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Acute developing transient paraparesis after celiac plexus block: MRI findings
European Journal of Radiology Extra 78 (2011) e35–e37
Contents lists available at ScienceDirect
European Journal of Radiology Extra journal homepage: intl.elsevierhealth.com/journals/ejrex
Acute developing transient paraparesis after celiac plexus block: MRI findings Ahmet Mete a,∗ , Lutfiye Pirbudak Cocelli b , Ruveyda Olmez a , Betul Kocamer b a b
Gaziantep University, School of Medicine, Department of Radiology, Sahinbey, 27310 Gaziantep, Turkey Gaziantep University, School of Medicine, Department of Anaesthesiology and Algology, Sahinbey, Gaziantep, Turkey
a r t i c l e
i n f o
Article history: Received 23 December 2010 Accepted 30 December 2010
Keywords: Cancer pain Celiac plexus block Neurolytic technique Reversible paraparesis Magnetic resonance imaging
a b s t r a c t Purpose: An endometrium cancer with liver metastasis, developing continuous and severe abdominal pain with vomiting and constipation, following phenol celiac plexus neurolysis, is described to find out if MRI can explain the reason of neurologic deficit. Materials and methods: A 81-year-old woman with metastatic endometrium cancer underwent celiac plexus phenol neurolysis for management of severe pain at right hypochondriacal region. In spite of apparently adequate needle position, she developed transient paraplegia consistent with anterior spinal artery syndrome. At 48 h after celiac plexus block MRI was performed. Results: In this patient, paraplegia suddenly ensued after instillation of the phenol solution, and postprocedure spinal MRI showed increased signal in the thoracic spinal cord consistent with edema. The patient was discharged 25 days after the block with clinically insignificant neurological deficit. Conclusion: We present a case of a patient who had paraparesis after the performance of celiac plexus block (CPB). We propose that the mechanism for this rare but devastating complication is the neurotoxicity of phenol on spinal cord which may result from spasmotic effect of phenol on spinal feeding arteries. In such cases MRI, especially the short tau inversion recovery (STIR) sequence should be performed to see the acute changes in spinal cord in patients with acute developing neurologic deficit following CPB. © 2011 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Neuroablative techniques for cancer pain treatment have been used for more than a century. With the development of imaging facilities such as fluoroscopy, neuroablative techniques can be performed more precisely and efficiently [1]. Celiac plexus block (CPB) is effective and commonly used analgesic technique for patients with upper abdominal visceral cancer pain [2,3]. Although neurologic complications are infrequent but, permanent paraplegia may occur after CPB [3,4]. Electroneuromyography (ENMG) changes associated with denervation due to neurologic injury require 14–21 days to appear in the lower extremities [5]. At this point MRI become important for demonstrating early changes in the spinal cord. Herein we present a case of transient paraparesia following phenol CPB with MRI findings. 2. Case report A 81-year-old woman with endometrium cancer with liver metastasis underwent celiac plexus phenol neurolysis for manage-
∗ Corresponding author. Tel.: +90 342 3606060/77339; fax: +90 342 3601617. E-mail addresses: [email protected] (A. Mete), lutfi[email protected] (L. Pirbudak Cocelli), [email protected] (R. Olmez), [email protected] (B. Kocamer). 1571-4675/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2010.12.018
ment of severe pain at right hypochondriacal region. Abdominal ultrasonography and MRI demonstrated the presence of multiple extensive lesions in both hepatic lobes suggesting multiple metastases. About two months ago, the patient had an operation (total abdominal hysterectomy and bilateral salpingoophorectomy + total omentectomy + repair of bowel) in the gynecology clinic. For palliative care, she refused pain therapy regimen consisted of regular nonsteroidal anti-inflammatory drugs, tramadol, and low dose transdermal fentanyl. Thus a phenol CPB was performed.
2.1. Technique for CPB The classic technique was used with fluoroscopy. Nonionic contrast was used to confirm a layering out of the radiocontrast in a vertical narrow line along the anterior aspect of T12 and L1 vertebrae. In the posterior–anterior view, the contrast was confined to the region surrounding the middle and upper L1 and lower T12 vertebrae. Standard noninvasive monitoring (electrocardiogram, oxygen saturation, and blood pressure) was performed throughout the procedure while 1 mg midazolam and 25 mcg fentanyl was administered intravenously and oxygen was administered by face mask. Bupivacaine (0.25%, 5 mL through needle) was then injected after checking via aspiration that the needles were neither intravascular nor
e36
A. Mete et al. / European Journal of Radiology Extra 78 (2011) e35–e37
Fig. 1. There is subtle high signal intensity throughout thoracic cord on sagittal TSE T2-weighted (A) and STIR (B) mid-sagittal images.
subarachnoid. Phenol (6%, 10 mL) was then injected through needle. The patient reported complete pain relief. Blood pressure decreased slightly from 150/95 to 115/75 mm Hg after the block. But in spite of apparently adequate needle position during CPB, approximately 10 min post-block, the patient complained of paresthesias in the right leg. This episode worsened over a period of 10–15 min and spread to the left leg. At 2 h after the block the paresthesias had intensified and he could not move her legs. On examination of the both lower limbs, she had complete loss of flexion and extension of the muscles supplying both hips, gross weakness of flexion and expansion of both the knee, and weak dorsoflexion and plantar flexion of both the foot. The parasthesias continued and she also complained of numbness of both the thigh and gluteal region. On neurological examination, the deep tendon reflexes were brisk in both the leg, and both the plantar reflexes gave flexor responses. Sensation to light touch was normal and complete. The cremasteric reflex was also decreased. Upper limb examination was normal. At 48 h after the block, spinal MRI was performed in a 1.5 T superconductive unit with a spinal coil (Intera Master, Philips Medical Systems). Turbo spin echo (TSE) T2 (TR/TE scan time: 3500/120 s), spin echo (SE) T1 (TR/TE scan time: 400/10 s) and short tau inversion recovery (STIR) (TR/TE scan time: 3500/120 s) sequences in the sagittal plain, SE T1 and TSE T2 sequences in the axial plain and post-contrast axial and sagittal T1 sequences were performed. Sagittal T2 weighted and STIR images demonstrate high signal intensity within the centre of the cord extending from T6 to T12 levels, with no expansion of the cord and no cervical cord abnormalities (Fig. 1). Axial TSE T2 images confirmed the central grey matter high signal intensity throughout the thoracic cord at T6 to T12 levels (Fig. 2). The negative MRI sequences were sagittal and axial T1, and post contrast T1 sagittal and axial sequences. She was treated empirically with steroids (prednisolone), B12 vitamin and piracetam therapy. Physiotherapy (both passive and active assisted) was started in a scheduled program within 60 h after the block. A gradual improvement was finally able to walk with mild support with walking stick. The patient was discharged 25 days after the block with clinically insignificant neurological deficit. The block produced excellent pain relief and the patient was still pain free 5 months after the CPB.
3. Discussion Celiac plexus block with a neurolytic agent is a possible treatment for upper abdominal pain due to cancer [2]. Several techniques of CPB are used. The percutaneous bilateral posterior
Fig. 2. Axial TSE T2-weighted image taken from T11 level also shows central grey matter hyperintensity in spinal cord.
A. Mete et al. / European Journal of Radiology Extra 78 (2011) e35–e37
approach (classic retrocrural) has been the most widely used [6]. The aim of all techniques to get better analgesia by trying to locate the optimal needle position to improve the spread of the injectate to the plexus area. Complete (four quadrants) spread of the neurolytic solution in the celiac area can guarantee long-lasting analgesia [7]. Contrarily, it would not always be able to improve the spread of the injectate in the plexus area because of anatomical limitations such as regional infiltration by cancer tissue or previous therapies. With the classic technique, between 70% and 85% of patients with severe upper abdominal cancer pain obtained pain relief lasting from 1 month up to 1 year [8]. The patient in our case also reported complete pain relief after CPB during 5 months. A frequent adverse side effect of CPB with a local anesthetic is extensive vasomotor block, and subsequently hypotension develops. More serious complications of CPB include postinjection neuropathy with neuralgia, paraplegia consequent to thrombosis of a major feeder artery to the spinal cord, accidentally injection of neurolytic solution into the kidney resulting with necrosis and hemorrhage, and failure of ejaculation. Paraplegia is arguably the most devastating complication [8]. After phenol CPB, the complication mentioned here in our case is possibly an acute ischemic neuropathy in the area supplied by the anterior spinal artery, due to involvement of the anterior radicular artery of Adamkiewicz. It is hypothesized that alcohol-induced vasospasm of the feeding arteries of Adamkiewicz could be a possible cause of neurologic deficit following CPB [3,9]. Alcohol, more than phenol, causes vascular spasm, another potential cause of spinal cord infarction [8]. Kumar et al. [10] reported a case reversible paraparesis following CPB. MRI of the thoracic and lumbo-sacral spine was performed twice. Both MRIs (the first at 48 h after the block and the second 10 days later) did not reveal any positive finding. Kinoshita et al. [11] report a case of paraplegia following celiac plexus block by anterior approach under direct vision. The patient complained of numbness and weakness of his legs 14 h later. The consequence of neurological events was diagnosed as ischemic infarct of the spinal cord by myelo-CT and MRI. As demonstrated in this case, even when celiac plexus block was performed by open anterior approach under direct vision, paraplegia might be a possible complication due to the anatomical proximity of celiac plexus to the Adamkiewicz’s artery. MRI has become the technique of choice for the investigation of myelopathy, although findings may be non-specific such in this case. The main differentials of myelopathy in this setting would be malignancy, viruses, paraneoplastic myelopathy or celiac plexus block. In this case there was no evidence of infection. The sudden
e37
onset of neurologic deficit after phenol CPB and the imaging findings noted in the spinal cord was consisted with that as the cause of the myelopathy. Our hypothesis is that paraparesis may result from neurolytic drug induced spasm of lumbar segmental arteries that perfuse the spinal cord resulting myelopathy. As a result, to our knowledge no report has been previously described with MRI feature of a patient following CPB using with phenol. In such cases, MRI, especially the T2 and STIR sequences should be performed to demonstrate the acute changes in spinal cord in patients with acute developing neurologic deficit following CPB. Although hyperintensity localized to the central grey matter as demonstrated in our case has previously been described in an only report described by Counsel and Khangure [12] subjected myelopathy due to intrathecal chemotherapy. This is the second case presenting with this same finding with another etiology and for such conditions this may have been evident as a result of very early imaging finding in that case too. Conflict of interest None of the authors have any conflict of interest to declare. References [1] Erdine S. Neurolytic blocks: when, how, why. Agri 2009;21:133–40. [2] Cherry DA, Lamberty J. Paraplegia following celiac plexus block. Anaesth Intensive Care 1984;12:59–61. [3] Jabbal SS, Hunton J. Reversible paraplegia following celiac plexus block. Anaesthesia 1992;47:857–8. [4] De Conno F, Caraceni A, Aldrighetti L, et al. Paraplegia following celiac plexus block. Pain 1993;55:383–5. [5] Brown DL. Spinal block. In: Brown DL, editor. Atlas of regional anesthesia. 2nd ed. Philadelphia, PA: WB Saunders; 1999. [6] Moore DC, Bush WH, Burnett LL. Celiac plexus block: a roentgenographic, anatomic study of technique and spread of solution in patients and corpses. Anesth Analg 1981;60:369–79. [7] De Cicco M, Matovic M, Balestreri L, Fracasso A, Morassut S, Testa V. Singleneedle celiac plexus block: is needle tip position critical in patients with no regional anatomic distortions? Anesthesiology 1997;87:1301–18. [8] Butler SH, Charlton JE. Neurolytic blockade and hypophysectomy. In: Loeser JD, editor. Bonica’s management of pain. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2001. [9] Woodham MJ, Hanna MH. Paraplegia after celiac plexus block. Anaesthesia 1989;44:487–9. [10] Kumar A, Tripathi SS, Dhar D, Bhattacharya A. A case of reversible paraparesis following celiac plexus block. Reg Anesth Pain Med 2001;26:75–8. [11] Kinoshita H, Denda S, Shimoji K, Ohtake M, Shirai Y. Paraplegia following celiac plexus block by anterior approach under direct vision. Masui 1996;45:1244–6. [12] Counsel P, Khangure M. Myelopathy due to intrathecal chemotherapy: magnetic resonance imaging findings. Clin Radiol 2007;62:172–6.
Contents lists available at ScienceDirect
European Journal of Radiology Extra journal homepage: intl.elsevierhealth.com/journals/ejrex
Acute developing transient paraparesis after celiac plexus block: MRI findings Ahmet Mete a,∗ , Lutfiye Pirbudak Cocelli b , Ruveyda Olmez a , Betul Kocamer b a b
Gaziantep University, School of Medicine, Department of Radiology, Sahinbey, 27310 Gaziantep, Turkey Gaziantep University, School of Medicine, Department of Anaesthesiology and Algology, Sahinbey, Gaziantep, Turkey
a r t i c l e
i n f o
Article history: Received 23 December 2010 Accepted 30 December 2010
Keywords: Cancer pain Celiac plexus block Neurolytic technique Reversible paraparesis Magnetic resonance imaging
a b s t r a c t Purpose: An endometrium cancer with liver metastasis, developing continuous and severe abdominal pain with vomiting and constipation, following phenol celiac plexus neurolysis, is described to find out if MRI can explain the reason of neurologic deficit. Materials and methods: A 81-year-old woman with metastatic endometrium cancer underwent celiac plexus phenol neurolysis for management of severe pain at right hypochondriacal region. In spite of apparently adequate needle position, she developed transient paraplegia consistent with anterior spinal artery syndrome. At 48 h after celiac plexus block MRI was performed. Results: In this patient, paraplegia suddenly ensued after instillation of the phenol solution, and postprocedure spinal MRI showed increased signal in the thoracic spinal cord consistent with edema. The patient was discharged 25 days after the block with clinically insignificant neurological deficit. Conclusion: We present a case of a patient who had paraparesis after the performance of celiac plexus block (CPB). We propose that the mechanism for this rare but devastating complication is the neurotoxicity of phenol on spinal cord which may result from spasmotic effect of phenol on spinal feeding arteries. In such cases MRI, especially the short tau inversion recovery (STIR) sequence should be performed to see the acute changes in spinal cord in patients with acute developing neurologic deficit following CPB. © 2011 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Neuroablative techniques for cancer pain treatment have been used for more than a century. With the development of imaging facilities such as fluoroscopy, neuroablative techniques can be performed more precisely and efficiently [1]. Celiac plexus block (CPB) is effective and commonly used analgesic technique for patients with upper abdominal visceral cancer pain [2,3]. Although neurologic complications are infrequent but, permanent paraplegia may occur after CPB [3,4]. Electroneuromyography (ENMG) changes associated with denervation due to neurologic injury require 14–21 days to appear in the lower extremities [5]. At this point MRI become important for demonstrating early changes in the spinal cord. Herein we present a case of transient paraparesia following phenol CPB with MRI findings. 2. Case report A 81-year-old woman with endometrium cancer with liver metastasis underwent celiac plexus phenol neurolysis for manage-
∗ Corresponding author. Tel.: +90 342 3606060/77339; fax: +90 342 3601617. E-mail addresses: [email protected] (A. Mete), lutfi[email protected] (L. Pirbudak Cocelli), [email protected] (R. Olmez), [email protected] (B. Kocamer). 1571-4675/$ – see front matter © 2011 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2010.12.018
ment of severe pain at right hypochondriacal region. Abdominal ultrasonography and MRI demonstrated the presence of multiple extensive lesions in both hepatic lobes suggesting multiple metastases. About two months ago, the patient had an operation (total abdominal hysterectomy and bilateral salpingoophorectomy + total omentectomy + repair of bowel) in the gynecology clinic. For palliative care, she refused pain therapy regimen consisted of regular nonsteroidal anti-inflammatory drugs, tramadol, and low dose transdermal fentanyl. Thus a phenol CPB was performed.
2.1. Technique for CPB The classic technique was used with fluoroscopy. Nonionic contrast was used to confirm a layering out of the radiocontrast in a vertical narrow line along the anterior aspect of T12 and L1 vertebrae. In the posterior–anterior view, the contrast was confined to the region surrounding the middle and upper L1 and lower T12 vertebrae. Standard noninvasive monitoring (electrocardiogram, oxygen saturation, and blood pressure) was performed throughout the procedure while 1 mg midazolam and 25 mcg fentanyl was administered intravenously and oxygen was administered by face mask. Bupivacaine (0.25%, 5 mL through needle) was then injected after checking via aspiration that the needles were neither intravascular nor
e36
A. Mete et al. / European Journal of Radiology Extra 78 (2011) e35–e37
Fig. 1. There is subtle high signal intensity throughout thoracic cord on sagittal TSE T2-weighted (A) and STIR (B) mid-sagittal images.
subarachnoid. Phenol (6%, 10 mL) was then injected through needle. The patient reported complete pain relief. Blood pressure decreased slightly from 150/95 to 115/75 mm Hg after the block. But in spite of apparently adequate needle position during CPB, approximately 10 min post-block, the patient complained of paresthesias in the right leg. This episode worsened over a period of 10–15 min and spread to the left leg. At 2 h after the block the paresthesias had intensified and he could not move her legs. On examination of the both lower limbs, she had complete loss of flexion and extension of the muscles supplying both hips, gross weakness of flexion and expansion of both the knee, and weak dorsoflexion and plantar flexion of both the foot. The parasthesias continued and she also complained of numbness of both the thigh and gluteal region. On neurological examination, the deep tendon reflexes were brisk in both the leg, and both the plantar reflexes gave flexor responses. Sensation to light touch was normal and complete. The cremasteric reflex was also decreased. Upper limb examination was normal. At 48 h after the block, spinal MRI was performed in a 1.5 T superconductive unit with a spinal coil (Intera Master, Philips Medical Systems). Turbo spin echo (TSE) T2 (TR/TE scan time: 3500/120 s), spin echo (SE) T1 (TR/TE scan time: 400/10 s) and short tau inversion recovery (STIR) (TR/TE scan time: 3500/120 s) sequences in the sagittal plain, SE T1 and TSE T2 sequences in the axial plain and post-contrast axial and sagittal T1 sequences were performed. Sagittal T2 weighted and STIR images demonstrate high signal intensity within the centre of the cord extending from T6 to T12 levels, with no expansion of the cord and no cervical cord abnormalities (Fig. 1). Axial TSE T2 images confirmed the central grey matter high signal intensity throughout the thoracic cord at T6 to T12 levels (Fig. 2). The negative MRI sequences were sagittal and axial T1, and post contrast T1 sagittal and axial sequences. She was treated empirically with steroids (prednisolone), B12 vitamin and piracetam therapy. Physiotherapy (both passive and active assisted) was started in a scheduled program within 60 h after the block. A gradual improvement was finally able to walk with mild support with walking stick. The patient was discharged 25 days after the block with clinically insignificant neurological deficit. The block produced excellent pain relief and the patient was still pain free 5 months after the CPB.
3. Discussion Celiac plexus block with a neurolytic agent is a possible treatment for upper abdominal pain due to cancer [2]. Several techniques of CPB are used. The percutaneous bilateral posterior
Fig. 2. Axial TSE T2-weighted image taken from T11 level also shows central grey matter hyperintensity in spinal cord.
A. Mete et al. / European Journal of Radiology Extra 78 (2011) e35–e37
approach (classic retrocrural) has been the most widely used [6]. The aim of all techniques to get better analgesia by trying to locate the optimal needle position to improve the spread of the injectate to the plexus area. Complete (four quadrants) spread of the neurolytic solution in the celiac area can guarantee long-lasting analgesia [7]. Contrarily, it would not always be able to improve the spread of the injectate in the plexus area because of anatomical limitations such as regional infiltration by cancer tissue or previous therapies. With the classic technique, between 70% and 85% of patients with severe upper abdominal cancer pain obtained pain relief lasting from 1 month up to 1 year [8]. The patient in our case also reported complete pain relief after CPB during 5 months. A frequent adverse side effect of CPB with a local anesthetic is extensive vasomotor block, and subsequently hypotension develops. More serious complications of CPB include postinjection neuropathy with neuralgia, paraplegia consequent to thrombosis of a major feeder artery to the spinal cord, accidentally injection of neurolytic solution into the kidney resulting with necrosis and hemorrhage, and failure of ejaculation. Paraplegia is arguably the most devastating complication [8]. After phenol CPB, the complication mentioned here in our case is possibly an acute ischemic neuropathy in the area supplied by the anterior spinal artery, due to involvement of the anterior radicular artery of Adamkiewicz. It is hypothesized that alcohol-induced vasospasm of the feeding arteries of Adamkiewicz could be a possible cause of neurologic deficit following CPB [3,9]. Alcohol, more than phenol, causes vascular spasm, another potential cause of spinal cord infarction [8]. Kumar et al. [10] reported a case reversible paraparesis following CPB. MRI of the thoracic and lumbo-sacral spine was performed twice. Both MRIs (the first at 48 h after the block and the second 10 days later) did not reveal any positive finding. Kinoshita et al. [11] report a case of paraplegia following celiac plexus block by anterior approach under direct vision. The patient complained of numbness and weakness of his legs 14 h later. The consequence of neurological events was diagnosed as ischemic infarct of the spinal cord by myelo-CT and MRI. As demonstrated in this case, even when celiac plexus block was performed by open anterior approach under direct vision, paraplegia might be a possible complication due to the anatomical proximity of celiac plexus to the Adamkiewicz’s artery. MRI has become the technique of choice for the investigation of myelopathy, although findings may be non-specific such in this case. The main differentials of myelopathy in this setting would be malignancy, viruses, paraneoplastic myelopathy or celiac plexus block. In this case there was no evidence of infection. The sudden
e37
onset of neurologic deficit after phenol CPB and the imaging findings noted in the spinal cord was consisted with that as the cause of the myelopathy. Our hypothesis is that paraparesis may result from neurolytic drug induced spasm of lumbar segmental arteries that perfuse the spinal cord resulting myelopathy. As a result, to our knowledge no report has been previously described with MRI feature of a patient following CPB using with phenol. In such cases, MRI, especially the T2 and STIR sequences should be performed to demonstrate the acute changes in spinal cord in patients with acute developing neurologic deficit following CPB. Although hyperintensity localized to the central grey matter as demonstrated in our case has previously been described in an only report described by Counsel and Khangure [12] subjected myelopathy due to intrathecal chemotherapy. This is the second case presenting with this same finding with another etiology and for such conditions this may have been evident as a result of very early imaging finding in that case too. Conflict of interest None of the authors have any conflict of interest to declare. References [1] Erdine S. Neurolytic blocks: when, how, why. Agri 2009;21:133–40. [2] Cherry DA, Lamberty J. Paraplegia following celiac plexus block. Anaesth Intensive Care 1984;12:59–61. [3] Jabbal SS, Hunton J. Reversible paraplegia following celiac plexus block. Anaesthesia 1992;47:857–8. [4] De Conno F, Caraceni A, Aldrighetti L, et al. Paraplegia following celiac plexus block. Pain 1993;55:383–5. [5] Brown DL. Spinal block. In: Brown DL, editor. Atlas of regional anesthesia. 2nd ed. Philadelphia, PA: WB Saunders; 1999. [6] Moore DC, Bush WH, Burnett LL. Celiac plexus block: a roentgenographic, anatomic study of technique and spread of solution in patients and corpses. Anesth Analg 1981;60:369–79. [7] De Cicco M, Matovic M, Balestreri L, Fracasso A, Morassut S, Testa V. Singleneedle celiac plexus block: is needle tip position critical in patients with no regional anatomic distortions? Anesthesiology 1997;87:1301–18. [8] Butler SH, Charlton JE. Neurolytic blockade and hypophysectomy. In: Loeser JD, editor. Bonica’s management of pain. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2001. [9] Woodham MJ, Hanna MH. Paraplegia after celiac plexus block. Anaesthesia 1989;44:487–9. [10] Kumar A, Tripathi SS, Dhar D, Bhattacharya A. A case of reversible paraparesis following celiac plexus block. Reg Anesth Pain Med 2001;26:75–8. [11] Kinoshita H, Denda S, Shimoji K, Ohtake M, Shirai Y. Paraplegia following celiac plexus block by anterior approach under direct vision. Masui 1996;45:1244–6. [12] Counsel P, Khangure M. Myelopathy due to intrathecal chemotherapy: magnetic resonance imaging findings. Clin Radiol 2007;62:172–6.