CHAUDHURI ET AL
neurologic status, but the patient complained of severe headaches.
Five days after admission, laminograms of the thoracic
spine revealed a transverse fracture of the body of T 3 and
subluxation of the vertebral body of T2. On the seventh
hospital day, laminectomy of T1, T2 and T 3 was performed
at which time a large comn~unicationwas noted posteriorly
between the subarachnoid space and both pleural spaces.
Additional findings were complete severance of the spinal
cord at T2, fracture of the lamina pedicle and apophyseal
joint of T2, avl~lsionof the ligamentum flavum from T I to T3.
A strip of gelatin soaked in thrombin was placed across the
subarachnoid-pleural fistula. At the end of the operation,
chest tubes were inserted bilaterally to expand the lungs.
Postoperatively the patient was kept supine, but no attempt
was made to lower CSF pressure by serial lumbar punctures.
The child's postoperative recovery was complicated by massive gastrointestinal hemorrhage and perforation of a stress
ulcer. These complications were managed nonoperatively.
There was no recurrence of the pleural effusions. Unfortunately, the neurologic status remained unchanged and the
patient was discharged to a rehabilitation center on July 1,
1968.
T h e diagnosis of traumatic subarachnoid-pleural fistula was suggested in this case and those previously reported1-' (Table 1) by the association of pleural effusion and signs of spinal cord injury. Symptoms of cerebrospinal fluid hypotension following thoracentesis and
failure to recover C S F on entering the subarachnoid
space added further support to this suspicion. Although
not done in this case, the diagnosis can be confirmed and
the site of the fistula localized by myelography. T h e
initial treatment of supine bed rest and daily lumbar
punctures in order to decrease the C S F pressure and
promote closure of the fistula is generally attempted
initially. In three of the previously reported cases, as well
as our own, multiple thoracenteses were performed to
alleviate symptoms of inadequate ventilation. Pleural
effusions of this magnitude suggest that the fistulae must
have been large, and not likely to close without operative
intervention.
In most instances, surgical exploration is performed
early in the post-injury period in a patient with the
symptoms and signs described in the hope that decompression of the spinal cord may relieve the frequently
associated paralysis. At operation, the presence and location of a subarachnoid-pleural fistula should b e searched
for. T h e use of muscle, fascia or absorbable materials,
such as gelatin, to close the fistula is usually successful.'-" Although endotracheal anesthesia would probably
be used in most patients undergoing laminectomy, it is
particularly important when a subarachnoid-pleural fistula exists. Unsuspected open pneumothorax occurring
during laminectomy in patients with a subarachnoidpleural communication could be a lethal complication.
ACKNO\YLEDGMENT: \Ye express our appreciation to Dr.
Eugene Stem, Head, Division of Neurosurgery, University of
California Medical Center at Los Angeles, for permission to
make use of the clinical case in this report.
REFERENCES
1 Milloy FJ, Correll NO, Langston HT: Persistent subarachnoid-pleural space fistula. JAMA 169:1467, 1959
2 Wilson C, Juner M : Traumatic spinal-pleural fistula.
JAMA 179:812-13, 1962
3 Overton hlD, Hood RhZ, Farris RG: Traumatic subarachnoid-pleural fistula. J Thorac and Cardiovasc Surg 51:72931, 1966
4 Branwit DN: Traumatic subarachnoid-pleural fistula. Radiology 89:737-38, 1987
Abnormal Deposition of
Radiostrontium in ~ u n ~ s *
Tapan K . Chaudhuri, M.D.; Tithin K . Chatrdhuri, M.D.;
Mark I . Muilenhurg, B.S.; and Jan1e.sH. Christie, M.D.
A report of unusual deposition of radiostrontium in the
lungs is presented. There was clear visualization of both
lungs. The possible mechanism is mentioned. The observation may further stimulate investigators to find the
exact reason for this.
E
xtensive deposition of radiostrontium in the lungs is
possible when there is a diffuse active calc6cation
occurring in the lungs, in which case strontium is likely
to be deposited in the lungs by the process of heterionic
exchange. Presented herein is a patient in whom an
attempted ""'ST bone scan revealed clear visualization
of both lungs without any radiologic evidence of diffuse
calcification.
A 46-~ear-old woman was admitted to this hospital for
evaluation of increasing tiredness of one year's duration.
Hematologic study, including bone marrow aspiration, established the diagnosis of multiple myeloma. She has been
receiving ~nelphalanand prednisone. She had high BUN (3040 mg percent ), senlm creatinine ( 2.4-2.9 mg percent) and
calcium ( 12-13 mg percent) with values waxing and waning
throughout the hospital course of three months. Because of
hypercalcemia, she wm given mithramycin, with temporary
response. Physical examination revealed a 2 cm diameter
tender swelling over the head of the left clavicle. Liver was
enlarged. Spleen was not alp able. Hb was 9.4 G percent,
Hct-29 percent, prothrombin time-normal. Repeat chest xray examination ( Fig 1 ) was negative. A skeletal survey was
normal except there were lytic lesions on the medial ends of
both clavicles. The left was much more pronounced than the
one on the right. "'"Sr bone scan (Fig 2 ) was done and
revealed normal bone scan, but the lungs showed increased
activity. A dynamic study was carried out with a gamma
camera coupled to a computer. This demonshated trapping
of most of the radiostrontium in first pass. KGr was administered to follow the retention of strontiu~uin the lungs. It
'From the Department of Radiology, Section of Nuclear
Medicine, University of Iowa, Iowa City, lowa.
Repint requests: Dr. Chaudhuri, Nuclear Medicine, Uniuersity of lowa, 1ou;a City 52240
CHEST, VOL. 61, NO. 2, FEBRUARY, 1972
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ABNORMAL DEPOSITION OF RADIOSTRONTIUM IN LUNGS
FIGURE1. Chest x-ray film of patient reveals normal lung
fields without extensive calcification.
remained in the lungs for several days ( Fig 3A and 3B ). A
profile scanning of the whole body showed that about 35-40
percent of the injected activity was present in the lungs one
day after injection.
"'"Sr is the radiopharmaceutical of choice for bone
scan. After intravenous injection, strontium stays in the
FIGURE
2. Whole body scan ( anterior view) with """S
' r four
hours postinjection. No evidence
of abnormal uptake in the bone.
Lungs are clearly delineated.
FIGURE
3. A (left): whole body scan (posterior view) with
"'Sr 75 min postinjection. Note uptake of radiostrontium in
the lungs. B (right): whole body scan (anterior view) with
""Sr 19 hours after injection. Lungs are still well visualized.
blood compartment for a while followed by deposition in
the bone (uptake TY-ten min) by heterionic exchange
with calcium ions.' Strontium is thus known to have
predilection not only for bone, but also for young calcified areas in the soft tissues.' The basis of this fact is that
strontium and calcium have the same biologic distribution and metabolic pathways.2 We have reported elsew h e ~ e ~the
- ~ deposition of strontium in the liver in
different chemical form namely, strontium phosphate,
due to possible formation of colloid. The deposition of
strontium in the lungs is unusual unless there is active
calcification and osteoid formation in the lungs. The case
presented here does not have radiologic evidence of
calcification (Fig 1). but still shows abnormal deposition
of radiostrontium in the lungs on scintiscan (Fig 2 and
3). The exact mechanism is not clear. There are two
possible explanations. The first is that heterionic exchange of strontium with calcium takes place in the
lungs assuming microscopic calcium deposition in the
lungs. The second is that strontium forms macroaggregates with calcium and phosphate (patient had altered
serum Ca/P level). The macroaggregates are then
trapped in the pulmonary capillaries. The second explanation is based on the observation made by the authors3-"
that strontium forms colloid with phosphate both in
~ i v and
o ~in~v i~t r ~ We
. ~ have also been able to make
macroaggregates of strontium phosphate in vitro." We
could assume that there is probably formation of some
kind of macrocolloid or macroaggregate in uivo. It is
difficult to choose between the two possibilities. However, the second possibility does seem to be more reason-
CHEST, VOL. 61, NO. 2, FEBRUARY, 1972
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able as evide~lcedfrom our in uitro s t u d p simulating
altered Ca/P ratio. The macroaggregates were trapped
in the lungs in the first pass. In contrast, heterionic
exchange is a slow process. The possibility of preformed
strontium macroaggregates was ruled out because *i'uSr
from the same lot was not taken u p by the lungs of other
patients who had bone scans done on the same day. The
problem needs further study. We are presently studying
strontium kinetics in multiple myeloma cases, as well as
in patients with altered calcium and phosphorus level of
other etiology, such as renal failure. Animal experiments
are also underway with a hypocalcemic drug, mithramycin, which was received by our patient.
McLachlan et a17 reported radiologically evident
metastatic pulmonary calcification in patients with renal
failure on dialysis. The mechanism underlying their finding could possibly be explained on the basis of our
observation.
study would probably provide a
means to detect radiologically undemonstrable early
metastatic calcification process in hypercalcemia of diverse etiologies.
1 Freeman LM, Johnson PM: Clinical Scintillation Scanning.
New York, Harper and Row Publisher, 1969, pp 336
2 Bronner F, Aubert JP, Richelle LJ, et al: Strontium and its
relation to calcium metabolism. J Clin Invest 42:1095,
1963
3 Chaudhuri TK, Chaudhuri TK. Peterson RE, et al: Mechanism of action of phosphate on serum strontium. Clin Res
8:622, 1970
4 Chaudhuri TK, Chaudhuri TK. Peterson RE et al: Effect
of phosphate on serum strontium. Proc Soc Exp Biol Med
137:1, 1971
5 Chaudhuri TK, Chaudhuri TK, Christie JH: 87"Sr phosphate as a liver scanning agent. Int J Appl Radiation (in
press )
6 Chaudhuri TK. Chaudhuri TK. Christie JH: Lung scan
with 87"'Sr-phosphate macroaggregates. J Nucl Med 12:
347, 1971
7 McLachlan MSF, Wallace M, Seneviratne C: Pulmonary
calcification in renal failure. Report of three cases. Brit J
Radio1 41 :99. 1968
T
otal correction of common ventricle seems to be a
contraindication because of its complicated malformation and few operated cases have been reported. This
is a case successfully operated by creating the ventricular septum with Dacron patch without damaging the
conduction system.
Radical corrective measures in patients with common
ventricle still present challenging problems because of
the complex anatomic features involved, although there
have been scattered reports of limited successes on this
subject.'-3
The patient was a ten-year-old girl. Her symptoms consisted
of failure to thrive, repeated episodes of upper respiratory
infection, and limited exercise tolerance.
On auscultation of the heart, we found a grade 4/6 systolic
murmur at the base, best heard in the 3rd to 4th intercostal
space on the left sternal border, and a grade 2/6 systolic
murmur at the apex with transmission to the left axilla. The
pulmonary component of the second sound was markedly
accentuated, single and palpable. Marked precordial heave
was present. Chest x-ray examination showed moderate cardiomegaly with a CTR of 57 percent, prominence of the
pulmonary conus, and engorged pulmonary vascular markings. Electrocardiogram showed regular sinus rhythm, as
indeterminate axis, and biventricular hypertrophy. Right
heart catheterization revealed a left-to-right shunt with a ratio of 61 percent at the ventricular level, a pulmonary to systemic pressure ratio of 100 percent and a resistance ratio of
38 percent. Arterial oxygen saturation was 94 percent and
pulmonary arterial pressure was 110/60.
Angiocardiogram (Fig 1 ), taken with a catheter through
Successful Total Correction of
Common Ventricle
Shigeru Sakakibara, M.D., F.C.C.P.;. Seiichi Tominaga,
1U.D.; Ynsuharu Imai, M.D.; Kichisahuro Uehara, M.D.; and
Masatorno Matsurnuro, M.D.
A patient who had total corntion of common ventricle
is reported. Surgical techniques are discussed in detail
and the imporbnee of avoiding injury to the conduction
system is stressed.
'Director, the Heart Institute of Japan, Tokyo Women's
\ l ~ l i c a College,
l
Tokyo, a an.
Re wint requerts: Dr. Sal!aEbnr, Heart Institute o Japan,
~ o k y oWomen's Medical CoUege, 10 Kaw&ho,
S f,injukuku, Tokvo, Japan
FIGURE1. Preoperative selective letr venrrncurar anglugram
shows a huge pulmonary artery and small aorta, both of which
are opacified simultaneously. The diameter of the former is
three times that of the latter. Opacification of the large ventricular cavity alone was demonstrated, and visualization of
the right ventricle was unobtainable. There is a grade 1/4
mitral insufficiency.
CHEST, VOL. 61, NO. 2, FEBRUARY, 1972
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