1990, The British Journal of Radiology, 63, 726-728
Case reports
there is no hearing, a translabyrinthine approach is used (Lo et al, 1984). Thus combined use of CT and MRI can differentiate petrous apex cholesteatomas from cholesterol granulomas and greatly facilitate appropriate surgical management.
GRIFFIN, C , D E LA PAZ, R. & ENZMAN, D., 1987. MR and
LATACK, J. T., GRAHAM, M. D., KEMINK, J. L. & KNAKE, J. E.,
1985a. Giant cholesterol cysts of the petrous apex: Radiological features. American Journal of Neuroradiology, 6, 409^13. LATACK, J. T., KARTUSH, J. M., KEMINK, J. L., GRAHAM, M.
References AMEDEE, R.
G.,
MARKS, H.
W.
&
LYONS, M.
D.,
Cholesterol granuloma of the petrous apex. Journal of Otology, 8, 48-55.
1987.
American
GHERINI, S. G., BRACKMANN, D. E., LO, W. W. M. & SOLTI-
BOHMAN, L. G., 1985. Cholesterol granuloma of the petrous apex. Laryngoscope, 95, 659-664.
CT
correlation of cholesterol cysts of the petrous bone. American Journal of Neuroradiology, 8, 825-829.
D.
& KNAKE, J. E., 1985b. Epidermoidomas of the cerebellopontine angle and temporal bone: CT and MR aspects. Radiology, 157, 361-366. Lo, W. W. M., SOLTI-BOHMAN, L. G., BRACKMANN, D. E. &
GRUSKIN, P., 1984. Cholesterol granuloma of the petrous apex: CT diagnosis. Radiology, 153, 705-711.
Ultrasonic detection of a retroperitoneal haematoma causing duodenal obstruction following ureterolithotomy By *D. A. Ritchie, FRCR, C. K. Frazer, MBChB, A. D. Taylor, FRCR and tD. W. Newling, FRCS Departments of Radiology and tUrology, Hull Royal Infirmary, Hull HU3 2JZ (Received November 1989 and in revised form February 1990)
Many authors have documented the clinical features and ultrasonic appearances of retroperitoneal haematomas which are usually a result of blunt epigastric trauma, bleeding diatheses or leaking aneurysms (McVerry et al, 1977; Foley & Teele, 1979; Shirkoda et al, 1983; Mittelstaedt, 1987). With adequate perioperative drainage, retroperitoneal haemorrhage is an uncommon complication of ureteric surgery (Straffon, 1986), although there may be an increased risk where the surgery is complicated. We present a case of duodenal obstruction resulting from a retroperitoneal haematoma following ureteric surgery diagnosed by ultrasound. Case report A 51-year-old man, with a history of several previous operations for bilateral recurrent urinary calculi, presented with a 2month history of intermittent right renal colic and an intravenous urogram confirmed a calculus in the distal right ureter. Following unsuccessful attempted dormia basket removal, an open ureterolithotomy was performed to remove the impacted calculus. Although scarring and adhesions from previous surgery made the operation technically difficult, he made a satisfactory recovery and was discharged after 10 days. Four days later he was re-admitted with a history of bile stained vomiting and upper abdominal distension. Abdominal examination revealed some epigastric swelling and satisfactory healing of his right lower abdominal wound. His serum amylase was normal. A barium meal confirmed an obstruction at the mid-portion of the second part of the duodenum, and appearances suggested an extramural lesion (Fig. 1). Delayed radiographs showed passage of barium distally indicating an incomplete obstruction. •Present address: Department of Radiology, Hospital, Liverpool.
726
Broadgreen
Ultrasound examination of right upper abdomen (Fig. 2) revealed a large inhomogeneous but mainly hypoechoic mass, which extended down into the right paracolic gutter and lay inferior to the liver and anterior to the right kidney. There was slight compression of the inferior vena cava posteriorly and the stomach and duodenal cap appeared dilated. Postero-medially
Figure 1. Radiograph from a barium meal, showing obstruction to the 2nd part of duodenum. Note the tapered appearance of the stricture with preservation of the mucosal folds suggesting an extramural rather than an intramural cause. The British Journal of Radiology, September 1990
Case reports the mass contained a central vertically orientated tubular structure with echogenic walls which converged inferiorly. In view of the recent surgery, these features led us to suspect a retroperitoneal haematoma in the anterior pararenal space encasing and obstructing the duodenum. Needle aspiration was attempted but was unsuccessful. Laparotomy confirmed the ultrasonic findings demonstrating extension of the retroperitoneal haematoma into the right infra-colic compartment to the site of the previous surgery. The solid nature, surrounding inflammatory tissue and position of the haematoma would have made dissection and subsequent removal difficult and hazardous and therefore a gastro-jejunostomy was performed. After a satisfactory recovery, the patient remained well at outpatient follow-up 12 months later.
Discussion
Figure 2. (a) and (b) Longitudinal and transverse sonograms (3.5 MHz sector scanner) showing the retroperitoneal mass (black arrows) lying mainly anterior to and encasing the 2nd part of duodenum (white arrows). Note the characteristic appearance of converging echogenic walls outlined internally by intraluminal fluid and externally by the inhomogeneous mass, (c) Transverse scan 8 cm caudad to (b) showing extension of the mass into the right infra-colic compartment with some compression of the inferior vena cava (arrowheads).
Vol. 63, No. 753
The 2-week delay in presentation after the initial surgery was almost certainly because of organization and contraction of the haematoma causing constriction and obstruction of the duodenum; other authors have also recorded a similar delay following aortic surgery (Reasbeck, 1980). The administration of oral fluids prior to ultrasonic examination has been shown to help in the sonographic interpretation of stenotic processes of the duodenum (Brambs et al, 1986). This is well shown in the present case where the converging echogenic duodenal walls are outlined by fluid internally and haematoma externally. Anatomically the second and third parts of the duodenum are relatively immobile within the confines of the anterior pararenal space and consequently are liable to compression and obstruction by any adjacent retroperitoneal lesion. Previous authors have described the effects of fluid collections in the anterior pararenal space on adjacent structures and in particular how the 2nd part of the duodenum is usually displaced anteriorly (Meyers, 1982). In our case, most of the haematoma was situated anterior to the duodenum. This may be attributed to "tethering down" of the 2nd part of duodenum owing to fibrous adhesions from the previous pyelolithotomy and also to the integrity of the retroduodenal vessels which are usually ruptured when the haematoma is post-traumatic. While easily detected, the ultrasonic findings are not specific and inflammatory lesions can produce similar appearances. The most common abscesses in the anterior pararenal space are enteric in origin resulting from pancreatitis, diverticulitis, perforated peptic ulcer, Crohn's disease and, in younger patients, retroperitoneal appendicitis (Meyers, 1982; Mittelstaedt, 1987). Retroperitoneal neoplasia, possibly complicated by perforation, bleeding or fibrosis should also be considered and would include lymphoma, sarcoma and metastatic disease. Similar findings have also been demonstrated with intramural haematomas, especially when they occur with retroperitoneal bleeding which commonly accompanies blunt epigastric trauma (Foley & Teele, 1979). 727
1990, The British Journal of Radiology, 63, 728-730
Retroperitoneal haemorrhage has been well documented in patients with a bleeding tendency (McVerry et al, 1977; Kumari et al, 1979; Shirkoda et al, 1983) including those on anticoagulant therapy. Haematomas localized to the anterior pararenal space have also been recorded in patients with a hepatic or splenic artery aneurysms (Meyers, 1982); only very rarely does a spontaneous haematoma occur with no predisposing cause. The ultrasonic appearances of haematomas are variable and depend on various factors including age and location (Wicks et al, 1978). Although some acute haematomas may be transonic (Kumari et al, 1979), the majority tend to be echogenic and experimental evidence shows this is because of the interaction between erythrocytes and fibrin (Van Sonnenberg et al, 1983). As clot fragmentation occurs, most cases show an inhomogeneous pattern with variable amounts of internal echoes. They usually have irregular walls and decrease in size with time unless there is further haemorrhage. Most haematomas undergo liquefaction and resolution becoming anechoic after a month. Modern management of duodenal obstruction due to retroperitoneal/duodenal haematoma favours conservative treatment with parenteral nutrition, serial sonography and contrast studies, especially in patients with bleeding diatheses (Foley & Teele, 1979; Touloukian, 1983). In conclusion, the ultrasonic appearances together with the clinical history were highly suggestive of the diagnosis; this case illustrates the value of ultrasound in demonstrating the features of a retroperitoneal mass including its pressure effects, and revealed a characteristic sign of duodenal obstruction.
Case reports References BRAMBS, H. J., SPAMER, C , VOLK, B. & HOLSTEGE, A., 1986.
Diagnostic value of ultrasound in duodenal Gastrointestinal Radiology, 11, 135-138.
stenosis.
FOLEY, L. C. & TEELE, R. L., 1979. Ultrasound of epigastric
injuries after blunt trauma. Roentgenology, 132, 593-598.
American
Journal
of
KUMARI, J. K., FULCO, J. D., KARAYALCIN, G. & LIPTON, R.,
1979. Gray scale ultrasound: evaluation hematomas in hemophiliacs. American Roentgenology, 133, 103-106.
of iliopsoas Journal of
MCVERRY, B. A., VOKE, J., VICARY, F. R. & DORMANDY, K.
M., 1977. Ultrasound in the management of haemophilia. Lancet, 23, 872-874. MEYERS, M. A., 1982. Dynamic Radiology of the Abdomen, 2nd edn (Springer-Verlag, New York), pp. 104-124. MITTELSTAEDT, C. A., 1987. Abdominal Ultrasound (Churchill Livingstone, New York), pp. 381-440. REASBECK, P. G., 1980. Vascular compression of the duodenum following resection of an abdominal aortic aneursym. New Zealand Medical Journal, 92, 198-199. SHIRKODA, A., MAURUO, M. A., STAAB, E. V. & BLAT, P. M.,
1983. Soft-tissue hemorrhage in hemophiliac patients. Radiology, 147, 811-814. STRAFFON, R. A., 1986. Surgery for calculus disease of the urinary tract. In Campbell's Urology, 5th edn, ed. by P. C. Walsh (W. B. Saunders, Philadelphia), pp. 2496-2503. TOULOUKIAN, R. J., 1983. Protocol for the nonoperative treatment of obstruction of intramural duodenal haematoma during childhood. American Journal of Surgery, 145, 330-334. VAN SONNENBERG, E., SIMEONE, J. F., MUELLER, P. R., WITTENBERG, J., HALL, D. A. & FERRUCCI, JR., J. T., 1983.
Sonographic appearance of hematoma in liver, spleen, and kidney: a clinical, pathologic, and animal study. Radiology, 147, 507-510. WICKS, J. D., SILVER, T. M. & BREE, R. L., 1978. Gray scale
features of hematomas: an ultrasonic spectrum. American Journal of Roentgenology, 131, 977-980.
A cranio-cerebral erosion (growing skull fracture) causing anisometropia By *R. W. Whitehouse, BSc, MB, ChB, FRCR and tB. Leatherbarrow, BSc, MB, ChB, DO, FRCSE, FCOphth Department of Diagnostic Radiology, The Medical School, University of Manchester, Oxford Road, Manchester M13 9PT and tDepartment of Ophthalmology, Manchester Royal Eye Hospital, Oxford Road, Manchester {Received December 1989 and in revised form February 1990)
The progressive enlargement of a skull fracture is a rare complication of head injury in children. The true incidence is unknown but it probably occurs in less than 5% of skull fractures in infancy. It is seen most often in children under the age of 3 years who have sustained a diastatic fracture (greater than 3-4 mm of edge separation) following a fall of at least 10 feet (Tandon et al, 1987). Experimentally, a laceration of both the dura and *Author for correspondence. 728
arachnoid is also necessary for the lesion to develop (Goldstein et al, 1967). Until the series of 60 cases published by Tandon et al, the high incidence of associated brain injury and progressive neurological abnormality in patients with growing fractures had been underemphasized in the literature. In Tandon's series, only two patients had growing fractures of the orbit and these were neither illustrated nor specifically described. No other published series in the radiological or neurosurgical literature refers to an orbital location. We The British Journal of Radiology, September 1990
Case reports
there is no hearing, a translabyrinthine approach is used (Lo et al, 1984). Thus combined use of CT and MRI can differentiate petrous apex cholesteatomas from cholesterol granulomas and greatly facilitate appropriate surgical management.
GRIFFIN, C , D E LA PAZ, R. & ENZMAN, D., 1987. MR and
LATACK, J. T., GRAHAM, M. D., KEMINK, J. L. & KNAKE, J. E.,
1985a. Giant cholesterol cysts of the petrous apex: Radiological features. American Journal of Neuroradiology, 6, 409^13. LATACK, J. T., KARTUSH, J. M., KEMINK, J. L., GRAHAM, M.
References AMEDEE, R.
G.,
MARKS, H.
W.
&
LYONS, M.
D.,
Cholesterol granuloma of the petrous apex. Journal of Otology, 8, 48-55.
1987.
American
GHERINI, S. G., BRACKMANN, D. E., LO, W. W. M. & SOLTI-
BOHMAN, L. G., 1985. Cholesterol granuloma of the petrous apex. Laryngoscope, 95, 659-664.
CT
correlation of cholesterol cysts of the petrous bone. American Journal of Neuroradiology, 8, 825-829.
D.
& KNAKE, J. E., 1985b. Epidermoidomas of the cerebellopontine angle and temporal bone: CT and MR aspects. Radiology, 157, 361-366. Lo, W. W. M., SOLTI-BOHMAN, L. G., BRACKMANN, D. E. &
GRUSKIN, P., 1984. Cholesterol granuloma of the petrous apex: CT diagnosis. Radiology, 153, 705-711.
Ultrasonic detection of a retroperitoneal haematoma causing duodenal obstruction following ureterolithotomy By *D. A. Ritchie, FRCR, C. K. Frazer, MBChB, A. D. Taylor, FRCR and tD. W. Newling, FRCS Departments of Radiology and tUrology, Hull Royal Infirmary, Hull HU3 2JZ (Received November 1989 and in revised form February 1990)
Many authors have documented the clinical features and ultrasonic appearances of retroperitoneal haematomas which are usually a result of blunt epigastric trauma, bleeding diatheses or leaking aneurysms (McVerry et al, 1977; Foley & Teele, 1979; Shirkoda et al, 1983; Mittelstaedt, 1987). With adequate perioperative drainage, retroperitoneal haemorrhage is an uncommon complication of ureteric surgery (Straffon, 1986), although there may be an increased risk where the surgery is complicated. We present a case of duodenal obstruction resulting from a retroperitoneal haematoma following ureteric surgery diagnosed by ultrasound. Case report A 51-year-old man, with a history of several previous operations for bilateral recurrent urinary calculi, presented with a 2month history of intermittent right renal colic and an intravenous urogram confirmed a calculus in the distal right ureter. Following unsuccessful attempted dormia basket removal, an open ureterolithotomy was performed to remove the impacted calculus. Although scarring and adhesions from previous surgery made the operation technically difficult, he made a satisfactory recovery and was discharged after 10 days. Four days later he was re-admitted with a history of bile stained vomiting and upper abdominal distension. Abdominal examination revealed some epigastric swelling and satisfactory healing of his right lower abdominal wound. His serum amylase was normal. A barium meal confirmed an obstruction at the mid-portion of the second part of the duodenum, and appearances suggested an extramural lesion (Fig. 1). Delayed radiographs showed passage of barium distally indicating an incomplete obstruction. •Present address: Department of Radiology, Hospital, Liverpool.
726
Broadgreen
Ultrasound examination of right upper abdomen (Fig. 2) revealed a large inhomogeneous but mainly hypoechoic mass, which extended down into the right paracolic gutter and lay inferior to the liver and anterior to the right kidney. There was slight compression of the inferior vena cava posteriorly and the stomach and duodenal cap appeared dilated. Postero-medially
Figure 1. Radiograph from a barium meal, showing obstruction to the 2nd part of duodenum. Note the tapered appearance of the stricture with preservation of the mucosal folds suggesting an extramural rather than an intramural cause. The British Journal of Radiology, September 1990
Case reports the mass contained a central vertically orientated tubular structure with echogenic walls which converged inferiorly. In view of the recent surgery, these features led us to suspect a retroperitoneal haematoma in the anterior pararenal space encasing and obstructing the duodenum. Needle aspiration was attempted but was unsuccessful. Laparotomy confirmed the ultrasonic findings demonstrating extension of the retroperitoneal haematoma into the right infra-colic compartment to the site of the previous surgery. The solid nature, surrounding inflammatory tissue and position of the haematoma would have made dissection and subsequent removal difficult and hazardous and therefore a gastro-jejunostomy was performed. After a satisfactory recovery, the patient remained well at outpatient follow-up 12 months later.
Discussion
Figure 2. (a) and (b) Longitudinal and transverse sonograms (3.5 MHz sector scanner) showing the retroperitoneal mass (black arrows) lying mainly anterior to and encasing the 2nd part of duodenum (white arrows). Note the characteristic appearance of converging echogenic walls outlined internally by intraluminal fluid and externally by the inhomogeneous mass, (c) Transverse scan 8 cm caudad to (b) showing extension of the mass into the right infra-colic compartment with some compression of the inferior vena cava (arrowheads).
Vol. 63, No. 753
The 2-week delay in presentation after the initial surgery was almost certainly because of organization and contraction of the haematoma causing constriction and obstruction of the duodenum; other authors have also recorded a similar delay following aortic surgery (Reasbeck, 1980). The administration of oral fluids prior to ultrasonic examination has been shown to help in the sonographic interpretation of stenotic processes of the duodenum (Brambs et al, 1986). This is well shown in the present case where the converging echogenic duodenal walls are outlined by fluid internally and haematoma externally. Anatomically the second and third parts of the duodenum are relatively immobile within the confines of the anterior pararenal space and consequently are liable to compression and obstruction by any adjacent retroperitoneal lesion. Previous authors have described the effects of fluid collections in the anterior pararenal space on adjacent structures and in particular how the 2nd part of the duodenum is usually displaced anteriorly (Meyers, 1982). In our case, most of the haematoma was situated anterior to the duodenum. This may be attributed to "tethering down" of the 2nd part of duodenum owing to fibrous adhesions from the previous pyelolithotomy and also to the integrity of the retroduodenal vessels which are usually ruptured when the haematoma is post-traumatic. While easily detected, the ultrasonic findings are not specific and inflammatory lesions can produce similar appearances. The most common abscesses in the anterior pararenal space are enteric in origin resulting from pancreatitis, diverticulitis, perforated peptic ulcer, Crohn's disease and, in younger patients, retroperitoneal appendicitis (Meyers, 1982; Mittelstaedt, 1987). Retroperitoneal neoplasia, possibly complicated by perforation, bleeding or fibrosis should also be considered and would include lymphoma, sarcoma and metastatic disease. Similar findings have also been demonstrated with intramural haematomas, especially when they occur with retroperitoneal bleeding which commonly accompanies blunt epigastric trauma (Foley & Teele, 1979). 727
1990, The British Journal of Radiology, 63, 728-730
Retroperitoneal haemorrhage has been well documented in patients with a bleeding tendency (McVerry et al, 1977; Kumari et al, 1979; Shirkoda et al, 1983) including those on anticoagulant therapy. Haematomas localized to the anterior pararenal space have also been recorded in patients with a hepatic or splenic artery aneurysms (Meyers, 1982); only very rarely does a spontaneous haematoma occur with no predisposing cause. The ultrasonic appearances of haematomas are variable and depend on various factors including age and location (Wicks et al, 1978). Although some acute haematomas may be transonic (Kumari et al, 1979), the majority tend to be echogenic and experimental evidence shows this is because of the interaction between erythrocytes and fibrin (Van Sonnenberg et al, 1983). As clot fragmentation occurs, most cases show an inhomogeneous pattern with variable amounts of internal echoes. They usually have irregular walls and decrease in size with time unless there is further haemorrhage. Most haematomas undergo liquefaction and resolution becoming anechoic after a month. Modern management of duodenal obstruction due to retroperitoneal/duodenal haematoma favours conservative treatment with parenteral nutrition, serial sonography and contrast studies, especially in patients with bleeding diatheses (Foley & Teele, 1979; Touloukian, 1983). In conclusion, the ultrasonic appearances together with the clinical history were highly suggestive of the diagnosis; this case illustrates the value of ultrasound in demonstrating the features of a retroperitoneal mass including its pressure effects, and revealed a characteristic sign of duodenal obstruction.
Case reports References BRAMBS, H. J., SPAMER, C , VOLK, B. & HOLSTEGE, A., 1986.
Diagnostic value of ultrasound in duodenal Gastrointestinal Radiology, 11, 135-138.
stenosis.
FOLEY, L. C. & TEELE, R. L., 1979. Ultrasound of epigastric
injuries after blunt trauma. Roentgenology, 132, 593-598.
American
Journal
of
KUMARI, J. K., FULCO, J. D., KARAYALCIN, G. & LIPTON, R.,
1979. Gray scale ultrasound: evaluation hematomas in hemophiliacs. American Roentgenology, 133, 103-106.
of iliopsoas Journal of
MCVERRY, B. A., VOKE, J., VICARY, F. R. & DORMANDY, K.
M., 1977. Ultrasound in the management of haemophilia. Lancet, 23, 872-874. MEYERS, M. A., 1982. Dynamic Radiology of the Abdomen, 2nd edn (Springer-Verlag, New York), pp. 104-124. MITTELSTAEDT, C. A., 1987. Abdominal Ultrasound (Churchill Livingstone, New York), pp. 381-440. REASBECK, P. G., 1980. Vascular compression of the duodenum following resection of an abdominal aortic aneursym. New Zealand Medical Journal, 92, 198-199. SHIRKODA, A., MAURUO, M. A., STAAB, E. V. & BLAT, P. M.,
1983. Soft-tissue hemorrhage in hemophiliac patients. Radiology, 147, 811-814. STRAFFON, R. A., 1986. Surgery for calculus disease of the urinary tract. In Campbell's Urology, 5th edn, ed. by P. C. Walsh (W. B. Saunders, Philadelphia), pp. 2496-2503. TOULOUKIAN, R. J., 1983. Protocol for the nonoperative treatment of obstruction of intramural duodenal haematoma during childhood. American Journal of Surgery, 145, 330-334. VAN SONNENBERG, E., SIMEONE, J. F., MUELLER, P. R., WITTENBERG, J., HALL, D. A. & FERRUCCI, JR., J. T., 1983.
Sonographic appearance of hematoma in liver, spleen, and kidney: a clinical, pathologic, and animal study. Radiology, 147, 507-510. WICKS, J. D., SILVER, T. M. & BREE, R. L., 1978. Gray scale
features of hematomas: an ultrasonic spectrum. American Journal of Roentgenology, 131, 977-980.
A cranio-cerebral erosion (growing skull fracture) causing anisometropia By *R. W. Whitehouse, BSc, MB, ChB, FRCR and tB. Leatherbarrow, BSc, MB, ChB, DO, FRCSE, FCOphth Department of Diagnostic Radiology, The Medical School, University of Manchester, Oxford Road, Manchester M13 9PT and tDepartment of Ophthalmology, Manchester Royal Eye Hospital, Oxford Road, Manchester {Received December 1989 and in revised form February 1990)
The progressive enlargement of a skull fracture is a rare complication of head injury in children. The true incidence is unknown but it probably occurs in less than 5% of skull fractures in infancy. It is seen most often in children under the age of 3 years who have sustained a diastatic fracture (greater than 3-4 mm of edge separation) following a fall of at least 10 feet (Tandon et al, 1987). Experimentally, a laceration of both the dura and *Author for correspondence. 728
arachnoid is also necessary for the lesion to develop (Goldstein et al, 1967). Until the series of 60 cases published by Tandon et al, the high incidence of associated brain injury and progressive neurological abnormality in patients with growing fractures had been underemphasized in the literature. In Tandon's series, only two patients had growing fractures of the orbit and these were neither illustrated nor specifically described. No other published series in the radiological or neurosurgical literature refers to an orbital location. We The British Journal of Radiology, September 1990
