We prospectively correlated the findings of magnetic resonance angiography (MRA) with those of transfemoral four-vessel angiography in 54 patients to investigate the direction of flow within the circle of Willis. Our primary goal was to assess the direction of flow using the size of the vessel and signal intensity, without saturation techniques. Analysis of the circle of Willis, especially the communicating arteries, was performed double-blind by two groups of two radiologists. Three types of arteries were identified: high flow or cross-cerebral circulation, patent and nonvisualised arteries. Cerebral angiography was the standard for comparison between the two methods. MRA did not reveal any arteries invisible on angiography, thus providing a specificity of 100%. The sensitivity of MRA was 89.2% for the anterior and 81.3% for the posterior communicating arteries, and 100% for the anterior, middle and posterior cerebral arteries. MRA was shown to be a useful technique for the assessment of patency of the circle of Willis.

Cyst with Fat-Fluid Level and Budd-Chiari Syndrome. 2001; 21(3-4): [225][226][227] Hepatic hydatid cyst is a parasitic infestation due to the development of the larval form of the tapeworm Echinococcus granulosus in the liver.1 Although compression of hepatic veins is commonly noticed on imaging studies, hepatic hydatidosis is a very rare cause of Budd-Chiari syndrome.2 Fat-fluid level in a hepatic hydatid cyst (HHC) was first reported in 1996 by Montero et al., 3 who documented three cases of the condition on CT and MRI, and explained it by its rupture into the biliary tree. Although no other cases have been published in the literature to our knowledge since then, there has been controversy on the significance of the presence of intraparasitic fat. Beric et al. feel that the fat-fluid level in a HHC is related to the degeneration of hydatid membranes rather than to biliocystic communication. 4 The purpose of this study was to report an exceptional case of large fat-fluid level in a hepatic hydatid cyst in the left lobe with no biliocystic communication, but associated with chronic Budd-Chiari syndrome due to compression of hepatic veins by multiple HHC of the right lobe. Case ReportA 55-year-old female patient was admitted for epigastric pain and heartburn of a year's duration. On examination, no jaundice or fever was noted. Abdominal palpation revealed an enlarged liver with a bulging mass in the left lobe. Liver function tests were normal (total bilirubin, 15 μmol/L; unconjugate bilirubin, 8 μmol/L; direct bilirubin, 7 μmol/L, and alkaline phosphatase, 112 IU/L). Serological tests for hepatitis B and C were negative. Test for echinococcosis using IHA was negative. On abdominal ultrasound, the liver was dysmorphic, showing undulating outlines with severe enlargement of the left lobe and caudate lobe, which were suggestive of chronic liver disease. The right lobe of the liver exhibited four masses. A huge multiseptated cystic mass, 12 cm in diameter and suggestive of multivesicular hydatid cyst (type 3 of Gharbi), occupied the whole right lateral sector, encroaching upon the right medial sector and totally compressing the right and middle hepatic veins. Three masses of solid heterogeneous echogenicity were in the segments 5 and 8, showing well-defined outlines with slight enhancement of posterior echoes. These three masses contained long hypoechoic spirals highly suggestive of pseudotumoral hydatid cyst (type 4 of Gharbi). The gallbladder harbored a large stone, whereas the biliary ducts were normal. The left hepatic lobe exhibited two superficial anterior echogenic heterogeneous masses, the largest of which was in segment 2. It was 13 cm in its long axis, and displayed a horizontal level separating a lower hyperechoic layer and an upper hypoechoic layer. The second mass, 5 cm in diameter, was located in segment 3 and showed peripheral calcifications. Also, ultrasound noted mild ascitis as well as splenorenal collateral venous circulation near the lower pole of the spleen denoting portal hypertension. CT wit...

It is very unusual to forget a surgical sponge in an operative wound, but the consequences are severe. Traditionally, textiloma produces a reticulated, textiform mass of mixed pattern, the appearance of which is highly suggestive on both plain abdomen radiograph and computerized tomography (CT) scan. [1][2][3] We report an atypical case of giant abdominal cystic textiloma mimicking a hydatid cyst arising from the spleen with spontaneous rupture into the stomach. Case ReportA 40-year-old male patient was referred to the surgical clinic of King Khalid Military City Hospital with complaints of epigastric swelling and pain of three years' duration, without fever. On inquiry, no other symptoms were noted, but the patient reported a past history of surgical operation for a road traffic accident 9 years previously. Clinical examination revealed a large firm abdominal mass extending from the left to the right hypochondrium. Its lower margin was well-circumscribed, but its upper margin could not be felt. A right upper abdominal paramedian laparotomy scar was noted. Biological tests were unremarkable. Plain abdominal radiographs showed an opacity in the epigastrium and left hypochondrium, displacing the gastric bubble and bowel gas. Ultrasound of the abdomen revealed a huge cyst in the left upper quadrant, measuring 25 cm in its long axis. The cyst was in close contact with the inner surface of the spleen, which showed multiple large calcifications with marked posterior acoustic shadowing (Figure 1). The cyst demonstrated multiple tiny mobile low-level echoes, with the presence of dependent hyperechoic serpiginous structures. These features were suggestive of hydatid cyst of the abdomen complicated by membrane detachment (type 2 of Gharbi). 4 Ultrasound could not confirm the organ of origin of the cyst. Abdominal CT scan with oral and intravenous contrast enhancement disclosed a well-defined encapsulated, non-enhancing cystic mass in the left upper quadrant. The liver, pancreas, stomach and great vessels had been pushed to the right. Inside the cyst, dependent hyperattenuated serpiginous structures were noted (Figure 2). CT scan could not determine whether the mass arose from the spleen, the left lobe of the liver or the peritoneum. Magnetic resonance imaging (MRI) of the abdomen was done in transverse, sagittal and coronal planes by using SE T 1 -weighted sequences in order to detail the location and extent of this mass. On MRI, the lesion appeared isointense to the spleen, suggesting a thick content. Coronal and transverse cuts demonstrated that the cyst was independent of the liver. On sagittal cuts, the mass showed a close relation to the anterior surface of the spleen that was displaced downwards (Figure 3). No intracystic formation was identified on MRI. Although the serological agglutination test for ecchinococcosis was negative, the radiological picture was suggestive of a huge abdominal hydatid cyst with detached membrane, probably arising from the spleen.

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