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Pulmonary scintigraphy and fatal pulmonary embolism
Chmcal Radtology (1985) 36, 659-644 © 1985 Royal College of Radiologists
0009-9260/85/120659502.00
Abstracts Abstracts of papers presented at the Joint Radiological Meeting held at the University of Leicester, 29-30 March 1985, by the Royal College of Radiologists, the British Institute of Radiology and the Royal Society of Medicine Radiology Section RADIODIAGNOSIS SECTION 29 March 1985 Chairman: E. Rhys Davies (Bristol) PULMONARY SCINTIGRAPHY AND FATAL PULMONARY EMBOLISM J. M. B E R R Y
Leicester Royal Infirmary, Leicester The medical records of all patients medically certified to have died of pulmonary embolism in a year in a single large health district (population 850 000) were reviewed. Of about 9000 deaths, 148 were certified to be due to pulmonary embolism. Seventeen of the 101 in-patients who died had pulmonary scintigraphy. Eleven were reported as showing evidence of pulmonary embolism. Ten of these recewed appropriate treatment and in three the diagnosis was confirmed at autopsy Two were reported as not having pulmonary embolism and, although the medically certified cause of death before autopsy was pulmonary embolism, none was found. There were no incorrect scmtlgraphlc reports compared with autopsy findings Four scintigrams were reported as indeterminate because ventilation scans were not possible. Three of these patients were anticoagulated and in the only autopsy no pulmonary embolism was found. Of the 15 hospital deaths medically certified to be duc to pulmonary embolism, with subsequent autopsy this diagnosis was confirmed in only seven cases. Another 10 hospital deaths were certified as being due to pulmonary embolism after a coroner's autopsy. The mean age of 25 in-patients dying from autopsyproven puhnonary embolism was 75 (43-99) years. None of 41 patients dying outside hospital had puhnonary scmtigraphy. There were 28 autopsies and 17 patients had not been seen at a hospital in the previous 6 months. The mean age was 74 (60-68) years. Pulmonary embolism had not been suspected in the 11 who had been seen at a hospital (mean age 74 (45-94) years). In an unselected group of patients who had pulmonary sclntigraphy the mortality rate of those with a report of pulmonary embolism was 5%. The incidence of pulmonary embohsm reported on scintigraphy rose with age, which is in keeping wJth the age distribution of fatal cases. No fatalities occurred m patients under 40 years There is probably a large pool of undlagnosed pulmonary embolism in the elderly. Embolism did not appear to cause premature death in this study. Most patients dying of pulmonary embolism do not have pulmonary scintigraphy.
MAGNETIC RESONANCE IMAGING: INITIAL CLINICAL EVALUATION OF PARAMAGNETIC CONTRAST AGENTS DENIS H C A R R
Department of Dzagnostic Radtology, Royal Postgraduate Me&cal School, Hammersmith Hospital, Du Cane Road, London The use of paramagnet~c ions as potential contrast agents in magnetic resonance imaging (MRI) was first suggested by Lauterbur in 1978 (Lauterbur et al., 1978). The most effective relaxation enhancer to date has been gadolinmm, but as a free ion it is toxic. However, when chelated to ethylenediamine tetra-acetate or diethylenetriamine penta-acetate (DTPA) its toxmity is reduced and these chelates have been shown to act as effective contrast agents in experimental animals (Cart et al.. 1984a). The purpose of this study was to determine whether gadolinium (Gd 3+) DTPA (Schering AG) was an effective and safe paramagnetic contrast agent in man. As with iodinated agents, Gd3+-DTPA is excreted mainly by glomerular filtration, is distributed mainly in the extracellular space and will cross a damaged blood-brain barrier. Prehminary data on its use in man in malignant disease of the brain and abdomen have been published (Cart et al., 1984b; Carr et al., 1984c). Twenty-three patients with brain tumours were given Intravenous Gd3+-DTPA and, of these, 20 showed enhancement allowing differentiation of tumour from peritumoral oedema. Fifteen cases showed
greater enhancement than was seen with contrast-enhanced computed tomography. Maximum enhancement was seen on inversion-recovery sequences. Twenty-five patients with tumours of the liver, pancreas, kidney and bladder had contrast-enhanced MR1 and 21 cases showed enhancement, although in some cases the contrast between liver tumour and surrounding normal parenchyma was reduccd. No significant s~de-effects have been determined but, as with any new agent, caution is required. Gadolinium-DTPA shows promise as a useful addition to MRI, but further work remains to be done to determine optimmn sequences, timing of imaging and optimum dose of contrast agent.
References
Carr, D H., Brown, J., Leung, A W.-L. & Pennock, J. M (1984a) The in vivo use of iron and gadolinium chelates as contrast agents in NMR imaging - preliminary studies. Journal of Computer Assisted Tomography, 8, 385-389. Cart, D. H., Brown, J., Bydder, G. M., Welnmann, H.-J , Speck, U , Thomas, D. J. et al. (1984b). Clinical use of intravenous gadohnlum-DTPA as a contrast agent in N M R imaging. Lancet, i, 484-486. Cart. D. H., Brown, J.. Bydder, G. M., Steiner, R. E., Weinmann. H.-J., Speck, U. et al. (1984c). Gadolinium D T P A as a contrast agent in MRI: initial clinical experience in 20 patients American Journal of Roentgenology, 143, 215-224. Lauterbur, P C., Mendonca-Dias, M. H. & Rudin, A. M. (1978). Augmentation of tissue water proton spin-lattme relaxation rates by in vivo addition of paramagnetic ions. In Fronuers of Biological Energetics, ed. Sutton, P. L , Leigh, J S & Scarpa, A., Vol. 1. Academic Press, New York.
CYCLOSPORIN A TOXICITY DIFFERENTIATED FROM REJECTION BY OBJECTIVE MEASUREMENT OF RENAL SIZE BY ULTRASOUND Y REES, S. D. P A R V I N and P. S. VEITCH
Departments o t Radiology and Surgery, Leicester General Hospital, Gwendolen Road, Leicester Despite improvements in operative techlques, better matching and the introduction of cyclosporin A, about 15% of renal allografts are still lost through rejection in the first year after transplantation. The climcal assessment of allograft size, coupled with knowledge of the serum creatinine, remains one of the most helpful ways of diagnosing rejection. Accurate ultrasound measurement of cross-sectional area of the transplanted kidney has been used to differentiate betwecn cyclosporin A toxicity and rejection both In the immediate posttransplant period and at the time of conversion from cyclosporln A to azathioprinc. Patients were scanned daily after transplantation for 3 weeks, as out-patients if clinically indicated, and daring the convcrsicm period from cyclosporin A to azathloprine 3 months after transplantation. At each scan four measurements of cross-sectional area were made and the mean recorded. A rise m cross-sectional area of greater than 10% over two consecutive days coupled with a rise in creatmlne of greater than 30/~mol/litre was taken to indicate rejection, whilst a similar rise in creatinine without the rise in cross-sectional area was taken to indicate toxicity. Forty patients have been studied and 21 have been converted from c2closporm A to azathioprine. The results are shown below
Early rejection Conversion rejection Toxicity
No. of ktdneys
No. of patwnts
Ultrasound Correct
Btopsyproven
12 7 8
9 7 7
12 7 7
8 -
0009-9260/85/120659502.00
Abstracts Abstracts of papers presented at the Joint Radiological Meeting held at the University of Leicester, 29-30 March 1985, by the Royal College of Radiologists, the British Institute of Radiology and the Royal Society of Medicine Radiology Section RADIODIAGNOSIS SECTION 29 March 1985 Chairman: E. Rhys Davies (Bristol) PULMONARY SCINTIGRAPHY AND FATAL PULMONARY EMBOLISM J. M. B E R R Y
Leicester Royal Infirmary, Leicester The medical records of all patients medically certified to have died of pulmonary embolism in a year in a single large health district (population 850 000) were reviewed. Of about 9000 deaths, 148 were certified to be due to pulmonary embolism. Seventeen of the 101 in-patients who died had pulmonary scintigraphy. Eleven were reported as showing evidence of pulmonary embolism. Ten of these recewed appropriate treatment and in three the diagnosis was confirmed at autopsy Two were reported as not having pulmonary embolism and, although the medically certified cause of death before autopsy was pulmonary embolism, none was found. There were no incorrect scmtlgraphlc reports compared with autopsy findings Four scintigrams were reported as indeterminate because ventilation scans were not possible. Three of these patients were anticoagulated and in the only autopsy no pulmonary embolism was found. Of the 15 hospital deaths medically certified to be duc to pulmonary embolism, with subsequent autopsy this diagnosis was confirmed in only seven cases. Another 10 hospital deaths were certified as being due to pulmonary embolism after a coroner's autopsy. The mean age of 25 in-patients dying from autopsyproven puhnonary embolism was 75 (43-99) years. None of 41 patients dying outside hospital had puhnonary scmtigraphy. There were 28 autopsies and 17 patients had not been seen at a hospital in the previous 6 months. The mean age was 74 (60-68) years. Pulmonary embolism had not been suspected in the 11 who had been seen at a hospital (mean age 74 (45-94) years). In an unselected group of patients who had pulmonary sclntigraphy the mortality rate of those with a report of pulmonary embolism was 5%. The incidence of pulmonary embohsm reported on scintigraphy rose with age, which is in keeping wJth the age distribution of fatal cases. No fatalities occurred m patients under 40 years There is probably a large pool of undlagnosed pulmonary embolism in the elderly. Embolism did not appear to cause premature death in this study. Most patients dying of pulmonary embolism do not have pulmonary scintigraphy.
MAGNETIC RESONANCE IMAGING: INITIAL CLINICAL EVALUATION OF PARAMAGNETIC CONTRAST AGENTS DENIS H C A R R
Department of Dzagnostic Radtology, Royal Postgraduate Me&cal School, Hammersmith Hospital, Du Cane Road, London The use of paramagnet~c ions as potential contrast agents in magnetic resonance imaging (MRI) was first suggested by Lauterbur in 1978 (Lauterbur et al., 1978). The most effective relaxation enhancer to date has been gadolinmm, but as a free ion it is toxic. However, when chelated to ethylenediamine tetra-acetate or diethylenetriamine penta-acetate (DTPA) its toxmity is reduced and these chelates have been shown to act as effective contrast agents in experimental animals (Cart et al.. 1984a). The purpose of this study was to determine whether gadolinium (Gd 3+) DTPA (Schering AG) was an effective and safe paramagnetic contrast agent in man. As with iodinated agents, Gd3+-DTPA is excreted mainly by glomerular filtration, is distributed mainly in the extracellular space and will cross a damaged blood-brain barrier. Prehminary data on its use in man in malignant disease of the brain and abdomen have been published (Cart et al., 1984b; Carr et al., 1984c). Twenty-three patients with brain tumours were given Intravenous Gd3+-DTPA and, of these, 20 showed enhancement allowing differentiation of tumour from peritumoral oedema. Fifteen cases showed
greater enhancement than was seen with contrast-enhanced computed tomography. Maximum enhancement was seen on inversion-recovery sequences. Twenty-five patients with tumours of the liver, pancreas, kidney and bladder had contrast-enhanced MR1 and 21 cases showed enhancement, although in some cases the contrast between liver tumour and surrounding normal parenchyma was reduccd. No significant s~de-effects have been determined but, as with any new agent, caution is required. Gadolinium-DTPA shows promise as a useful addition to MRI, but further work remains to be done to determine optimmn sequences, timing of imaging and optimum dose of contrast agent.
References
Carr, D H., Brown, J., Leung, A W.-L. & Pennock, J. M (1984a) The in vivo use of iron and gadolinium chelates as contrast agents in NMR imaging - preliminary studies. Journal of Computer Assisted Tomography, 8, 385-389. Cart, D. H., Brown, J., Bydder, G. M., Welnmann, H.-J , Speck, U , Thomas, D. J. et al. (1984b). Clinical use of intravenous gadohnlum-DTPA as a contrast agent in N M R imaging. Lancet, i, 484-486. Cart. D. H., Brown, J.. Bydder, G. M., Steiner, R. E., Weinmann. H.-J., Speck, U. et al. (1984c). Gadolinium D T P A as a contrast agent in MRI: initial clinical experience in 20 patients American Journal of Roentgenology, 143, 215-224. Lauterbur, P C., Mendonca-Dias, M. H. & Rudin, A. M. (1978). Augmentation of tissue water proton spin-lattme relaxation rates by in vivo addition of paramagnetic ions. In Fronuers of Biological Energetics, ed. Sutton, P. L , Leigh, J S & Scarpa, A., Vol. 1. Academic Press, New York.
CYCLOSPORIN A TOXICITY DIFFERENTIATED FROM REJECTION BY OBJECTIVE MEASUREMENT OF RENAL SIZE BY ULTRASOUND Y REES, S. D. P A R V I N and P. S. VEITCH
Departments o t Radiology and Surgery, Leicester General Hospital, Gwendolen Road, Leicester Despite improvements in operative techlques, better matching and the introduction of cyclosporin A, about 15% of renal allografts are still lost through rejection in the first year after transplantation. The climcal assessment of allograft size, coupled with knowledge of the serum creatinine, remains one of the most helpful ways of diagnosing rejection. Accurate ultrasound measurement of cross-sectional area of the transplanted kidney has been used to differentiate betwecn cyclosporin A toxicity and rejection both In the immediate posttransplant period and at the time of conversion from cyclosporln A to azathioprinc. Patients were scanned daily after transplantation for 3 weeks, as out-patients if clinically indicated, and daring the convcrsicm period from cyclosporin A to azathloprine 3 months after transplantation. At each scan four measurements of cross-sectional area were made and the mean recorded. A rise m cross-sectional area of greater than 10% over two consecutive days coupled with a rise in creatmlne of greater than 30/~mol/litre was taken to indicate rejection, whilst a similar rise in creatinine without the rise in cross-sectional area was taken to indicate toxicity. Forty patients have been studied and 21 have been converted from c2closporm A to azathioprine. The results are shown below
Early rejection Conversion rejection Toxicity
No. of ktdneys
No. of patwnts
Ultrasound Correct
Btopsyproven
12 7 8
9 7 7
12 7 7
8 -