Gunshot wounds of the abdomen studied by computed tomography. The authors' personal experience in 30 cases

INTRODUCTION: CT plays an important role in depicting gunshot wounds in parenchymal and hollow organs in the abdomen. Relative to other techniques and to emergency laparotomy, CT permits good assessment of abdominal content, major injuries and changes in other districts, such as chest, pelvis and skull. We investigated the yield and role of CT in diagnosing abdominal gunshot wounds, with their rich and varied radiological signs and associated injuries. MATERIAL AND METHODS: We retrospectively reviewed the findings of 30 patients with abdominal gunshot wounds examined in 4 years at Loreto-Mare Hospital, Naples. All patients were men, age ranging 19-54 years (mean: 35); 6 of them were not from the European Union. Examinations were carried out from diaphragm to pubis with i.v. contrast injection and the CT angiography technique. CT was integrated with chest studies in 6 cases and with skull studies in 5. Subsequent CT follow-ups were necessary in 12 cases submitted to conservative treatment. RESULTS: Liver was the most damaged parenchyma, with hemorrhage and lacerocontusion in 7 cases and mashed in 1 case; spleen was involved in 4 cases; hemoperitoneum was found in 18 cases. Diaphragm was involved in 5 cases and pancreas in 2; gallbladder, stomach and duodenum were involved in 1 case each and jejunum-ileum and colon in 3 and 6 cases, respectively. CT showed renal injury in 3 cases and bladder injury in 2. Eight patients had vertebral gunshot damage. Pneumothorax, hemothorax and lacerocontusion were found in 7 cases; brain was injured in 4 cases and limbs in 16. DISCUSSION AND CONCLUSIONS: Tissue damage extent depends on the speed and kinetic energy the bullet carries into the abdomen. Abdominal radiography shows the bullet and its site, pneumoperitoneum from gastrointestinal perforation, crash bone injuries, vertebral trauma and subcutaneous emphysema. Instead, CT depicts early parenchymal damage and vascular injury and thus becomes a complete and necessary tool for imaging gunshot wounds. CT provides early diagnostic information which help plan emergency treatment and thus decrease mortality. As for angiography and US, we suggest they be used subsequently because in emergency they may delay the diagnosis. Moreover, vessel rupture and active intraabdominal bleeding are easily detected with spiral CT, which appears the best tool for prompt assessment of the injuries associated with gunshot wounds in other districts such as, the skull. To conclude, CT permits adequate planning of emergency surgery and helps select the cases for follow-up, intensive care and conservative treatment.     

Anatomy and computed tomography of the normal lumbosacral plexus

Summary The main nerves of the pelvis and lower limbs arise from the lumbar and sacral plexuses. These nerves can be affected by any of a large number of pathologic processes that occur in the paravertebral and pelvic regions. Understanding of the neurological findings related to paravertebral and pelvic pathology needs complete and accurate knowledge of the anatomy of these regions. The axial transverse sections of computed tomography give perfect visualisation of the anatomy of osseous, muscular, and vascular structures of the vertebral and paravertebral area and pelvic walls. Visualisation of the nerves in this regions is much more difficult, because direct demonstration of nervous structures by computed tomography is usually impossible. To be able to identify components of the lumbosacral plexus on axial CT sections the radiologist has to know the location of the nervous structures and the relationships of these structures to vascular, muscular and osseous structures which are easily demonstrated.     

Depiction of celiac ganglia on positron emission tomography and computed tomography in patients with lung cancer

ObjectiveTo differentiate imaging characteristics of celiac ganglia from metastatic lesion on positron emission tomography–computed tomography (PET-CT) in patients with lung cancer and correlate these findings to postmortem multidetector row computed tomography (MDCT).MethodsOne hundred twenty-nine patients were included. Imaging characteristics and fluorodeoxyglucose (FDG) avidity of the celiac ganglia were recorded. Postmortem MDCT of 20 subjects were reviewed.ResultsCeliac ganglia were identified unilaterally in 127 and bilaterally in 108 patients without abnormal FDG uptake. Postmortem images showed celiac ganglia in all cases with no significant difference compared to our patients.ConclusionsFamiliarity with CT characteristics and FDG-avidity of celiac ganglia enable us to distinguish them from metastatic lesions in their vicinity.     

Urography with non-ionic contrast media. Multicenter experience on the optimization of the technic

The authors report the results of a multicentric experience based on 1200 urograms performed with nonionic contrast medium. The global diagnostic reliability is evaluated, together with the specific reliability for kidneys, ureters, and bladder, according to the various pathologies. The eventual need of radiographs of completion is showed. In searching for an optimization of the technique for nonionic contrast medium, a panoramic radiograph performed 10' after the end of the injection is pointed out as the key-moment of the test, being extremely rich in information, so as to help defining the most appropriate technique to continue the examination. For its excellent tolerability and high reliability, the nonionic contrast medium is recommended also in routine IVP, not only in risk patients.     

The anatomy and pathology of the brachial plexus as demonstrated by computed tomography

Computed tomography (CT) scanning can demonstrate a wide range of abnormalities affecting both the brachial plexus and the surrounding structures. Narrow section (4 mm) CT was used with bolus intravenous enhancement to examine the root of the neck and axilla in 62 patients with cancer, many of whom had symptoms of brachial plexus neuropathy. The normal anatomy of the plexus and its relations are described and illustrated. Examples of pathological changes caused by tumour and irradiation are also presented. The narrow scanning width (4 mm) is needed as the details sought are small and will be missed on thicker slice widths, particularly the changes of fibrosis in the upper axilla. Injection of intravenous contrast medium is essential for identifying the vascular structures which are used to locate the brachial plexus, especially when disease processes and post-irradiation fibrosis have destroyed the tissue planes.     

The influence of breathing technic on the visualization of lung metastases in computed tomography

The importance of CT imaging in maximum inspiratory position for the identification of lung metastases is emphasised. In a woman patient suffering from respiratory insufficiency and hypernephroma and clinically suspected of lung metastases, it became necessary to produce two computed tomographs of the thorax at short intervals to clarify the number and size of the pulmonary foci. Since the first examination could not be conducted in a position of maximum inspiration because the patient was short of breath, the procedure was repeated six days later after intensive breathing exercises and subjective improvement of the patient's feeling tone. It was found that three of the four pulmonary metastases could not be seen on the technically unsatisfactory tomographs of the first examination, or could be detected only retrospectively.     

The role of computed tomography in gunshot lesions of the chest. The authors' personal experience

PURPOSE: CT is a valuable tool in assessing thoracic gunshot wounds. CT is also the method of choice in emergency, because it permits rapid depiction of bullet damage to the chest and to other body districts. This in turn permits correct assessment of the main thoracic injuries, plus adequate and prompt planning of surgical treatment or support intensive care. We report on the role of CT in diagnosing the complex pleuropulmonary, cardiovascular and thoracic wall injuries caused by gunshot wounds, with their specific and acute signs which differ greatly from those of other types of chest trauma. MATERIAL AND METHODS: In the last 4 years, we observed 76 cases of gunshot injury, twenty-six of them involved the chest. The patients, 25 men and 1 woman (mean age: 32 years, range: 17-48), were all submitted to emergency CT with i.v. contrast agent injection and the CT-angiography technique. The reanimator was always present to monitor the patients' vital functions and shock state. CT of the chest was integrated with CT of the abdomen and pelvis in 4 cases and with CT of the skull in 3 cases, to detect associated bullet wounds if any. RESULTS: The most frequent CT finding was lung parenchyma tear and bruise (25 cases), followed by hemothorax (18 cases) and subcutaneous chest wall emphysema (9 cases). Pneumothorax was seen in 5 cases, associated with hemothorax in 6; rib injuries were found in 7 cases; pneumomediastinum was found in 4 cases and areas of pulmonary atelectasis in 3; the diaphragm was ruptured in 4 cases. CT showed spinal involvement in 11 patients, with injury of D3 and D5 in 4 and 3 cases, respectively; signs of interrupted spinal marrow were found in 7 cases. Damage from gunshot wounds was detected in the liver, spleen, skull and limbs in 3, 2, 3 and 10 cases, respectively. DISCUSSION AND CONCLUSIONS: Chest radiography shows major gunshot wound damage to the chest and lungs, except for heart injuries and minimal pneumothorax. When abdominal and skull injuries are associated, CT should be the method of choice because it permits prompt and panoramic assessment of the severity of pulmonary and extrathoracic damage. This results in prompt and targeted treatment, avoiding unnecessary delays which may damage the patient further.     

X-ray computed tomography in pheochromocytoma. Apropos of 20 cases

Study of 20 pheochromocytomas in 19 patients confirmed the remarkable sensitivity of computed tomography (100%) for the detection of their adrenal and juxtarenal localizations. However, ultrasonography was as effective as the CT scan in these same patients, and even detected latent tumors in several cases. Certain pheochromocytomas in this series presented unusual appearances, particularly two large tumors which were manifest as abdominal masses and a malignant form which provoked a total infarct of the homolateral kidney.     

High-definition computed tomography in the study of the pulmonary parenchyma. The author's own experience]

High-resolution CT (HRCT) scans were performed on 156 patients, using a bone-reconstruction algorithm, 1.5 collimation at 4 cm intervals from apex to base of the lungs and a 512 x 512 matrix. The patients appeared to have a pathologic condition on chest film, or else they presented positive clinical symptoms--i.e., cough, dyspnea, fever--and questionable/negative chest films. Since HRCT is capable of showing the secondary lobule, we employed it to study both its anatomy and the alterations that can modify its normal morphology--i.e., thickening of interlobular septa, reticular pattern, nodular pattern, high-density areas, sub-pleural lines, honeycomb pattern. HRCT findings in secondary lobules, airways, and pleura were examined. They were: lymphangitic spread of carcinoma, pulmonary fibrosis, sarcoidosis, pneumoconiosis, interstitial edema, phlogosis, bronchiectasis, emphysema, and bullae. Even though some limitations still exist due to the aspecificity of HRCT findings, the latter is the best method currently available to recognize and locate interstitial conditions and, sometimes, to make a diagnosis--e.g., of lymphangitic spread of carcinoma, interstitial edema, fibrosis, emphysema, bronchiectasis. Moreover, HRCT can accurately locate pathologic areas for lung biopsy and can be used instead of chest radiographs in the follow-up.     

MRI evaluation in tracheal pathology. Comparison with tomography and x-ray computed tomography. Apropos of 30 cases]

The authors report a standardised comparison between MRI, CT and Tomography, in 30 cases of tracheal lesions (postintubation, tumors, external compressions and invasions). They conclude on the superiority of MRI because of its multiplanar visualisation, its soft-tissue contrast resolution and its capability to differentiate inflammatory granuloma.     

Computed tomography in the evaluation of osteosarcoma: experience with 25 cases.

Experience with computed tomography (CT) in 25 patients with histologically proven osteosarcoma is presented. CT was as accurate as conventional radiographic methods in determining the presence of a lesion, but it was definitely superior in defining the extent of disease, particularly intramedullary extension and soft tissue extraosseous tumor component. CT was capable of demonstrating skip metastases in one patient. CT plays a key role in the preoperative evaluation of osteosarcoma patients, particularly when less than radical surgery is planned as primary treatment and when postoperative recurrence is suspected. CT is also useful in assessing the response to therapy in nonsurgical cases. The technique involved in the performance of this examination is discussed.     

The results of the percutaneous treatment of obstructed ureteral diversions. The technic and personal experience in 46 cases

The ureteral diversions performed in the treatment of mainly malignant lesions of the pelvis with ureteral or bladder involvement may be complicated by strictures and cause hydronephrosis, pyelonephritis and lithiasis. Personal experience and technique are described as applied in the percutaneous antegrade drainage of different urinary diversions (cutaneous ureterostomy, ileal conduit, colon conduit, ureterosigmoidostomy, ureterocolostomy) in 46 patients. The good results obtained (70% success rate), the absence of major complications, the low cost and the little patient discomfort confirm the leading role of percutaneous treatment versus surgery in obstructed urinary diversions.     

Magnetic resonance in the staging of renal carcinoma. The results compared with computed tomography in 42 cases]

In order to investigate the value of MRI in the staging of renal cell carcinoma and to compare the results of MRI and CT, the authors evaluated by means of MRI and CT 42 patients affected with renal cell carcinoma. All patients underwent surgery, and pathology of the surgical specimens was performed. A comparison was made between the surgical and pathologic data and MRI and CT results. Moreover, a comparative evaluation of MRI and CT findings was also made. From the comparison between pathologic data and CT and MRI results MRI was seen to have correctly staged 36 of 42 cases (85%), versus CT 33 of 42 cases (78%). Moreover, MRI proved to be superior to CT in evaluating venous involvement (stages III A and III C) and extra-fascial tumor spread (stage IVA). On the contrary, no significant differences were found between MRI and CT in the evaluation of perirenal involvement (stages I-II) and lymph node metastases (stage III B). MRI misdiagnosed 6 of 42 cases: 2 false negatives in evaluating extracapsular tumor spread, 1 false positive of mesenteric infiltration, 1 false positive of renal vein thrombosis, 1 false positive and 1 false negative in evaluating lymph node metastases. CT misdiagnoses (9 of 42 cases) were the same as those of MRI in 5 cases, while in the MRI false positive of renal vein thrombosis CT was correct. The extant 4 incorrect CT findings were: 2 false positive of renal vein thrombosis, 1 false negative of infiltration of diaphragm and psoas muscle, 1 false positive infiltration of the right liver lobe. As yet, therefore, MRI cannot be routinely employed to stage all renal cancer patients. On the contrary, MRI should be considered as a second-choice diagnostic tool to employ in selected cases when CT alone cannot solve all the problems relative to staging.     

Interventional computed tomography in thoracic oncology. Apropos of 170 cases

The authors report their experience with follow-up cytohistological examination of subclinical thoracic lesions in oncology by transparietal puncture with CAT-scanning localization in 170 patients. They detail a few special points concerning the material used and their techniques, in view of reducing the most common incidents and of managing the most severe complications. They analyze their results in two groups of patients, one investigated in a context of known malignancy and the other, with no history of malignancy in whom bronchoscopy, bronchial lavage and brushing were negative. They found an overall sensitivity and specificity of 86% and 100%, respectively, in the diagnosis of malignant disease. The method showed an efficacy of 83.5%. For the two populations, sensitivity was 84% and 87% respectively, and efficacy was 82 and 85% respectively. Thus, the results were better in the patients who had never received anticancer therapy. They also observed significant differences depending on whether the targets were mediastinal, pleuropulmonary or parietal. While the rapid diagnostic information appears invaluable in both groups of patients, in contrast, the small volume of the specimens, which may be hemorrhagic, necrotic, with more or less extensive fibrosis of the stroma, and the immaturity of certain tumors, sometimes make it impossible for the pathologist to give a precise diagnosis of the tumor other than the benign or malignant structural character of the lesion. This represents a significant obstacle in hematology for affections which, although non surgical, nevertheless require precise identification of the lesion for effective therapy. The elaboration of more effective sampling material, repeated punctures and immunohistoenzymatic analysis techniques would probably further improve the results of the method.     

Tumours involving the intrathoracic vagus and phrenic nerves demonstrated by computed tomography: anatomical features.

Four cases of mediastinal tumours involving the intrathoracic vagus and phrenic nerves are presented and their computed tomographic (CT) features are described with particular attention to the intrathoracic course of these nerves. One case of mediastinal plexiform neurofibromatosis appeared as a series of low attenuation masses along the intrathoracic course of the nerves. Three examples of neurilemmomas of the vagus nerve appeared as masses with central low attenuation; one in the retrocaval area, one to the left of the aortic arch, and one in the right paraoesophageal area. Familiarity with the CT anatomy of the vagus and phrenic nerves will greatly assist in the diagnosis of mediastinal tumours.     

Cervical epidural injection technic under computed tomography guidance in the treatment of cervicobrachial neuralgia

Epidural injections of corticosteroids in the cervical spine can provide effective treatment of cervicobrachial neuralgia. This technique is mainly described by anesthesiologists who perform injections without imaging control. We demonstrate that this infiltration can be easily performed under CT-guidance by radiologists.     

Imaging of the pancreas with computed tomography.

In this paper we present our experience with computerized tomographic imaging of the pancreas, both in normal and abnormal conditions. Eighty patients were studied for evaluation of pancreatic disease. A further 50 patients, all with a normal pancreas, were studied for abnormalities of other abdominal organs and served as the control group. Helpful signs in establishing the diagnosis of carcinoma of the pancreas were mass effect within the pancreas, alteration of organ contour and obliteration of retroperitoneal fat planes. We found that differentiation from pancreatitis or retroperitoneal lymphadenopathy may at times be difficult. Our results showed that in 22 out of 23 patients with proven normal pancreas, the pancreas size on the CT display was within the adopted normal range. In 30 patients with proven carcinoma of the pancreas, a pancreatic mass was seen in 24 (83%). Computerized tomography is clearly a valuable method for viewing both normal pancreatic anatomy and anatomical variations and pathologies.