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We evaluated the usefulness of skull fracture analysis using three-dimensional computed tomography skull fracture scores (3DCT-SFs) in cases of fatal falls.From April 2016 to September 2020, 46 cases of fatal falls from great heights (33 males, 13 females; mean age: 52.7 (range: 18-89) years) were examined using routine postmortem CT. The 3DCT-SFs were determined as the sum of the fracture line lengths measured on a volume rendering image. Skull fracture severity was classified into four stages according to the 3DCT-SFs. These stages were compared by macroscopic evaluation of skull fracture severity (injury level 0: no fracture; injury level I: fracture without deviation; injury level II: fracture with deviation; injury level III: comminuted open skull fracture). The relationship between 3DCT-SFs values, the fall distance, and the hardness of the landing surface was also examined.Skull fractures occurred in 26 cases (56.5%). The mean 3DCT-SFs of the cases that were classified as stages I, Ⅱ, and III were 86.6 (5.0-187.0), 832.0 (235.1-1865.8), and 3582.5 (2171.6-4787.6), respectively. Upon macroscopic evaluation of fracture severity, there were 8, 10, and 8 cases of injury levels I, II, and III, respectively. The 3DCT-SFs-based stages correlated significantly with the macroscopic skull fracture severity levels (RThe 3DCT-SFs correlate well with macroscopic findings and are useful as an objective skull fracture index.

Postmortem computed tomography (CT) is a minimally invasive technique to examine internal organs before a forensic autopsy. The purpose of our study was to estimate lung weight in a forensic setting in cases of various lung states, including fluid accumulation (congestion, edema, hypostasis, and inflammation etc.) using postmortem CT. From January 2016 to July 2018, 111 deceased bodies (62 males and 59 females, aged from 18 to 95 (average 59.6) years) were examined by CT before autopsy. Both lungs of the 111 deceased were analyzed separately, making it a total of 222 samples. We extracted lung fields from CT images manually after semi-automatic detection using an image workstation. The total lung volume and 6 categories of lung volume divided according to their CT density were measured. Multiple regression analysis was performed with lung weight in autopsy as the response variable, while the 6 categories were labelled as explanatory variables. The relation between lung weight in autopsy and lung weight estimated using postmortem CT showed a high Pearson’s correlation coefficient (R2 = 0.9106). Using postmortem CT, the lung weight can be estimated in forensic settings.

Purpose The aim of this study is to estimate the lung weight using postmortem CT in well aerated lung autopsy cases. The correlation coefficients to the lung weight were also evaluated for the cadavers' height, weight, whole body surface area (WBSA), body mass index, and estimated lung volume. Materials and methods From October 2015 to July 2016, 31 cadavers (male 12, female 19, age 20–98 (mean 66.9) y.o., postmortem interval 0.3–75.0 (5.7) days) were compared as regards body weight, height, whole body surface area (WBSA), body mass index (BMI), lung volume on CT, and total lung volume classified into several CT number categories, with their lung weight in autopsy. Results The lung weight (mean ± SE) was 284.9 ± 14.8 g in right lung and 249.3 ± 12.9 g in left lung. The %ALV was 79.9 ± 0.9 HU (mean ± standard error (SE)) in both lungs, 80.3 ± 1.3 HU in right lung, and 77.6 ± 2.0 HU in left lung. Using a simple linear regression test, there was no statistically significant correlation between the lung weight and the categories (R 2 : body height 0.234, weight 0.224, WBSA 0.309, BMI 0.046, lung volume 0.059). The volume for each individual CT density category showed no significant correlation, but the stepwise regression test yielded an excellent correlation coefficient (R 2 = 0.840). Conclusion The well aerated lung weight was 284.9 ± 14.8 g in right lung and 249.3 ± 12.9 g in left lung, and the postmortem CT could estimate the lung weight with high correlation coefficient.

Purpose: We retrospectively evaluated the cerebro-spinal fluid (CSF) CT density at the lateral ventricle to compare the postmortem intervals in cadavers. Materials and methods: The number of cadavers enrolled in this study was 189 (male 120, female 69). According to the estimated postmortem time, the cadavers were divided into 13 groups (postmortem day 0.5, 1, 1.5, 2, 2.5, 3, 4, 5, 7, 10, 14, 21, 30), and were also re-grouped into 3 groups according to the postmortem time-width: group A (postmortem day 0.5-2.5), group B (day 3-7), and group C (day 10-30). Comparisons between the CSF density and estimated postmortem time were also analyzed. Results: The CSF density was around 20 HU up to day 2.5, and it increased gradually after day 3. Day 3 and 4 presented higher CSF density than day 1 and 1.5 (p < 0.05). Day 7 presented higher CSF density than day 3 (p < 0.05). According to the postmortem time-width, the CSF density increased with postmortem time (p < 0.05). The simple linear regression equations presented negative correlation between CSF density and estimated postmortem time, and R2 was 0.119. Conclusion: The CSF density increased, but not linearly, according to the postmortem time, and the 3rd postmortem day was the earliest time allowing the difference to be detected. The CSF density needs further evaluation to enable estimation of the postmortem time.

Postmortem CT (PMCT) is increasingly used in forensic practice, and knowledge and classification of typical postmortem imaging findings would facilitate the interpretation of PMCT. The goal of this study was to define the time-related course of postmortem chest findings. Twelve cadavers (eight male, four female, 27–81 [mean, 60.0]years) were examined twice by PMCT within an interval of time (4–164h [mean, 30.8; median, 17.5]). The pleural-space-fluid volume, pulmonary parenchyma volume, decreased aerated lung volume (DLV), %DLV (=DLV/pulmonary parenchyma volume) and chest cavity volume were compared between the first and second PMCT examinations. To evaluate the volume change rate, the rate of increase in pleural space fluid volume (mL/h) and the DLV rate (mL/h) were plotted according to the postmortem period. On the second PMCT, the volume of pleural space fluid (p=0.0469) and %DLV (p=0.0161) were significantly increased. The increase rate of the pleural space fluid increased at approximately 30h and the volume continued to increase until approximately 40h after death. The rate of DLV constantly decreased in the early postmortem period. In conclusion, the pleural-space-fluid collection and the DLV increased over different time-related courses in the postmortem period.

To identify lung findings specific to fatal hypothermia on postmortem computed tomography (CT) imaging. Whole body CT scans were performed followed by full autopsy to investigate causes of death. There were 13 fatal hypothermia cases (group A) and 118 with other causes of death (group B). The chest cavity (CC), dead space including fluid/pneumothorax (DS), aerated lung volume (ALV), percentage aerated lung (%ALV), and tracheal aerated volume (ATV) were measured. Autopsy findings of groups A and B were compared. Receiver operating characteristics (ROC) curves were used to identify factors specific to fatal hypothermia. There were no differences in age, sex, number with emphysema, or time from death to CT examination between the 2 groups. CC, DS, ALV, %ALV, and ATV were 2601.0±247.4 (mL), 281.1±136.5 (mL), 1564.5±281.1 (mL), 62.1±6.2(%), and 21.8±2.7 (mL) in group A and 2339.2±67.7 (mL), 241.1±38.0 (mL), 739.9±67.0 (mL), 31.4±2.3(%), and 15.9±0.8 (mL) in group B, respectively. There were statistically significant differences between groups A and B in ALV, %ALV and ATV. The multiple comparison procedure revealed that ALV and %ALV differed significantly between fatal hypothermia and other causes of death (p0.05). Using ROC evaluation, %ALV had the largest area under the curve (0.819). This study demonstrates that the %ALV is greater in fatal hypothermia cases than in those with other causes of death on postmortem CT chest imaging. Based on CT, hypothermia is very likely to be the cause of death if the %ALV is70%.

Purpose: To evaluate the usefulness of the applied freezing technique in putrefied brain for macroscopic investigation. Materials and methods: From October 2015 to September 2016, first the brains of 10 cadavers (control group: male 6, female 4, age 20-80 (mean 61.5), postmortem intervals (PMI) 14-75 (mean 29.7) days) were inspected following the standard practice (without freezing preparation), and then with 10 cadavers (freezing group: male 7, female 3, age 41-88 (mean 60.4), PMI 7-75 (mean 29.2) days) the freezing technique was used before the autopsy. The cut brain was investigated, and the gray-white matter difference was evaluated macroscopically. Results: In the control group, the brain parenchyma leaked out like sludge in 5, and there was difficulty maintaining its structure in 7. The gray-white matter difference was well visible in 3, but hard to distinguish in 3, and the total scores ranged from 0 to 9 (mean 4.4) points. In the freezing group, the entire putrefied brain was extracted as a solid organ, the gray-white matter differences were well visible, and the total scores were 6.7-9 (8.3) points. The gray-white matter difference was preserved in the freezing group (p < 0.05). Conclusion: The freezing procedures to evaluate the putrefied brain have been successfully applied, and it could be statistically more useful in putrefied brain investigation than the ordinary procedure. Postmortem CT can be useful to evaluate not only the degree of brain putrefaction, but also the degree of brain parenchyma freezing.

To evaluate for how long patients should be isolated after I-131 treatment for thyroid cancer according to the guidelines issued by the Japanese Ministry of Welfare.We reviewed 92 therapies performed in 76 patients who were administered I-131 at our hospital from July 2007 to September 2009. Fifty-six patients were given 2220 or 2960 MBq I-131 at the first therapy, and 29 patients underwent 36 repeated therapies using 2960, 3700, 5550 or 7400 MBq I-131. We surveyed radioactivity for a 1 cm dose equivalent rate at 1 m intervals at 30 and 48 h after administration of I-131, obtained planar scintigrams at 48 h, and surveyed radioactivity repeatedly until it fell to under 30 μSv/h.The radioactivity was under 30 μSv/h at 30 h in 51 out of 92 cases (55%). Among the remaining 41 (45%) cases, 27 (29%) and 32 (35%) cases showed decreased radioactivity under 30 μSv/h at 48 and 72 h, respectively, and it remained higher than 30 μSv/h at 72 h in another 9 cases (10%). In 5 (38%) of the 13 cases with bone metastasis, the radioactivity remained over 30 μSv/h after 72 h, and scintigrams showed strong accumulation in bone metastases. Among the 27 cases demonstrating below 30 μSv/h at 48 h, 26 showed radioactivity being below 50 μSv/h at 30 h, while it was above 50 μSv/h at 30 h in all 14 cases which demonstrated above 30 μSv/h at 48 h. We compared the radioactivity levels of 27 cases under 30 μSv/h at 48 h and 14 cases over 30 μSv/h at 48 h using a cutoff value of under 50 μSv/h at 30 h to release patient at 48 h, the positive predictive value and negative predictive value were 100 and 93%, respectively, and radioactivity was found to differ significantly (P0.001).To predict external radiation levels at 48 h, it is helpful to consider external radiation levels at 30 h after treatment. Consideration of intracellular uptake in thyroid cancer, especially in cases of bone metastases, digestive tract function, and renal function, is important for predicting isolated period.

The purpose of this study was to assess the control of nidus blood flow and the association between such control and clinical outcomes after ethanolamine oleate (EO) sclerotherapy for vascular malformations. Morphological grades on magnetic resonance (MR) images (grades 1–3), preprocedure nidus blood flow control, and clinical results in 22 cases of vascular malformation were reviewed. Cases were subdivided by MR morphological grade as follows: grade 1, 3 patients; grade 2A, 6 patients; grade 3, 13 patients. Responses to EO sclerotherapy were as follows: excellent, 3 patients; good, 5 patients; poor, 14 patients. An excellent response was achieved in one grade 1 case, one grade 2A case, and one grade 3 case. Preprocedure nidus flow was controlled in 8 lesions (type A) and not controlled in 14 lesions (type B). Three (37.5%) type A lesions had an excellent response, five had a good response; and none had a poor response. All type B lesions had a poor response. Flow control predicted an excellent result (P < 0.05). Preprocedure nidus blood flow control (versus lack of control) is associated with a significantly higher incidence of favorable clinical responses to EO sclerotherapy for vascular malformations.

Purpose: We evaluated the efficacy of magnetic resonance angiography (MRA) for detecting the artery of Adamkiewicz (AKA) and the vertebral level of its feeding arteries branching from the aorta. Materials and Methods: Eighty-two patients (67 men, 15 women; aged 34 to 86 years, mean age 68.6 years) with thoracic descending and thoracoabdominal aortic lesions (aneurysm in 55, dissection in 25, coarctation in 2) underwent MRA to detect AKA. MRA was performed using 6-phase, dynamic-enhanced, 3-dimensional, fast spoiled gradient recalled acquisition in steady state (GRASS) on a 1.5-tesla (T) system, with double-dose bolus contrast injection. The vertebral levels of AKA branching and the AKA feeder artery branching from the aorta were determined. Results: The AKA was detected in 67 patients (81.7%). Branching of AKA occurred at levels T7 to T12 on the left side (n=52) and on the right (n=15). Vascular continuity from the aorta to the anterior spinal artery was demonstrated in 55 patients (67.1%). Comparing the vertebral level of arterial branching from the aorta to that of the AKA at the intervertebral foramen, the AKA branched at the same vertebral level in 44 patients (80.0%), one vertebral level above/below in 10 (18.2%), and 2 vertebral levels above in one (1.8%). Conclusion: MRA can be useful in the preoperative work-up of patients with thoracoabdominal aortic lesions to localize AKA and the segmental trajectories of vessels supplying blood to the AKA.

Peripheral vascular malformations are now described according to some accepted guidelines, and the principle of proper treatment (nodus ablation) is becoming clear. An appropriate classification schema for vascular anomalies and definite indications for treatment are important to successful treatment overall. Non-invasive imaging (US, CT, and MRI) in association with clinical findings is critical in establishing the diagnosis, evaluating the extent of the malformation, and planning appropriate treatment. Direct nidus phlebography is useful not only in making a correct diagnosis but also in treating the lesion by sclerotherapy. When a patient suffers clinical complications, the nidus sclerotherapy becomes mandatory. If the vascular malformation remains bloodstream to a drainage vein during nidus opacification, flow control is necessary to achieve complete nidus ablation. A multidisciplinary approach is needed in the treatment of a high-flow lesion. A dedicated team approach is necessary for appropriate management in most cases. .

The stent-graft is a device constructed from a stent and vascular graft and is inserted by means of an interventional procedure under imaging guidance. In 1986, Balko et al.1 reported the first stentgraft experiment, in which a Z stent covered with polyurethane was inserted into an animal aorta. In the early 1990s, Parodi et al.2 reported clinical introduction of the stent-graft for abdominal aortic aneurysm. In comparison to the abdominal aortic stent-graft, the thoracic stent-graft has several disadvantages, including difficulties associated with the aortic arch curvature and the relatively large caliber of the stent-graft, and the risk of central nervous system or spinal complication. However, the thoracic stentgraft is advantageous because of minimal procedural invasiveness in comparison to surgical graft replacement. In 1994, Dake et al.3 reported transluminal placement of an endovascular stent-graft for thoracic aortic aneurysm, and Kato et al.4 reported use of a stent-graft for aortic dissection and suggested that the stent-graft could be considered an alternative to surgical treatment.

Thiosulfate measurement is crucial to diagnosis of hydrogen sulfide (H2S) poisoning in forensic toxicology. Although GC-MS method is currently regarded as a standard thiosulfate measurement, it requires complicated sample preparation prior to analysis. This study presents a simple, rapid, and highly sensitive method for the quantitative analysis of serum thiosulfate by using liquid chromatography-tandem mass spectrometry (LC-MS/MS). This method is based on selected reaction monitoring and has high sensitivity with a lower quantification limit of 0.5μM. Precision and accuracy of this method meet the basic requirements for quantitative analysis (intra- and inter-day tests have a relative standard deviation of ⩽10.4%; range of analytical recovery is 94.3-102.6%). On the measurements of serum thiosulfate by our developed method, a thiosulfate concentration as 57.5μM was detected clearly in the H2S poisoning case comparing to the non poisoning case in which only a trace amount of thiosulfate was observed.

Two 60-year-old males were found at their homes whose bodies had deteriorated due to putrefaction. To prevent worm invasion and minimize deterioration, dry ice was used prior to the autopsy investigation. Prior to autopsy, postmortem CT demonstrated a decreased density in brain parenchyma at the dry-iced side, and autopsy revealed deteriorated brain parenchyma with frozen effect (presented like sherbet). Moreover, the deteriorated cerebral parenchyma maintained their structure and they were evaluated by cutting. When lower CT density presents in postmortem CT, the freezing effect may need to be considered and the physician should evaluate the cadaver's postmortem condition to prevent misdiagnoses.

Postmortem CT (PMCT) is increasingly used in forensic practice, and knowledge and classification of typical hemopericardium on PMCT would help to assure correct radiological interpretation. The goal of this study was to evaluate the pericardial and pleural space fluid volumetry, and to evaluate the signs on PMCT pointing to cardiac tamponade as the cause of death, and their pitfalls. Fourteen cadavers (eleven male, three female, 49-87 [mean, 70.9] years) were examined by PMCT. The pericardial volume and pericardial findings with/without pleural space fluid collection were compared with autopsy findings. In addition, the appearance of pericardial lesions on PMCT was documented and compared with the autopsy findings. The respective volumes of pericardial space, and right and left pleural space fluid showed as 172.0-711.0 (mean 368.7) ml, 0-1830.0 (266.1) ml, 0-231.0 (75.2) ml on PMCT, and were 136.0-652.0 (311.1) ml, 0-2100 (299.0) ml, and 0-300.0 (61.3) ml on autopsy. In statistical evaluation, the pericardial space volume was significantly greater on PMCT (p

We have developed a technique of CT-guided needle placement in the destructed human body in forensic practice. A sixty-year-old male was found in a burned car and he was also destructed severely. Although blood was needed for the external examination, it was difficult to approach the vessels because of the severely burned condition of the cadaver. Thus, we attempted to obtain a blood sample from a vessel using a CT-guided technique. Postmortem CT demonstrated the presence of blood-containing vessels in the pelvis. Indeed, CT-guided needle placement had no difficulty with surface markers, table location, or depth measurement from the surface. CT-guide needle placement is a feasible and reliable technique, so that when the tissue/blood sample is at risk of being spoiled, CT-guided needle placement could be a substitute for conventional sampling techniques.

Post-traumatic high flow priapism is a rare disease. A review of English published reports revealed 63 cases. Enhanced computed tomography (CT) of the penis has not previously been used as a diagnostic method for post-traumatic high flow priapism. We present a case of post-traumatic high flow priapism diagnosed with enhanced CT of the penis. Additionally, diagnostic modalities for post-traumatic high flow priapism are discussed with review of published work.

To evaluate the indication and advantages of venous sac embolization of pulmonary arteriovenous malformations (PAVMs) using interlocking detachable coils (IDCs).We performed percutaneous embolization in 12 PAVMs in four patients using IDCs, initially placed in the venous sac or at the feeding artery to prevent systemic migration of additional coils. We placed the IDCs in the venous sac in PAVMs with the following vascular architecture: the draining vein was larger than the feeding arteries and both vessels were interposed with the venous sac or there were short feeding arteries.Complete occlusion was achieved in all 12 PAVMs without significant complications. We deployed IDCs in the venous sac in eight PAVMs and in the feeding artery in four.Venous sac embolization may be beneficial in PAVMs with large out-flow vessels or short feeding arteries. IDCs are suitable for this procedure.

Laparoscopic microwave coagulation (LMC) for hepatocellular carcinomas (HCCs) was performed on 26 HCCs in 17 patients. Contrast-enhanced CT (CECT) and MR images (T1-weighted imaging [T1WI], T2WI, gadolinium-diethylenetriamine pentaacetic acid [Gd-DTPA] T1WI) were obtained to determine changes over time. The irradiated center exhibited low to moderate intensity with surrounded high intensity (HI) on T2WI and Gd-DTPA T1WI. On T1WI, lesions showed four patterns of intensity: uniform HI (30.8%), arcuate HI (26.9%), mainly low with spot HI (30.8%), and isointensity to hypointensity (11.5%). Follow-up imaging at more than 170 days revealed isointensity to hypointensity on T1WI (96.2%) and reduced HI on T2-weighted imaging (T2WI) and Gd-DTPA T1WI. All lesions became less conspicuous and were reduced in volume. HCC shows time-related changes in signals and size after LMC. Identifying the irradiated lesion is necessary to estimate the adequacy of treatment by comparison with the pretherapeutic image.

AIM The hypothesis of this multicentric study is performing a specific typification in the selection of grafts for the endoluminal treatment of an aneurysmally altered distal aorta based on mathematical information and the correlation of a number of morphological parameters diagnosed by 64-multidetector computed tomographic (CT) aortography. MATERIALS AND METHODS The study is multicentric and encompassed 30 Asian and 30 European patients. Examinations were performed on the same type of 64- multidetector CT equipment and under same conditions of examination technique and postprocessing. Several statistical methods were applied to analyze the results. RESULTS Statistically significant differences were found between Asian and European patients in the morphology of the central part of the aneurysm at the level of the abdominal aorta and the width and length of the iliac arteries. The principal cause of the most frequent complication observed was defined by a CT aortographic study. CONCLUSIONS Computed tomographic aortographic quantification of significant parameters makes it possible to plan the exact dimensions of grafts in each individual case. Computed tomographic examinations make possible very exact measurements and positioning of the graft of the novel design proposed by the authors and expected to substantially reduce the incidence of complications.

Gandolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) is a hepatobiliary contrast agent for MRI. It was reported that Gd-EOB-DTPA is useful to detect liver tumors and differentially diagnose benign and malignant pathologies in the liver. Since Gd-EOB-DTPA partially accumulates in the hepatocytes and bile via various transporters after intravenous injection, signal intensity in the liver increases on T1-weighted images. The signal intensity of the liver after Gd-EOB-DTPA injection depends on the Gd-EOB-DTPA uptake by hepatocytes and bile excretion. It is known tha the Gd- EOB-DTPA accumulating in the kidney is excreted to the urine through glomerular filltration. Because Gd- DTPA is concentrated in the renal tubules after being filtered at the Bowman’s capsule, and since it is neither secreted nor reabsorbed the concentrating and diluting function of the renal tubules can be studied by imaging techniwues. since renal function can be evaluated with Gd-EOB-DTPA can also be used to evaluate renal function. Eith the development of MRI equipment and rapid imaging techniques, temporal resolution had improved greatly. However, no previous study has been carried out on renal function using Gd- EOB-DTPA dynamic MR study that was correlated with estimated glomerular filtration rate (eGFR) and stage of chronic kidney disease (CKD) in the Japan Association of chronic kidney disease initiative.

The aim of this study is to analyze the morphological differences of infrarenal aortic aneurysms and common iliac arteries that are important for endovascular management between patients of different body mass index using 64 slice multidetector row CT aortography. This was a multicenter study of 100 patients (50 Europeans and 50 Japanese). All patients had risk factors, manifest symptoms, and ultrasound verified aneurysmal dilation of the infrarenal aorta. All examinations were performed on the same CT platform using the same post-processing protocols. Due to the heterogeneity of the population, several statistical models were used. Significant differences were found in morphological parameters of infrarenal aorta in relation to BMI. In over one out of three patients with BMI less than 23, endovascular treatment is contraindicated due to the dimensions of the aneurysmal neck. Relative to BMI value, differences were found in transverse diameters of the medium part of the aneurysm and in the length of common iliac arteries. CT aortography performed on a 64 slice multidetector row CT platform provides precise and numerous data for the analysis of anatomical and pathological differences of infrarenal aortic aneurysms that are of crucial importance for the planning of treatment and the analysis of the differences relating to body habitus.

Open repair of aortic aneurysm causes spinal cord perfusion pressure to decrease due to the steal phenomenon from the bleeding of intercostal arteries and cross-clamping of the aorta. We attempted to perfuse the intercostal arteries for preoperative detection of the artery of Adamkiewicz using newly developed catheters. Fifteen patients underwent selective spinal perfusion with our original catheter as spinal protection during the procedure of distal descending thoracic aneurysm (DTA) or thoracoabdominal aortic aneurysm (TAAA) repair. Seven patients had distal DTA and eight had TAAA. Monitoring of motor evoked potential (MEP) was performed in all patients throughout the operation. The perfusion flow was 30-40 ml/min for each intercostal artery and was adjusted to keep the proximal circuit pressure at 150-200 mmHg. The average number of perfused intercostal arteries was 2.3 per patient and the number of intercostal arteries reimplanted per patient was 2.5. Intercostal arteries were reimplanted using an interpositional graft. MEPs were still observable after graft replacement in all patients and there were no cases of paraparesis/paraplegia. All patients were discharged ambulatory. Selective spinal perfusion maintains the quantity of total blood flow in the spinal cord and is very useful for reducing the incidence of ischemic injury of the spinal cord during operation.

The aim of this study was to evaluate the accuracy of dynamic gadolinium (Gd)-enhanced magnetic resonance imaging (MRI) with endorectal coil for assessing tumor invasion based on simple classification criteria. A total of 58 patients with operable primary rectal cancer underwent preoperative MRI. An enhancement pattern in Gd-enhanced dynamic MRI with regard to tumor penetration was clarified. Retrospectively, two observers independently scored T2-weighted MRI and T2-weighted MRI combined with Gd-enhanced dynamic MRI for tumor penetration using the following criteria: With Gd-enhanced dynamic MRI, T1 tumors showed an early enhanced line around the tumor as rim enhancement; T2 tumors appeared as black lines or double layers, as the muscularis propria kept its integrity; T3 tumors showed partial discontinuity of the muscularis propria as a dotted line and a perforated area as an interrupted line. A confidence level scoring system was used, and receiver operating characteristic curves were generated. There were no significant differences at the T1 stage. There were significant differences for observer 1 (P = 0.001 for observer 1) at the T2 stage. There were significant differences for both observers (P = 0.001 for observer 1 and P = 0.005 for observer 2) at the T3 stage. Our criteria for Gd-enhanced dynamic MRI were effective for T3 stage tumors.

BACKGROUND AND PURPOSE: Flow voids within the cavernous sinuses and/or certain venous drainage on spin-echo MR imaging and time-of-flight (TOF) flow enhancement on MR angiography (MRA) have indicated high-velocity shunt flow and have been used for screening patients with dural arteriovenous fistulas (DAVFs) of the cavernous sinuses. In this investigation, the capabilities of 3D dynamic MRA as a flow-independent approach and those of conventional MR imaging techniques were compared with selective angiography for the diagnosis of DAVFs of the cavernous sinuses. MATERIALS AND METHODS: This retrospective study involved 18 patients with angiographically proved DAVFs of the cavernous sinuses and 12 control subjects. Sixteen partially overlapping sequential MR images were acquired on contrast-enhanced 3D dynamic MRA between the petrosal bone and the orbital roof. Two experienced observers blinded to the clinical data and results of angiography independently graded 3D dynamic MRA, fast spin-echo T2-weighted imaging (FSE T2WI), and TOF MRA. RESULTS: The average area under the receiver operating characteristic curve values and interobserver κ scores for the diagnosis of DAVFs on 3D dynamic MRA, FSE T2WI, and TOF MRA were 0.99, 0.89, and 0.95; and 0.92, 0.71, and 0.73, respectively. Those for the diagnosis of anterior, posterior, and retrograde cortical venous drainage on 3D dynamic MRA were 0.72, 0.95, and 0.81; and 0.56, 0.50, and 0.49, respectively. CONCLUSION: In this small series, screening 3D dynamic MRA directly demonstrates DAVFs of the cavernous sinuses and has improved diagnostic capability.

Purpose To evaluate the efficacy of double-subtraction magnetic resonance angiography (MRA) (subtraction of the subtracted venous phase image from the subtracted arterial dominant phase image) for depicting the artery of Adamkiewicz and differentiating it from the drainage vein. Materials and Methods A total of 170 patients (123 men, 47 women; aged 17–84 years, mean = 67 years), with a thoracoabdominal vascular lesion underwent MRA for detection of the artery of Adamkiewicz. MRA was performed as a five-phase dynamic-enhanced three-dimensional (3D) fast spoiled gradient recalled acquisition in steady state (GRASS) sequence on a 1.5-T system, with double-dose bolus contrast and saline injection. The levels at which the artery of Adamkiewicz and drainage vein originated were determined. Signal intensities of the two vessels were measured with source images to assess the signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and necessity of the double-subtraction technique. Results The artery of Adamkiewicz was detected in 140 patients (82.4%). Branching occurred at levels T8–T12 on the left and T8–T11 on the right. An additional anterior radiculomedullary artery was detected in 18 patients. The drainage vein was detected in 133 patients (78.2%). It merged at the T9–L2 level on both sides. In six of the 133 patients (4.5%), the drainage vein branched upwardly. Neither SNR nor CNR differed significantly between the artery of Adamkiewicz and the drainage vein in the arterial phase; but on the subtraction image, signal intensity of the artery was higher than that of the drainage vein (P < 0.05). Conclusion Double-subtraction MRA is useful for detecting the artery of Adamkiewicz when it is necessary to differentiate it from the drainage vein. J. Magn. Reson. Imaging 2007. © 2007 Wiley-Liss, Inc.

Background: We reviewed our experience to investigate the determinants of paraplegia/paraparesis after endovascular stent-graft repair of the thoracic aorta, to assess the influence of the artery of Adamkiewicz (ARM) detected by preoperative magnetic resonance angiography (MRA) and to identify patients at risk. Methods: Over a 5-year period (March 2001—June 2006), 149 patients underwent elective endovascular stentgraft repair of the descending thoracic aorta. Patient demographics and perioperative factors relating to the endovascular procedure were evaluated by using univariate statistical analyses. To assess the influence of the ARM in the thoracolumbar region, patients in whom ARM was detectedbypreoperativeMRAweredividedintotwogroups:patientswhohadocclusionoftheintercostalarteryforARMduetostent-graft(group A, n = 33) and patients who had patency of the intercostal artery for ARM following stent-graft (group B, n = 38). Results: Five (3.6%) of the 144 patients had paraparesis/paraplegia. Two of these five patients had previously undergone operation for total arch replacement with elephant trunk and one had surgery for descending aortic repair. Univariate analyses identified only prior aortic surgery as a significant risk factor (p = 0.04). Paraparesis/paraplegia rates were 10% (three patients) in group A and 0% in group B (p = 0.09). Conclusion: Prior thoracic aortic replacement was found to be a significant predictor of spinal cord ischemia, and therefore vigilance is needed regarding occlusion of the intercostal artery for ARM detected prior to stent-graft repair. # 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Peripheral vascular malformations are now described according to some accepted guidelines, and the principle of proper treatment (nidus ablation) is becoming clear. An appropriate classification scheme for vascular anomalies and definite indications for treatment are important to successful treatment overall. The findings from noninvasive imaging (ie, Doppler ultrasonography, computed tomography, or magnetic resonance imaging) in association with clinical findings are critical in establishing the diagnosis, evaluating the extent of the malformation, and planning appropriate treatment. Direct opacification of the nidus is useful, not only in making a correct diagnosis, but also in treating the lesion with sclerotherapy. In most cases, conservative treatment is recommended, but when a patient suffers clinical complications (eg, ulceration, pain, hemorrhage, cardiac failure, or unacceptable cosmetic consequences), the nidus sclerotherapy becomes mandatory. If the vascular malformation has blood outflow to a drainage vein during nidus opacification, flow control (with balloon occlusion, tourniquet, or embolization) is necessary to achieve sclerosant stasis within the nidus. Embolotherapy (with a coil, n-butyl cyanoacrylate, or small particles) should be used for subsequent multifaceted palliative therapy. A multi-disciplinary approach is needed in the treatment of a high-flow lesion, and a dedicated team approach is necessary for appropriate management in most cases.

To prospectively evaluate the detection of the artery of Adamkiewicz at magnetic resonance (MR) angiography and the effect such detection has on outcome after surgical graft placement in a series of patients with thoracoabdominal aortic disease.This study had ethics committee approval, and written informed consent was obtained from all patients. Fifty patients (38 men, 12 women; age range, 47-83 years; mean age, 67.2 years) who were scheduled to undergo thoracoabdominal aortic surgery for treatment of thoracoabdominal aortic aneurysm (n = 42) or thoracoabdominal aortic dissection (n = 8) were enrolled in the study. MR angiography was performed with a 1.5-T system by using dynamic three-dimensional fast spoiled gradient-recalled acquisition in the steady state with a bolus of contrast material and saline injection (4 mL/sec). Differences in the cross-clamping time, bypass time, total surgery time, and spinal complication rate between patients in whom the artery of Adamkiewicz was identified (group A) and those in whom the artery was not identified (group B) were evaluated with chi(2) or Mann-Whitney U testing.In 42 of the 50 patients (84% [group A]), at least one artery of Adamkiewicz was seen to arise from an intercostal artery. Two arteries of Adamkiewicz were identified in four of the patients (8%). The artery of Adamkiewicz could not be detected with MR angiography in eight patients (group B). The ranges of cross-clamping, bypass, and total surgery times, respectively, were 30-199 minutes (mean, 78.4 minutes +/- 39.1 [standard deviation]), 30-298 minutes (mean, 96.9 minutes +/- 60.0), and 135-665 minutes (mean, 354.9 minutes +/- 133.9) in group A and 53-124 minutes (mean, 72.8 minutes +/- 29.8), 10-124 minutes (mean, 66.0 minutes +/- 41.0), and 220-405 minutes (mean, 315.6 minutes +/- 68.8) in group B. Spinal complications occurred in two patients in group B but in none of the patients in group A (P.001).The artery of Adamkiewicz was detected in a large percentage of patients in whom there were no spinal complications, unlike the spinal complications that occurred in the patients in whom the artery was not detected.

Background. The purpose of this study was to determine whether the artery of Adamkiewicz (ARM) can be detected by magnetic resonance angiography and to determine the usefulness of preoperative magnetic resonance angiography evaluation of the ARM. Methods. Between April 2000 and December 2003, 120 patients underwent magnetic resonance angiography for detection of the ARM. The morphology of the anterior spinal artery at the ARM junction, as revealed by magnetic resonance angiography, in 99 patients in whom ARM was preoperatively detected was classified into the following three types: noncontinuation of the anterior spinal artery above the ARM junction (type A), continuation of the anterior spinal artery above and below the ARM junction (type B), and noncontinuation of the anterior spinal artery below the ARM junction (type C). Results. The ARMs were detected in 99 (83%) of 120 patients, and from a total of 110 ARMs 105 (95%) originated from intercostal arteries branching from the left side and 94 (86%) originated between Th9 and Th11. Two ARMs were found in 11 (11%) of 99 patients in whom ARMs were detected. In 107 patients, who underwent magnetic resonance angiography to reveal the morphology of the anterior spinal artery at the ARM junction, the patterns of the anterior spinal artery were type A in 59 patients (55%), type B in 21 patients (20%), type C in 3 patients (3%) and not classified in 24 patients (22%). No spinal cord injury occurred in patients in whom the ARM had been preoperatively detected. Conclusions. Preoperative detection of the ARM is possible by magnetic resonance angiography and is very useful for reducing the incidence of ischemic injury of the spinal cord.

Objective: The outcome of thoracoabdominal or descending aortic aneurysm repair after preoperative demonstration of the artery of Adamkiewicz (ARM) by magnetic resonance angiography (MRA) was investigated. Methods: Between January 2000 and December 2001, 40 consecutive patients who had aneurysms of the thoracoabdominal or descending aorta underwent preoperative MRA to visualize the ARM. Thirty-two patients underwent replacement of the aneurysms, and 25 patients (TAAA, 11; TAA, 14) underwent replacement of the aneurysms with preoperative detection of the ARM. Only intercostal or lumbar arteries in aneurysms, which were detected as the origin of the ARM, were reattached to the graft. The results of thoracoabdominal aortic aneurysm operations in 11 patients in whom the ARM was preoperatively detected (group I) were compared with the results of TAAA operations in 26 patients in whom the ARM was not preoperatively detected (group II). Results: MRA demonstrated the ARM in 29 (73%) of the 40 patients. The laterality of the arteries originated from the left side in 29 (100%) and between Th9 and Th12 in 25 (86%), between Th9 and L1 in 28 (97%) of the 29 patients. No spinal cord injury occurred in patients (TAAA and TAA) in whom the ARM had been preoperatively detected. Major complications following TAAA operations included paraplegia (0% in group I and 8% in group II), respiratory failure (9% in group I and 23% in group II), and renal failure requiring hemodialysis (18% in group I and 22% in group II). Operation times were 439 ^ 99 min in group I and 620 ^ 200 min in group II ðP ¼ 0:008Þ. Conclusions: Preoperative detection of the ARM is possible by MRA and is very useful for reducing the incidence of ischemic injury of the spinal cord and for reducing the time of an operation for repair of an aneurysm of the thoracoabdominal or descending aorta. q 2002 Elsevier Science B.V. All rights reserved.

Two high-risk patients underwent a graft replacement for descending thoracic or thoracoabdominal aortic aneurysms without the reconstruction of any intercostal and lumbar arteries. The first patient was an 81-year-old woman with asthma and renal dysfunction who was diagnosed to have a descending thoracic aortic aneurysm extending from the Th8 to Th12 level. Contrast magnetic resonance angiography (MRA) demonstrated the Adamkiewicz artery to originate from the left second lumbar artery. The second patient was a 59-year-old man with left ventricular dysfunction due to aortic and mitral stenoses who was diagnosed to have a Crawford type IV thoracoabdominal aortic aneurysm. Contrast MRA showed the Adamkiewicz artery to originate from the left ninth intercostal artery. In general, the reestablishment of the spinal cord's blood supply, whenever possible, is generally considered to be necessary in such patients to prevent spinal cord injury. However, the reimplantation of intercostal vessels is the most complex aspect of this surgical modality, and therefore, it may cause a substantial increase in the cardiopulmonary bypass time. However, at least in some cases, such as the two cases presented herein, the use of contrast MRA was found to reduce the risk in surgery for descending thoracic or thoracoabdominal aortic aneurysms by eliminating the need for any intraoperative management of the intercostal and lumbar arteries.

We report the case of a young man presenting with high-flow arteriovenous malformation (AVM), in whom percutaneous direct nidus puncture ethanolamine oleate (EO) sclerotherapy was useful in the management of the AVM. To our knowledge, this is the first report of percutaneous trans-nidus EO sclerotherapy for AVM in the extremities. Percutaneous trans-nidus sclerotherapy should be considered as an alternative choice for the management of symptomatic AVM.

The esophagus occasionally crosses the descending aorta at an unusually high level (3-5 cm inferior to the carina) in right-sided scoliosis. The purpose of this study was to analyze the mechanism of this finding. We prospectively evaluated thoracic CT scans in 30 patients with right-sided scoliosis. We assessed the alterations in the positions of the esophagus and the descending aorta by the thoracic deformity. The descending aorta followed the scoliotic curve of the spine in 26 (87%) patients. The esophagus followed the scoliotic curve of the spine in 14 (47%) patients and did not in 16 (53%). The anteroposterior diameter of the thorax in the former group was significantly smaller than that in the latter (p < 0.01). High level cross of both structures was identified in 14 (47%) patients, and all of them belonged to the group in which the esophagus did not follow the scoliotic curve of the spine. The unusual high level cross of the esophagus with the descending aorta occasionally seen in scoliosis is due to a difference in the positional alterations of the two structures resulting from the scoliosis. 6 refs., 3 figs.