life-threatening
to treatment with corticosteroid therapy, and the are often serendipitous in the early stages. The
adrenal glands must be thoroughly
evaluated
during CT examination
of patients with blunt abdominal trauma, because adrenal hemorrhage is often overshadowed
by more spectacular
from the data, all marathon
run-
and injured runners would be quite different those in asymptomatic runners.
when compared
with
Michael M. Tersegno Auburn Memorial Hospital Auburn, NY 13021
REFERENCE 1 . Shellock
FG, Deutsch AL, Mink JH, Kerr R. Do asymptomatic marathon have an increased prevalence of meniscal abnormalities? An MR study of the knee in 23 volunteers. AJR 1991;157: 1239-1 241 runners
vein that emerges any acute increase
vein. Therefore,
in adrenal venous pressure would result in hemorrhage into the gland. Traumatic adrenal hemorrhage has three possible mechanisms: direct
statement
runners, the asympIn order to make a
ners, symptomatic or asymptomatic, would need to be included in the selection set, even those who have stopped running because of injury. I suggest that the MR meniscal findings in symptomatic runners
branches of the inferior phrenic artery, the aorta, and the renal artery. from the hilum as a single adrenal
1992
conclusion states, “Our results indicate that the prevalence of meniscal tears in marathon runners is no higher than the prevalence reported for sedentary persons, and the runners have the same
and cannot be extended
ated
August
findings
Reply I agree with Dr. Tersegno that the results of the study [1] specifipertain to the knees of asymtomatic marathon runners and that further study of symptomatic runners would be necessary in order to make a statement about marathon runners in general. My colleagues cally
and I were particularly
images because of their age (average, 40 years) and intense training (average time in training, 10 years; average distance per week training,
41 miles);
elsewhere. Carlos Valls Eduard Andia Isabel Gil
Hospital
de Be/lvitge
Barcelona,
Spain
Isabel Conde University
of Barcelona
Barcelona,
Spain
explicit with our inclusion criteria for this study
so that we could compare our results with those of previous studies that reported MR findings in the knees of asymptomatic populations of athletes and more sedentary persons. We think that our data were of interest because our subjects represent a group who would likely have a higher prevalence of meniscal signal abnormalities on MR
yet, they did not.
University
Frank G. Shellock Tower Musculoskeletal Imaging Center of California, Los Angeles, School of Medicine Los Angeles, CA 90048
REFERENCE 1 . Shellock FG, Deutsch AL, Mink JH, Kerr R. Do asymptomatic marathon runners have an increased prevalence of meniscal abnormalities? An MR study of the knee in 23 volunteers. AJR 1991;157: 1239-1 241
REFERENCES 1 . Rao RH, Vagnucci AH, Amico JA. Bilateral massive adrenal hemorrhage: early recognition and treatment. Ann Intern Med 1989;1 10:227-235 2. Wolverson MK, Kannegiesser H. CT of bilateral adrenal hemorrhage with
acute adrenal insufficiency
in the adult. AiR 1984;142:31 1-314 J, Yrizarry JM. Traumatic adrenal hemorrhage: radiologic fIndings. Radiology 1988;169:70i-703 4. Wilms G, Marchal G, Baert A, et al. CT and ultrasound features of posttraumatic adrenal hemorrhage. J Comput Assist Tomogr 1987;1 1: 112-115
3.
Murphy
Meniscal Shellock
BJ, Casillas
Tears in Marathon et al. present an interesting
Runners
article [1] that gives encouragement to those of us who would call ourselves “runners.” The
Transfemoral Venous Catheterization Inferior Vena Caval Filters In their recent article [1], Hansen et al. with diagnostic and therapeutic procedures instruments were passed through existing from a femoral vein approach. They advocate of this technique, while suggesting that it
radiologists
Through
describe their experience in seven patients in which inferior vena caval filters the safety and feasibility is a practicable option for
who “may not find the transjugular
route
a desirable
alternative.” Notwithstanding their favorable results in these seven patients, we propose that this is a small series on which to base such
conclusions. the inferior
lodging
In addition, vena
an inferior
cava,
in our opinion, dislodging
the probable
thrombus,
risk of injuring
and damaging
or dis-
vena caval filter during a transfemoral-transfilter
catheterization is greater than the probable risk of performing these same procedures via a jugular vein puncture without traversing an
through patients.
implanted
be used to perform pulmonary arteriography, venous sampling, hepatic vein manometry, and right-sided heart catheterization as Hansen
filter.
Percutaneous
access
to the internal
standard procedure for interventional vein are easily detected by using
jugular
vein should
be a
radiologists. Landmarks for the inspection and palpation. One
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approach is to make the puncture posterior to the sternocleidomastoid muscle, just cranial to where the external jugular vein crosses, about midway between the mastoid tip and the clavicle. The needle is then directed toward the sternal notch while the carotid artery is deflected medially. A favored method in our division is a more anterior
approach: The needle is advanced with one hand from the apex of the division of the sternocleidomastoid muscle along the medial aspect of the lateral belly of the muscle while the carotid artery is palpated and retracted with the opposite hand. To minimize the risk of injury to adjacent structures in the neck and chest, especially the carotid artery and the apical pleura, we first use a 21-gauge needle
implanted filters to place additional Vena-Tech filters in two In addition, although a catheter may fit through a filter and
et al. advocate, the extensive manipulation of the catheter that frequently is required during these procedures causes us even greater concern. Working through a long sheath may help reduce this risk, but it would also add to the diameter of the system needed to pass through the filter. Finally, Hansen et al. do not discuss the implications
of puncturing
femoral veins that may have
damaged
been
or become
thrombosed during the initial filter placement and the effect repeat puncture might have on the development or worsening of chronic venous stasis disorders that occur in a small percentage of patients with vena caval filters, even the new smaller filter systems [4, 5]. Thrombosis of the jugular vein, on the other hand, is almost never chronically symptomatic [6]. In summary, we think the technique advocated by Hansen et al. should be used in only the most limited circumstances, when no other
(Cook Inc., Bloomington, IN) and a single-wall technique. After venous blood is aspirated, a 0.01 8 in. (0.46-mm) Cope mandril wire (Cook Inc.) is inserted via the needle and steered into the superior vena cava, across the eustachian valve, and into the inferior vena cava. At
approach is available. We encourage using jugular vein access for these procedures in order to avoid manipulation through or near a filter and associated caval thrombus. We agree with the authors that
this point,
clinical
the mandnl
wire
is exchanged
for a 0.035-
or 0.038-in.
judgment
should
be exercised
(0.89- or 0.97-mm) guidewire through a 4-French Desilets-Hoffman introducer (Cook Inc.). Access to the external jugular vein can be
experience
should be obtained.
lar venous
catheterization
obtained
clinically
with the same equipment
externaljugular occlusion.
helpful
and often
veins are superficial,
The
steerability
in negotiating
of the
because
visible, and distensible
0.01 8-in.
the turn from
is easier
mandril
the external
wire
most
by finger
is particularly
jugular vein into the used for placement of
safer,
transfemoral-transfilter ogists
in these
especially
should
when
the
of six transjugular intrahepatic portosystemic shunts, six transjugular liver biopsies, and placement of one hemodialysis catheter. Ten of the 12 filters were placed by the transjugular route because of iliofemoral or inferior vena caval thrombus, one because of recent bilateral emboli
groin
surgeries,
presumably
from
and one thrombus
because found
of recurrent partially
pulmonary
encasing
a Bird’s
Nest filter. In addition, hepatic venous (free and wedged) contrast studies and manometry were easily performed in conjunction with placement of portosystemic shunts and in conjunction with most of the liver biopsies; access to the hepatic venous system is a particularly direct approach and is much easier than turning sharply into the the hepatic veins from the inferior vena cava. All 25 procedures were technically successful and without complications; in most cases, puncture. In past years, helpful
in performing
jugular access was obtained with the first we also have found the transjugular route
pulmonary
arteriograms
in patients
who
the heart from the superior
vena cava, although
it is possible
to insert them with greater difficulty via the inferior vena cava. An additional advantage ofjugular vein access is the ease of hemostasis. After the removal of even large filter sheaths, a mild elevation of the patient’s upper body and head significantly reduces venous pressure and risk of hematoma.
We acknowledge
the limited experience of Hansen et al., which
the
transjugular
route
a standard
radiol-
technique
in
David J. Eschelman David M. Hovsepian Joseph Bonn Jefferson University Hospital Philadelphia, PA 19107
AC, Transfemoral venous catheterization through inferior vena caval filters: results in seven cases. AJR 1991;157:967-970 2. McCowan TC, Ferns EJ, Carver DK, Harshfield DL. Use of the extemal jugular vein as a route for percutaneous inferior vena caval filter placement. Radiology
1990176:527-530
3. Simon M, Athanasoulis CA, Kim D, et al. Simon nitinol inferior vena cava filter: initial clinical experience. Radiology 1989;1 72:99-1 03 4. Hicks ME, Middleton WD, Picus D, Darch MD, Kleinhofter MA. Prevalence of local venous thrombosis after transfemoral placement of a Bird’s Nest vena caval filter. J vasc Intervent Radiol 1990;1 :63-68 5. Ricco JB, Crochet D, Sebilotte P. et al. Percutaneous transvenous caval interruption with the LGM filter: early results of a multicenter trial. Ann Vasc Surg 1988;3:242-247 6. Greenfield U, Michna BA. Twelve-year clinical experience with the Greenfield vena caval filter. Surgery 1988;104:706-712
Periocular Pseudocyst Caused Contact Lens: CT Appearance
[1] shows
how
a 7.i -French catheter could fit between filter elements, it does not show the larger 12-French (outer diameter) filter sheath they passed
by a Displaced
A 21-year-old man was struck in the left eye with a croquet mallet when he was wearing rigid gas-permeable contact lenses composed of pasifocon
A and B. The patient
contact
lens was missing
ground.
Three
years
left eye. Palpation the left upper contact lens.
could
3 in the article
and
than
is used,
1 . Hansen ME, Geller SC, Yucel EK, Egglin TK, Waltman
transjugular
Figure
needle
easier
REFERENCES
with
Although
transjugu-
is technically
We think that interventional
Thomas
shows that it may be feasible to work through existing inferior vena caval filters. However, we are concerned that use of this technique would be advocated as being as safe as or safer than use of a approach.
patients
already
have jugular venous access (a pigtail catheter from Cook, Inc. with an additional U-shaped secondary curve is used), saving them a separate femoral puncture, and in placing Swan-Ganz catheters (Baxter Health Care Corp., Irvine, CA), which are designed ideally to access
and that further
their practice.
superior vena cava. This approach has been titanium Greenfield filters, and it would be expected that the smaller and more flexible Simon nitinol filter, which has been inserted via the internal jugular vein, would also make this turn [2, 3].
From July to November 1 991 , we performed 25 procedures via the right internal jugular vein. These included placement of 12 vena caval filters (i 1 titanium Greenfield and one Bird’s Nest), placement
case
in our judgment,
a small
approach.
make
in each
However,
Coronal
later, he became
showed
possible contact
be pulled
during lens
aware
(Fig.
to the
about
the
from
the globe
the initial examination. within
the
inner
with
the patient
suture, more
of the
under
the upper lid
force
This maneuver surface
a
mass contiguous
i). With
and with an eyelid traction
embedded
that the left
knocked
the lid did not reveal
a cystic-appearing
to the left globe away
been
of discomfort
of the area under
orbital CT showed
general anesthesia
noted
it had
a firm, slightly mobile mass deep within
lid. Inspection
and superior
subsequently
and assumed
than
was
revealed upper
eyelid,
a
scan of orsuperior to left globe is bounded by contact lens and posterior surface of eyelid and contains fluid.
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Fig. 1.-CoronalCT bit shows pseudocyst
near the superior
conjunctival
fornix,
with the convex
surface
the globe. A pair of forceps was used to remove the contact Contact conjunctival
lenses fornix,
facing
lens.
occasionally may be displaced into the superior either spontaneously or as a result of trauma. The
contact lens may become embedded in the upper lid, as in this case, or may migrate into adjacent eyelid or orbital tissues [1 2]. Although physical examination will sometimes detect a displaced contact lens, ,
this may not always be possible because of the patient’s discomfort, lid inflammation, or, in younger patients, relatively tight tissues. A displaced contact lens should be considered in the differential diag-
nosis of superior
periocular
cystic-appearing
University
of Tennessee
lesions shown by CT. Herbert J. GIatt Medical
Center at Knoxville Knoxville, TN 37920
REFERENCES 1 . Homblass A, Kass L. Contact lenses in the upper eyelid masquerading as lid masses. Ophthalmic Surg 1987;18:438-440 2. Nicolitz E, Flanagan J. Orbital mass as a complication of contact lens wear.
Arch Ophthalmol
1978;96:2238-2339
CT of Schizencephaly A 9-year-old
boy had psychomotor
retardation
and seizures
and
failure to thrive. CT scans showed moderate dilatation of the lateral ventricles and absence of the septum pellucidum. An apparent umbilication
was
seen
at the
border
of the
left
lateral
ventricle,
and
a
barely visible one was present on the right side (Fig. 1 A). In both hemispheres, abnormal (heterotopic) gray matter extending from the ventricular wall to the periphery was clearly detectable. A cleft was
visible localized
rounded
on the left side within defect
was
by heterotopic
present
the heterotopic near
gray matter
the
right
gray matter, ventricular
and a
edge,
sur-
Fig. 1.-Schizencephaly in a 9-year-old boy. A, CT scan shows moderate dilatation of lateral ventricles and absence of septum pellucidum. Note also apparent umbilication at left ventricular
border small CSF-filled cavity adjacent to left parietal bone, representing the peripheral end of a cleft (see B); and barely visible umbilication at right ventricular border. B, CT scan at level higher than A shows a cleft on left; surrounding heterotopic gray maSer is clearly identifiable. On right, a small cavity connects with ventricle and no cleft is visible; a large amount of heterotopic gray matter surrounds this cavity and extends to cortex.
heterotopic gray matter around a cleft is considered pathognomonic for schizencephaly, distinguishing it from an acquired condition. This finding can be shown by CT but is best delineated by MR [1-3]. In the present case, the cleft on the left side, which is lined with heterotopic gray matter, is typical for an open schizencephalic defect. On the right side, however, only a small CSF-filled cavity is present surrounded by heterotopic gray matter without an apparent cleft; this represents a closed schizencephalic defect. Therefore, this case represents a simultaneous manifestation of the two forms of schizencephaly. In addition, we think that the apparent umbilication, particularly at the left ventricular border, may be a secondary CT finding signifying the presence of schizencephaly, in the event that a cleft is not visible. A. Nun Sener G#{252}ner Bilgin Ahmet Memis and colleagues Hospital
(Fig. 1 B).
Bornova,
Schizencephaly is one of the migrational disorders of the brain, which include lissencephaly, pachygyria, heterotopia, and polymicrogyria. It is characterized by clefts extending across the hemispheres;
of Ege
lzmir,
University
35100,
REFERENCES 1 . Byrd SE, Osbom RE, Bohan TP, Naidich TP. The CT and MR evaluation
the clefts are lined with pial-ependymal tissue and bounded, either totally or in part, by heterotopic gray matter. The cleft may be open
of migrational disorders of the brain. Part II. Schizencephaly, and polymicrogyria. Pediatr Radiol 1989;19:219-222
heterotopia
(open schizencephaly) or closed (fused-lip schizencephaly). The clefts are commonly seen in the parietal and temporal regions. They are
2. Zimmermann
usually bilateral and may be symmetric. Unilateral clefts can also occur and should be distinguished from acquired clefts that can occur after a nonpenetrating contusive injury to the brain. The presence of
1983;25:257-263 3. Silverman FN. Caffey’s pediatric X-ray diagnosis: an integrated approach, 8th ed., vol. 1 . Chicago: Year Bock Medical, 1985:206
Letters
are published
at the discretion
of the Editor
migratory
RA, Bilaniuk LT, Grossman disorders
and are subject
of
human
brain
RS. Computed development.
to editing.
Letters to the Editor must not be more than two double-spaced, typewritten pages. One or two figures may be included. Abbreviations should not be used. Limit the number of authors to four, or we will list only the first three and add “and colleagues” to the end of the list. See Author Guidelines. Material being submitted or published elsewhere should not be duplicated in letters, and authors of letters
must disclose
financial
associations
or other
possible
conflicts
of interest.
Letters concerning reply to be published
a paper published in the AJA will be sent to the authors of the paper for a in the same issue. Opinions expressed in the Letters to the Editor do not
necessarily
opinions
reflect
the
of the
Editor.
Turkey
tomography Neuroradiology imaging
in
427
Letters
referral patterns.
The Selling of a Profession
specialty Increasingly,
economic
issues
dominate
the practice
of radiology,
often overshadowing the more stimulating intellectual challenges that attracted us to the specialty. Vexations such as turf battles, restrictions of third-party payers, and the rampant federal bureaucracy captured our attention and absorbed our energies during the decade of the eighties. Generally, radiology is weathering these trials, as it is a unified society bound to the commitment to abide by the ethical guidelines that best serve the specialty and, most importantly, our patients. As the centennial of radiology approaches, a little-publicized insidbus practice threatens the integrity of our discipline. I refer to the practice of allowing nonradiologists to interpret images and bill for or be paid for their services within radiologic facilities, an abuse that threatens the very core and foundation of the specialty. We witness fellow radiologists laying aside moral principles and medical ethics as they shamelessly sell their rights to imaging to nonradiologists. It is disheartening to see under the letterhead of a radiologist or an imaging group directed by radiologists reports generated by nonradiologists.
Such
sinister
ventures
to
which
radiologists
are
party
foretells a splintering and fragmenting of radiologic care. Although many of us left the bitter turf battles of the eighties bloodied
but resolute,
a few compromised
their
specialty
and wel-
the nonradiologist interlopers with open arms and open checkbooks. These radiologists were not coerced into such dangerous liaisons; indeed, some actively sought these arrangements.
comed
Clearly,
these
self-referral
abuses
represent
the extreme
in conflict
of interest inasmuch as the nonradiologist who perpetrates the misuse of imaging both requests and interprets the imaging study. In such practices, a spin-off of laissez-faire medicine, the goals are not improvement in the quality of imaging or better service but rather personal financial gain. These ersatz radiologists covet the crown jewels of radiology: MR and CT. The more prosaic and less well compensated plain films do not interest them; and please, paying patients only-no pro bono work. Recent Stark amendments may herald an increase in such practice patterns; the abusers cleverly attempt to bypass the sanctions of kickback regulations. The abusive arrangements, of which the patient is not aware or has been misled about, fall far short of the ideals of practice. How can organized radiology respond to such perilous intrusions? (1) Recognize that such practice patterns exist and should be discouraged. (2) Adopt more stringent ethical guidelines. The American College of Radiology should take a leadership role in this matter. (3) Let the public know of these practices and how such practices abuse
(4) Serve notice on radiologic
of radiology
pretenders
that the
is not for sale.
Congressman Stark (D, CA) sent a clear warning to all of medicine when he stated, “Physician ownership/referral arrangements represent an exploding virus which ultimately will erode the trust patients have traditionally placed in their physicians” [11. A profession is a bond, and trust is the glue that seamlessly holds the profession together and defines its nature. The professional societies in radiology seek to maintain a high level of standards and to promote excellence in imaging; as well, they foster intellectual exchange, encourage collegiality, and defend ethical practice patterns. Those who would shatter the links of that professional bond, who would sully the trust that holds them to professional standards, should make the rest of us fear for the future. Their chilling example reminds us of Gresham’s law that
the bad
Membership
drive
out the good.
in a society
of
specialists
carries
with
it an
implied
contract. Arnold Relman, in a recent Shattuck lecture, wrote, “Most of us believe we are parties to a social contract, not a business contract” [2]. In radiology, that contract, or covenant, charges us to provide quality imaging in an ethical and honest manner. That goal serves
best
the
paramount
interests
of
the
patient
and
eschews
those of the self-referring physician. When the boundaries of ethics are trespassed, it is the obligation of the other members of the specialty to condemn such transgressions and to serve notice that the interests of radiology and the patient are being poorly served. If we
are to survive
as a specialty,
the
collaboration
with
self-referring
nonradiologist physicians-in essence the selling of the professionmust cease as a viable practice option. James F. Lally Christiana
Hospita/,
Medica/
Center of Oe/aware Newark, DE 19718
REFERENCES
1 . Iglehart JK. Health policy report: Efforts to address the problem of physician self-referral. N EngI J Med 1991;325:1820-1824
2.
Relman
AS. Shattuck
lecture.
The health
care
industry:
where
is it taking
us? N Engl J Med 1991;325:854-859
Winning the Turf War It starts early, in medical school. “I’m on radiology next month. I the vacation to sit back, relax, and enjoy the friendly radiologists.” It has been 12 years since my third-year rotations, and I am still hearing the same remarks from today’s students. need
LETTERS
428
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As a radiologist in private practice (also 2 years as an assistant professor), I know radiology is no vacation, but my nonradiology colleagues do not. This hurts radiologists at the bargaining table from hospital committees to negotiations on Relative Value Schedules. It is time we stop spoon-feeding our medical students and instead give
AJR:159, August 1992
considered
as a possible
septicemia
or endocarditis.
cause
of hemoptysis
in patients Vincent
them a dose of the real world as the other specialties do. For example, night call with the emergency department resident, hours of arteri-
ography with lead apron, teaching assignments, and participation in communicating results to referring physicians would do for a start. I urge my academic colleagues to look beyond the textbooks and consider the political roots of preserving the prestige of our specialty. The Magnetic
Louis Institute
Resonance
A. Friloux III of Ar/ington
Ar/ington,
Mycotic Aneurysm of the Bronchial Cause of Hemoptysis
VA
22206
Poland’s
Vigo,
Erlangen,
Germany)
died 4 weeks
of dura
controlled
the
(Totoplast
Dura;
hemoptysis
(Fig.
later of multiple organ failure.
Bleeding from bronchial arteries is usually due to chronic pulmonary infection, pneumoconiosis, or tumor [1 2]. To our knowledge, rupture of a mycotic aneurysm of the bronchial artery in adults has not been previously reported. Angiographic features of mycotic aneurysm are ,
nonspecific,
and
congenital
aneurysms
Large Benign Fibroma
are difficult
to exclude.
of the Pleura in
A 31 -year-old man had routine chest radiography before sinus surgery. The radiographs showed a large right-sided pleural effusion (Fig. 1 A). The patient said he had had progressive exertional dyspnea for 4 years. Axial CT scans showed a large, heterogeneously enhancing soft-tissue mass and pleural effusion occupying much of the right hemithorax and absence of the right pectoralis muscle (Figs. 1 B
cartilage;
bronchoscopy no obstructing
of the right hand was noted incidentally. showed lesion
At the time of thoracotomy, After drainage of approximately circumscribed,
Grossly,
only was
absence
right
Sub-
bronchus
found.
the right lung was totally collapsed. 3 I of serosanguineous fluid, a well-
20 x 1 2 x 1 0 cm pleura-based
the adjacent
of the
mass
was
resected.
lung and chest wall were not involved.
Histo-
Rapid
Fig. 1.-Benign fibroma of pleura in a 31-year-old man with Poland’s syndrome. A, chest radiograph shows
growth of the aneurysm is associated with risk of rupture, and prompt treatment is required. Selective embolization of the bronchial arteries is simple and reliable. It results in rapid control of the hemoptysis, even in a patient whose condition is unstable [1 -3]. This case emphasizes that mycotic aneurysm of a bronchial artery should be
opacification
B
Fig. 1.-Mycotic aneurysm of bronchial artery in a 34-year-old man with hemoptysis. A, Arteriogram shows small aneurysm (arrow) on distal part of left bronchIal artery and no extravasation of contrast medium. B, Arteriogram obtained after embolization shows left bronchial artery is occluded.
of right
hemfthorax
and no mediastinal shift. B and C, contrast-enhanced cT scans show a large, heterogeneously enhancing mass in right hemithorax (B, C), absence of right pectoralis muscle(B), and right-sided pleural effusion (C).
A
A
France
Syndrome
sequent
1 B). The patient
Paris,
1 . Remy J, Arnaud A, Fardou H, Giraud R, Voisin C. Treatment of hemoptysis by embolization of bronchial arteries. Radiology 1977;122:33-37 2. Vujic I, Pyle R, Hungerford GD, Griffin CN. Angiography and therapeutic blockade in the control of hemoptysis. Radiology 1982;143:19-23 3. Rabkin J, Astavjef V. Gothman L, Grigorjev V. Transcatheter embolization in the management of pulmonary hemorrhage. Radiology 1987;163: 361-365
and 1 C). Syndactyly
Pfrimmer
Sibert
REFERENCES
dium.
fragments
Denys
Annie
H#{244}pita/Bichat 75018
severe hemoptysis occurred. Selective bronchial arteriography showed a small aneurysm (diameter, 1 7,000 examinations per year), we cannot break even
economically
of $50
at a charge
approximately
per examination-and
$45 per examination,
our cost
is
even with high volume. Ronald G. Evens
Malilnckrodt Institute of Radiology Washington University Medical Center St. Louis, MO 63110
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431
LETTERS
August 1992
AJR:159,
Dr. Evens
is mistaken
accounting
1 . Warren Burhenne Li, Hislop TG, Burhenne HJ. The British Columbia mammography screening program: evaluation of the first 15 months. AiR 2. Vogel VG, Peters GN, Evans WP, Texas Breast Screening Project Scientific Review Committee. Design and conduct of a low-cost mammography screening project: experience of the American Cancer Society, Texas division. AJR 1992;158:51-54 3. Sickles EA. Low-cost mass screening for breast cancer with mammography (commentary). AiR 1992;158:55-57
In regard
is done
to the recent
article
[1] on the British
Columbia
mam-
by independent
accountants.
during
The unit cost of $32.66
the first 15 months
has actually decreased
per examination.
Two
operation
that they might
were adopted
get exactly
what
and expanded
they paid for if a program
to a nationwide
like this
unit costs
of $26.54 in the
for the center
Lower
Mainland.
Charles North Bakersfield,
CA 93302-0119
provincial
volunteer
expenses
such
and the report
responsible
for follow-up.
We
states
do
not
that
understand
he cannot
be added
Dr.
Evens’s
even
which
is done by
as the Cancer
last
for
in all unit-cost
of the provincial add that the unit
is sent to this physician,
break
in
for the one
should
centers We should
now
each year show
and $30.24
$4.62
for promotion,
organizations
registration,
Society.
All
name on
who will then be
paragraph
economically
in which
he
though
he
even
that costs him $45. This runs contrary
to his request for defining cost with rigid science. We would also like to put Dr. North at ease, because any one of our 24 radiologist-
in seven centers can read and get his professional
1 00 screening
1 . Warren Burhenne U, Hislop TG, Burhenne HJ. The British Columbia mammography screening program: evaluation of the first 15 months. AJR
screened
in Victoria Again,
to $26.50
Columbia
women who are screened are required to give a physician’s
screeners REFERENCE
in British
but office rental is now included
amortization,
charges $50 for an examination
project.
We can now
and now amounts
centers
with more than 10,000 patients
in Surrey capital
additional
cost does not include
Consider
per examination
of our program.
woman screened
convinced that this is a truly realistic for a moment the concern about
as presented.
was
report cost accounting for 3Y2 years in the same pilot program center with mammography screening of 35,650 patients. The unit cost per
figures. Four additional mammography screening program opened last year.
breast cancer and think about undergoing a testing procedure knowing that the person who ultimately is responsible for interpreting the results will be paid slightly more than lunch at McDonald’s would cost. Persons do get what they pay for, and over a large series of screening examinations, I fear
US$32.66
amortization and $1 .08 for office rental. Cost detailed fashion by the director of finance of Cancer Agency, and annual audits are performed
mography screening program, although the concept of low-cost mammography screening certainly has merit, I am not the least bit program
that
in a
the British Columbia prevailed
1992;158:45-49
he assumes
all expenses (in U.S. dollars) such as salaries and benefits, professional fee, film cost, and equipment maintenance; $4.62 should be
added for equipment REFERENCES
when
“paid” per examination. We clearly state that this was the “cost” per patient allotted against a government grant, and the breakdown is analyzed in the Results section of our article [4]. The cost includes
mammograms
fees for
per hour, the same time that it probably
takes Dr. North to have lunch at McDonald’s. L. J. Warren Burhenne T. G. Hislop
1992;158:45-49
H. J. Burhenne University of British Vancouver, B.C., Canada
Replies We are pleased
to respond
to the concerns
of Drs.
Evens
and
North. Already in 1986, Dr. Evens [1] doubted documentation of lowcost screening mammography [2, 3] in the United States. The low cost of high-volume screening mammography depends, to some extent, on the differences between screening and diagnostic mammography. Diagnostic mammography in a radiology department is time-consuming for the radiologist: he or she must be in the department, ensure that a good history is obtained, be available to consult with the patient, review routine projections and request specialized views, mount the mammograms, and dictate a detailed report. He or she must sign the completed report and contact the referring physician in involved
cases.
Screening
mammography
while
he or she reads
the mammograms
and pushes
one of
two buttons on the computer, which generates a paragraph stating either that the mammogram is normal and the patient should return at a specified interval or that the mammograms appear to be abnormal and requesting the patient’s physician to proceed to diagnostic mammography. Two technicians have taken, during the daytime, in one room, mammograms at a rate of six to 10 patients per hour, and the patients have filled in a questionnaire. By contrast, diagnostic mammography
permits
scheduling
of no more than three patients
hour in a room with more sophisticated
equipment.
REFERENCES 1 . Evens
RG. Mammographic
cost (letter).
Radiology
screening: 1986;161 :850
how to operate
successfully
at low
2. Bird RE, McLelland R. How to initiate and operate a low-cost screening mammography center. Radiology 1986;161 :43-47 3. Sickles EA, Weber WN, Galvin HB, Ominsky SH, Sollitto RA. Mammographic screening: how to operate successfully at low cost. Radiology 1986;160:95-97
4. Warren
Burhenne
mammography 1992;15:45-49
Li, Hislop TG, Burhenne HJ. The British Columbia program: evaluation of the first 15 months. AiR
screening
in a free-standing
clinic, on the other hand, does not require the presence of a radiologist: He or she comes in the evening to read premounted films with only two views of each breast. No telephone or other interruptions occur
Columbia V5Z 1M9
per
Dr. Evens is correct that we did not define cost as an economist would [1 ]. The low cost refers to fees charged per examination, rather than cost of performing the examination. We also agree that in some instances even with high volume, it is not possible to perform screening mammography
$50. However, viable
situation
and break
even
economically
with
others [2, 3] have shown that screening provided
the
examination
can
a charge
of
is a financially
be performed
in a
nonhospital setting. The 1987 American Cancer Society Texas Breast Screening Projoct was principally designed as an activity to promote screening It greatly increased public awareness about breast and the value of early detection. Quality assurance standards
mammography.
cancer
LETTERS
432
throughout couraged
AJR:159,
August
1992
the state were markedly improved, and the project enthe development of accreditation standards by the Ameri-
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can College of Radiology. Most, if not all, of the 306 participating facilities subsidized the $50 mammogram and, like Dr. Evens, did not break even at that charge. Subsequently, however, we have seen the fees for screening mammography reduced throughout the state. Most high-volume facilities now charge $45 to $75 per examination. Victor Vogel The University of Texas, M. 0. Anderson Cancer Center Houston, TX 77030 George
Peters
W. Phil Evans Bay/or University Medical Center Oailas, TX 75246 REFERENCES
A
1 . Vogel VG, Peters GN, Evans WP, Texas Breast Screening Project Scientific Review Committee. Design and conduct of a low.cost mammography screening project: experience of the American Cancer Society, Texas dMsion. AiR 1992;158:51-54 2. Bird RE, McLelland A. How to initiate and operate a low.cost screening mammography center. Radiology 1986;161 :43-47 3. Sickles EA, Weber WN, GaMn HB, Ominsky SH, Sollitto RA. Mammographic screening: how to operate successfully at low cost. Radiology 1986;160:95-97
Gastroduodenal Intussusception Prolapsed Gastric Adenoma A 63-year-old man with a diagnosis
Due to a B
of gastric
cancer
was referred
C
to our hospital. Intermittent postprandial epigastric discomfort and weight loss had begun 6 weeks before. An upper gastrointestinal barium study performed 1 month before showed a polypoid mass in the antrum ofthe stomach (Fig. 1A). Endoscopy at admission showed a 7 x 10 cm, ulcerated, polypoid mass arising from the anterior wall of the proximal part of the antrum of the stomach. Biopsy of the mass indicated adenocarcinoma. CT scans obtained 1 month later showed a large mass in the duodenum (Figs. 1 B and 1C) and no evidence of a mass in the stomach. Oral contrast medium did not
due to prolapsed gastric adenoma. A, Radiograph shows large polypoid mass (arrows) in antrum of stomach. B and C, CT scans show large soft-tissue mass (arrows, B) in duodenum and beaklike narrowing in distal stomach (arrowheads, C). Central lowdensity area within mass (B) represents fluid in duodenal lumen.
pass beyond the duodenum during CT scanning, even when the patient was in the right lateral decubitus position. An upper gastrointestinal series was not performed at this time.
Byler disease, a progressive familial intrahepatic cholestasis syndrome, was first described in 1969 [1]. The disease is often diagnosed early in life on the basis of pruritis, hepatomegaly, and elevation of serum levels of bilirubin. Most patients die of hepatic failure in the second decade of life. In older patients with Byler disease, liver
At laparotomy,
a gastroduodenal
intussusception
caused
by a
mass in the stomach was found. The intussusception was easily reduced, although the gastric antrum and duodenal bulb were mod-
Fig.
1.-Gastroduodenal
Hepatoma
biopsies
intussusception
Complicating
often
show
Byler Disease
progression
to
biliary
cirrhosis
[1 -4].
We
de-
A subtotal gastrectomy with gastrojejunostomy was performed. The pathologic diagnosis was a sessile type of tubular adenoma of the stomach with early malignant transformation. Gastric intussusception is usually associated with benign gastric tumors such as leiomyoma, adenoma, and lipoma. CT findings in
scribe a case of Byler disease in a 29-year-old man in whom a hepatocellular carcinoma developed. The patient was being considered for orthotopic liver transplantation for treatment of Byler disease. At the time of the evaluation for liver transplantation, the patient
cases of gastroduodenal
Laboratory tests indicated that the patient had lipid-soluble hypovitaminosis, elevated levels of serum alkaline phosphatase, and markedly elevated levels of serum a-fetoprotein. Contrast-enhanced abdominal CT and MR imaging showed a low-attenuation region in the liver that was not present on a previous CT scan (Fig. 1 ). A sonographically guided percutaneous needle biopsy of the lesion was performed. Pathologic examination showed hepatoma with underlying micronodular biliary cirrhosis. The patient received an orthotopic liver transplant and had no evidence of recurrent or metastatic disease after 1 year. In 1969, Clayton et al. [1 ] described a progressive familial intra-
erately edematous.
intussusception are characteristic. The site can be seen as an abnormal targetlike mass in the
of the invagination duodenal region on CT scans. CT also may show foreshortening beaklike
narrowing
in the
distal
stomach.
be made on the basis of such findings
greater and lesser omentum. obstruction of the gastric outlet
The
correct
diagnosis
as an invagination
and can
of the
Other CT findings include signs of and
multiple
concentric
layers
within
a mass. Hyun K. Ha
Catholic
University Seoul
Kyung S. Shinn In C. Kim Yong W. Bahk Medical Co//ege 137-701,
Korea
had had vague
pain in the right upper
quadrant
for several
hepatic cholestasis syndrome in several descendants immigrant acids.
Byler
named Byler, all of whom had elevated disease
is the
second
most
common
months.
of an Amish
serum levels of bile form
of
familial
Pretoria
W. K. Andrew Eugene Marais Hospitaa/ 0002, Republic of South Africa
REFERENCE RM, Coidwell DM, Ben-Menachem V. Ligamentous compression the celiac axis: CT findings in five patients. AiR 1991;156:1101-1103
of
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1 . Patten
Reply
The median arcuate medial in a 29-year-old
Fig. 1.-Hepatocellular carcinoma ease. A, CT scan with contrast material
shows
man with Byler dis-
a peripherally
enhancing
mass
4 cm In diameter in left lobe of liver that proved to be hepatocellular carcinoma. Note also dilation of intrahepatic biliary ducts, consistent with
Byler disease. B, Corresponding
lateral
TI-weighted MR image shows area of low lobe of liver.
signal
in
of left
segment
decussate
cholestasis
that becomes
apparent
in infancy;
the first is
Alagille’s syndrome. Inheritance of the disorder is presumed to be autosomal recessive [4]. Patients characteristically have jaundice, pruritis, or hepatomegaly in the first year after birth. Laboratory tests
borders
ligament
originates
as a condensation
of the two crura of the hemidiaphragm
of the as they
toform
is a variable
the ventral border of the aortic hiatus. The ligament In most autopsy specimens, it can be seen as round, fibrous cord 1-3 mm wide; however, in others,
structure.
a well-defined
only an amorphous area of connective tissue can be detected. Similarly, the relationship of the origin of the celiac axis to the median arcuate ligament of the diaphragm is an extremely variable
one, because origin
intrahepatic
fibrous
of multiple
of the celiac
axis;
factors,
including
the height
the height and angle of
of the ligament;
and the body
habitus, sex, and age of the subject. We appreciate Dr. Andrew’s confusion
about the relationship
the median
axis
arcuate
ligament
to the celiac
as described
of
in our
[4]. Pathologic findings initially may be normal or show a giant-cell
paper [1]. We refer Dr. Andrew to an excellent 1971 clinicoanatomic analysis of this spatial relationship between the arcuate ligament of the diaphragm and the celiac artery in 75 fresh autopsy specimens [2]. In most cases, the median arcuate ligament resembles an inverted U, passing superior to the origin of the celiac axis in its midportion
hepatitis.
but extending
cirrhosis
more laterally. Yet in 36 (48%) of dissections, Lindner and Kemprud [2] found that the ligament sagged inferiorly in its midportion, passing anterior and inferior to at least part of the origin of the celiac artery, and thereby creating the potential for ligamentous compression of the artery against the aorta. Although the clinical syndrome of intes-
show elevated serum levels of bile acids, high serum levels of alkaline phosphatase,
and intermittent
elevation
of serum levels of bilirubin
Later in the course of the disease, micronodular biliary and portal hypertension may occur. Death because of hepatic failure in the second decade of life is the norm. Recently, orthotopic liver transplantation has been used to treat Byler disease. The neoplastic potential of familial intrahepatic cholestasis is not generally known. Two previous reports [3, 4] of malignant tumor in this disease have been described. Patients with Byler disease likely
have an increased risk of hepatocellularcarcinoma
developing if biliary
cirrhosis develops before they die of hepatic failure. Patients with biliary atresia, tyrosinosis, and a-i -antitrypsin deficiency have a similar risk. Frequent radiologic and laboratory examinations may make early diagnosis of complicating hepatoma possible and accelerate therapeutic intervention (transplantation) of this relatively rare complication of Byler disease. Shawn P. Quillin James A. Brink Ma//inckrodt Institute of Radiology Washington University Medical Center St. Louis, MO 63110
REFERENCES 1 . Clayton RJ, Iber FL, Ruebner BH, et al. Byler disease: fatal familial cholestasis in an Amish kindred. Am J Dis Child 1969;1 17:112-124 2. Dahms BB. Hepatoma in familial cholestatic cirrhosis of childhood. Arch Pathol Lab Med 1979;103:30-33 3. Ugarte N, Gonzales-Crussi F. Hepatoma in siblings with progressive familial cholestatic cirrhosis of childhood. Am J Clin Pathol 1981;76: 172-1 77 4. Riely CA. Familial intrahepatic cholestatic syndromes. Semin Liver Dis 1987;7:1 19-133
Ligamentous In their article,
Compression “Ligamentous
of the Celiac
Axis:
CT
Findings in Five Patients” [1], which appeared in the May 1991 issue of the AJA, Patten et al. state that the median arcuate ligament usually passes posterior and inferior to the origin of the celiac axis. This
seems
to me to be anatomically
axis is an intrathoracic structure, ligament of necessity is anterior to the origin of the celiac axis.
impossible,
unless
and inferior
tinal ischemia (median entity is controversial,
well documented
to the origin
of the celiac
arcuate ligament syndrome) related the anatomic relationship discussed
axis
to this here is
[3, 4]. R. M. Patten D. M. Coldwell
V. Ben-Menachem University
of Washington
School
of Medicine
Seattle,
WA 98195
REFERENCES
1 . Patten
RM, CoIdwell D, Ben-Menachem
the celiac axis: CT findings
in 5 patients.
V. Ligamentous AiR
1991;156:
compression 1101-1103
of
2. Lindner HH, Kemprud E. A clinicoanatomic study of the arcuate ligament of the diaphragm. Arch Surg 1971;103:600-605 3. Dunbar JD, Molnar W, Beman FF, Marable SA. Compression of the celiac trunk
and abdominal
angina.
AiR
1965;95:731-743
4. Reuter S. Accentuation of celiac compression by the median arcuate ligament of the diaphragm during deep expiration. Radiology 1971;98: 561-564
Bilateral Posttraumatic Detected with CT
Adrenal
Hemorrhage
A 26-year-old man was admitted to our hospital after being in a motor vehicle accident. Abdominal examination showed distension, rigidity, and tenderness. The patient rapidly became hemodynamically
of the Celiac Axis Compression
posterior
the celiac
which it is not. The median arcuate to the aorta and therefore superior
unstable. Exploratory bleeding
laparotomy
splenic laceration,
inal CT scans obtained of free intraabdominal
showed hemoperitoneum
and splenectomy
was performed.
and a Abdom-
24 hr after laparotomy showed a small amount fluid, hematoma of the splenic bed, and soft-
tissue contusion of the left flank. Both adrenal glands were enlarged and had an unusually high density (Fig. i). These findings were consistent with bilateral adrenal hemorrhage. The clinical course was not favorable, and 24 hr later the patient died of cardiac arrest.
434
LETTERS
Fig.
1.-Abdominal
CT
scan
shows enlarged, high-density ad-
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renal glands (arrows), infiltration of perirenal fat, and hematoma of sic bed.
AJR:i59,
amount of meniscal degeneration as do nonrunner athletes.” The study was constructed such that the only subjects were asymptomatic marathon runners who volunteered to participate. Therefore, the conclusions can relate to asymptomatic marathon runners only
to include marathon
runners in general. It is
possible, and in fact likely, that of all marathon tomatic runners make up only a small subset.
broad, more generalized
Adrenal hemorrhage in adults is uncommon and is usually associwith trauma, septicemia, or anticoagulant therapy [1 -3]. The CT findings of this condition have been well described [2, 4]: an adrenal mass with homogeneous hyperdensity and streaky infiltration of the periadrenal fatty tissue. In most cases, the lesions are unilateral, on the right side; approximately 20% of posttraumatic adrenal hemorrhages are bilateral [4]. A susceptibility to massive intraglandular bleeding
adrenal
is probably related to the complex vascular supply of the glands [1 ]. They have a rich vascular supply coming from
Each adrenal gland is drained
by a single central
trauma
that
compresses
the gland
against
the spine,
acute
increase in intraadrenal pressure due to compression of the inferior vena cava, and shearing of small vessels as a result of deceleration forces [3, 4]. In our case, hemorrhage as a result of compression of the inferior vena cava seems to be the most likely explanation for hemorrhage in the right adrenal gland, because blunt trauma occurred to the left side only. Detection
trauma
of bilateral
has important
condition amenable clinical manifestations
adrenal
hemorrhage
clinical implications.
in a patient
with
severe
This is a life-threatening
to treatment with corticosteroid therapy, and the are often serendipitous in the early stages. The
adrenal glands must be thoroughly
evaluated
during CT examination
of patients with blunt abdominal trauma, because adrenal hemorrhage is often overshadowed
by more spectacular
from the data, all marathon
run-
and injured runners would be quite different those in asymptomatic runners.
when compared
with
Michael M. Tersegno Auburn Memorial Hospital Auburn, NY 13021
REFERENCE 1 . Shellock
FG, Deutsch AL, Mink JH, Kerr R. Do asymptomatic marathon have an increased prevalence of meniscal abnormalities? An MR study of the knee in 23 volunteers. AJR 1991;157: 1239-1 241 runners
vein that emerges any acute increase
vein. Therefore,
in adrenal venous pressure would result in hemorrhage into the gland. Traumatic adrenal hemorrhage has three possible mechanisms: direct
statement
runners, the asympIn order to make a
ners, symptomatic or asymptomatic, would need to be included in the selection set, even those who have stopped running because of injury. I suggest that the MR meniscal findings in symptomatic runners
branches of the inferior phrenic artery, the aorta, and the renal artery. from the hilum as a single adrenal
1992
conclusion states, “Our results indicate that the prevalence of meniscal tears in marathon runners is no higher than the prevalence reported for sedentary persons, and the runners have the same
and cannot be extended
ated
August
findings
Reply I agree with Dr. Tersegno that the results of the study [1] specifipertain to the knees of asymtomatic marathon runners and that further study of symptomatic runners would be necessary in order to make a statement about marathon runners in general. My colleagues cally
and I were particularly
images because of their age (average, 40 years) and intense training (average time in training, 10 years; average distance per week training,
41 miles);
elsewhere. Carlos Valls Eduard Andia Isabel Gil
Hospital
de Be/lvitge
Barcelona,
Spain
Isabel Conde University
of Barcelona
Barcelona,
Spain
explicit with our inclusion criteria for this study
so that we could compare our results with those of previous studies that reported MR findings in the knees of asymptomatic populations of athletes and more sedentary persons. We think that our data were of interest because our subjects represent a group who would likely have a higher prevalence of meniscal signal abnormalities on MR
yet, they did not.
University
Frank G. Shellock Tower Musculoskeletal Imaging Center of California, Los Angeles, School of Medicine Los Angeles, CA 90048
REFERENCE 1 . Shellock FG, Deutsch AL, Mink JH, Kerr R. Do asymptomatic marathon runners have an increased prevalence of meniscal abnormalities? An MR study of the knee in 23 volunteers. AJR 1991;157: 1239-1 241
REFERENCES 1 . Rao RH, Vagnucci AH, Amico JA. Bilateral massive adrenal hemorrhage: early recognition and treatment. Ann Intern Med 1989;1 10:227-235 2. Wolverson MK, Kannegiesser H. CT of bilateral adrenal hemorrhage with
acute adrenal insufficiency
in the adult. AiR 1984;142:31 1-314 J, Yrizarry JM. Traumatic adrenal hemorrhage: radiologic fIndings. Radiology 1988;169:70i-703 4. Wilms G, Marchal G, Baert A, et al. CT and ultrasound features of posttraumatic adrenal hemorrhage. J Comput Assist Tomogr 1987;1 1: 112-115
3.
Murphy
Meniscal Shellock
BJ, Casillas
Tears in Marathon et al. present an interesting
Runners
article [1] that gives encouragement to those of us who would call ourselves “runners.” The
Transfemoral Venous Catheterization Inferior Vena Caval Filters In their recent article [1], Hansen et al. with diagnostic and therapeutic procedures instruments were passed through existing from a femoral vein approach. They advocate of this technique, while suggesting that it
radiologists
Through
describe their experience in seven patients in which inferior vena caval filters the safety and feasibility is a practicable option for
who “may not find the transjugular
route
a desirable
alternative.” Notwithstanding their favorable results in these seven patients, we propose that this is a small series on which to base such
conclusions. the inferior
lodging
In addition, vena
an inferior
cava,
in our opinion, dislodging
the probable
thrombus,
risk of injuring
and damaging
or dis-
vena caval filter during a transfemoral-transfilter
catheterization is greater than the probable risk of performing these same procedures via a jugular vein puncture without traversing an
through patients.
implanted
be used to perform pulmonary arteriography, venous sampling, hepatic vein manometry, and right-sided heart catheterization as Hansen
filter.
Percutaneous
access
to the internal
standard procedure for interventional vein are easily detected by using
jugular
vein should
be a
radiologists. Landmarks for the inspection and palpation. One
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approach is to make the puncture posterior to the sternocleidomastoid muscle, just cranial to where the external jugular vein crosses, about midway between the mastoid tip and the clavicle. The needle is then directed toward the sternal notch while the carotid artery is deflected medially. A favored method in our division is a more anterior
approach: The needle is advanced with one hand from the apex of the division of the sternocleidomastoid muscle along the medial aspect of the lateral belly of the muscle while the carotid artery is palpated and retracted with the opposite hand. To minimize the risk of injury to adjacent structures in the neck and chest, especially the carotid artery and the apical pleura, we first use a 21-gauge needle
implanted filters to place additional Vena-Tech filters in two In addition, although a catheter may fit through a filter and
et al. advocate, the extensive manipulation of the catheter that frequently is required during these procedures causes us even greater concern. Working through a long sheath may help reduce this risk, but it would also add to the diameter of the system needed to pass through the filter. Finally, Hansen et al. do not discuss the implications
of puncturing
femoral veins that may have
damaged
been
or become
thrombosed during the initial filter placement and the effect repeat puncture might have on the development or worsening of chronic venous stasis disorders that occur in a small percentage of patients with vena caval filters, even the new smaller filter systems [4, 5]. Thrombosis of the jugular vein, on the other hand, is almost never chronically symptomatic [6]. In summary, we think the technique advocated by Hansen et al. should be used in only the most limited circumstances, when no other
(Cook Inc., Bloomington, IN) and a single-wall technique. After venous blood is aspirated, a 0.01 8 in. (0.46-mm) Cope mandril wire (Cook Inc.) is inserted via the needle and steered into the superior vena cava, across the eustachian valve, and into the inferior vena cava. At
approach is available. We encourage using jugular vein access for these procedures in order to avoid manipulation through or near a filter and associated caval thrombus. We agree with the authors that
this point,
clinical
the mandnl
wire
is exchanged
for a 0.035-
or 0.038-in.
judgment
should
be exercised
(0.89- or 0.97-mm) guidewire through a 4-French Desilets-Hoffman introducer (Cook Inc.). Access to the external jugular vein can be
experience
should be obtained.
lar venous
catheterization
obtained
clinically
with the same equipment
externaljugular occlusion.
helpful
and often
veins are superficial,
The
steerability
in negotiating
of the
because
visible, and distensible
0.01 8-in.
the turn from
is easier
mandril
the external
wire
most
by finger
is particularly
jugular vein into the used for placement of
safer,
transfemoral-transfilter ogists
in these
especially
should
when
the
of six transjugular intrahepatic portosystemic shunts, six transjugular liver biopsies, and placement of one hemodialysis catheter. Ten of the 12 filters were placed by the transjugular route because of iliofemoral or inferior vena caval thrombus, one because of recent bilateral emboli
groin
surgeries,
presumably
from
and one thrombus
because found
of recurrent partially
pulmonary
encasing
a Bird’s
Nest filter. In addition, hepatic venous (free and wedged) contrast studies and manometry were easily performed in conjunction with placement of portosystemic shunts and in conjunction with most of the liver biopsies; access to the hepatic venous system is a particularly direct approach and is much easier than turning sharply into the the hepatic veins from the inferior vena cava. All 25 procedures were technically successful and without complications; in most cases, puncture. In past years, helpful
in performing
jugular access was obtained with the first we also have found the transjugular route
pulmonary
arteriograms
in patients
who
the heart from the superior
vena cava, although
it is possible
to insert them with greater difficulty via the inferior vena cava. An additional advantage ofjugular vein access is the ease of hemostasis. After the removal of even large filter sheaths, a mild elevation of the patient’s upper body and head significantly reduces venous pressure and risk of hematoma.
We acknowledge
the limited experience of Hansen et al., which
the
transjugular
route
a standard
radiol-
technique
in
David J. Eschelman David M. Hovsepian Joseph Bonn Jefferson University Hospital Philadelphia, PA 19107
AC, Transfemoral venous catheterization through inferior vena caval filters: results in seven cases. AJR 1991;157:967-970 2. McCowan TC, Ferns EJ, Carver DK, Harshfield DL. Use of the extemal jugular vein as a route for percutaneous inferior vena caval filter placement. Radiology
1990176:527-530
3. Simon M, Athanasoulis CA, Kim D, et al. Simon nitinol inferior vena cava filter: initial clinical experience. Radiology 1989;1 72:99-1 03 4. Hicks ME, Middleton WD, Picus D, Darch MD, Kleinhofter MA. Prevalence of local venous thrombosis after transfemoral placement of a Bird’s Nest vena caval filter. J vasc Intervent Radiol 1990;1 :63-68 5. Ricco JB, Crochet D, Sebilotte P. et al. Percutaneous transvenous caval interruption with the LGM filter: early results of a multicenter trial. Ann Vasc Surg 1988;3:242-247 6. Greenfield U, Michna BA. Twelve-year clinical experience with the Greenfield vena caval filter. Surgery 1988;104:706-712
Periocular Pseudocyst Caused Contact Lens: CT Appearance
[1] shows
how
a 7.i -French catheter could fit between filter elements, it does not show the larger 12-French (outer diameter) filter sheath they passed
by a Displaced
A 21-year-old man was struck in the left eye with a croquet mallet when he was wearing rigid gas-permeable contact lenses composed of pasifocon
A and B. The patient
contact
lens was missing
ground.
Three
years
left eye. Palpation the left upper contact lens.
could
3 in the article
and
than
is used,
1 . Hansen ME, Geller SC, Yucel EK, Egglin TK, Waltman
transjugular
Figure
needle
easier
REFERENCES
with
Although
transjugu-
is technically
We think that interventional
Thomas
shows that it may be feasible to work through existing inferior vena caval filters. However, we are concerned that use of this technique would be advocated as being as safe as or safer than use of a approach.
patients
already
have jugular venous access (a pigtail catheter from Cook, Inc. with an additional U-shaped secondary curve is used), saving them a separate femoral puncture, and in placing Swan-Ganz catheters (Baxter Health Care Corp., Irvine, CA), which are designed ideally to access
and that further
their practice.
superior vena cava. This approach has been titanium Greenfield filters, and it would be expected that the smaller and more flexible Simon nitinol filter, which has been inserted via the internal jugular vein, would also make this turn [2, 3].
From July to November 1 991 , we performed 25 procedures via the right internal jugular vein. These included placement of 12 vena caval filters (i 1 titanium Greenfield and one Bird’s Nest), placement
case
in our judgment,
a small
approach.
make
in each
However,
Coronal
later, he became
showed
possible contact
be pulled
during lens
aware
(Fig.
to the
about
the
from
the globe
the initial examination. within
the
inner
with
the patient
suture, more
of the
under
the upper lid
force
This maneuver surface
a
mass contiguous
i). With
and with an eyelid traction
embedded
that the left
knocked
the lid did not reveal
a cystic-appearing
to the left globe away
been
of discomfort
of the area under
orbital CT showed
general anesthesia
noted
it had
a firm, slightly mobile mass deep within
lid. Inspection
and superior
subsequently
and assumed
than
was
revealed upper
eyelid,
a
scan of orsuperior to left globe is bounded by contact lens and posterior surface of eyelid and contains fluid.
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Fig. 1.-CoronalCT bit shows pseudocyst
near the superior
conjunctival
fornix,
with the convex
surface
the globe. A pair of forceps was used to remove the contact Contact conjunctival
lenses fornix,
facing
lens.
occasionally may be displaced into the superior either spontaneously or as a result of trauma. The
contact lens may become embedded in the upper lid, as in this case, or may migrate into adjacent eyelid or orbital tissues [1 2]. Although physical examination will sometimes detect a displaced contact lens, ,
this may not always be possible because of the patient’s discomfort, lid inflammation, or, in younger patients, relatively tight tissues. A displaced contact lens should be considered in the differential diag-
nosis of superior
periocular
cystic-appearing
University
of Tennessee
lesions shown by CT. Herbert J. GIatt Medical
Center at Knoxville Knoxville, TN 37920
REFERENCES 1 . Homblass A, Kass L. Contact lenses in the upper eyelid masquerading as lid masses. Ophthalmic Surg 1987;18:438-440 2. Nicolitz E, Flanagan J. Orbital mass as a complication of contact lens wear.
Arch Ophthalmol
1978;96:2238-2339
CT of Schizencephaly A 9-year-old
boy had psychomotor
retardation
and seizures
and
failure to thrive. CT scans showed moderate dilatation of the lateral ventricles and absence of the septum pellucidum. An apparent umbilication
was
seen
at the
border
of the
left
lateral
ventricle,
and
a
barely visible one was present on the right side (Fig. 1 A). In both hemispheres, abnormal (heterotopic) gray matter extending from the ventricular wall to the periphery was clearly detectable. A cleft was
visible localized
rounded
on the left side within defect
was
by heterotopic
present
the heterotopic near
gray matter
the
right
gray matter, ventricular
and a
edge,
sur-
Fig. 1.-Schizencephaly in a 9-year-old boy. A, CT scan shows moderate dilatation of lateral ventricles and absence of septum pellucidum. Note also apparent umbilication at left ventricular
border small CSF-filled cavity adjacent to left parietal bone, representing the peripheral end of a cleft (see B); and barely visible umbilication at right ventricular border. B, CT scan at level higher than A shows a cleft on left; surrounding heterotopic gray maSer is clearly identifiable. On right, a small cavity connects with ventricle and no cleft is visible; a large amount of heterotopic gray matter surrounds this cavity and extends to cortex.
heterotopic gray matter around a cleft is considered pathognomonic for schizencephaly, distinguishing it from an acquired condition. This finding can be shown by CT but is best delineated by MR [1-3]. In the present case, the cleft on the left side, which is lined with heterotopic gray matter, is typical for an open schizencephalic defect. On the right side, however, only a small CSF-filled cavity is present surrounded by heterotopic gray matter without an apparent cleft; this represents a closed schizencephalic defect. Therefore, this case represents a simultaneous manifestation of the two forms of schizencephaly. In addition, we think that the apparent umbilication, particularly at the left ventricular border, may be a secondary CT finding signifying the presence of schizencephaly, in the event that a cleft is not visible. A. Nun Sener G#{252}ner Bilgin Ahmet Memis and colleagues Hospital
(Fig. 1 B).
Bornova,
Schizencephaly is one of the migrational disorders of the brain, which include lissencephaly, pachygyria, heterotopia, and polymicrogyria. It is characterized by clefts extending across the hemispheres;
of Ege
lzmir,
University
35100,
REFERENCES 1 . Byrd SE, Osbom RE, Bohan TP, Naidich TP. The CT and MR evaluation
the clefts are lined with pial-ependymal tissue and bounded, either totally or in part, by heterotopic gray matter. The cleft may be open
of migrational disorders of the brain. Part II. Schizencephaly, and polymicrogyria. Pediatr Radiol 1989;19:219-222
heterotopia
(open schizencephaly) or closed (fused-lip schizencephaly). The clefts are commonly seen in the parietal and temporal regions. They are
2. Zimmermann
usually bilateral and may be symmetric. Unilateral clefts can also occur and should be distinguished from acquired clefts that can occur after a nonpenetrating contusive injury to the brain. The presence of
1983;25:257-263 3. Silverman FN. Caffey’s pediatric X-ray diagnosis: an integrated approach, 8th ed., vol. 1 . Chicago: Year Bock Medical, 1985:206
Letters
are published
at the discretion
of the Editor
migratory
RA, Bilaniuk LT, Grossman disorders
and are subject
of
human
brain
RS. Computed development.
to editing.
Letters to the Editor must not be more than two double-spaced, typewritten pages. One or two figures may be included. Abbreviations should not be used. Limit the number of authors to four, or we will list only the first three and add “and colleagues” to the end of the list. See Author Guidelines. Material being submitted or published elsewhere should not be duplicated in letters, and authors of letters
must disclose
financial
associations
or other
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conflicts
of interest.
Letters concerning reply to be published
a paper published in the AJA will be sent to the authors of the paper for a in the same issue. Opinions expressed in the Letters to the Editor do not
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opinions
reflect
the
of the
Editor.
Turkey
tomography Neuroradiology imaging
in
