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Fifty-eight Israeli adults with mild to moderate mental retardation, living in Jerusalem, either in a residential institution, various sheltered apartments or in their parents' home, were studied with respect to their quality of life. Quality of life was evaluated through the assessment of individual's satisfaction with different elements of life. The results are presented in this article. Overall, significant differences were found in satisfaction with: current residence, friends and free time, and total lifestyle satisfaction. Residents of sheltered apartments expressed the most satisfaction in these three domains. Persons living in the residential institution expressed the least satisfaction with current residence, and people living in their parents' home expressed the least satisfaction with friends and free time and with total lifestyle satisfaction. The three groups differ significantly on the three domains of life satisfaction even after controlling for background and environmental characteristics such as: age, health limitations, adaptive behaviour, participation in leisure activities, and opportunity to choose and decide.

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Two patients with compound arteriovenous fistulae, in whom transarterial embolizations failed, were managed by embolization of the arterial tributaries of their fistulae from retrograde, transvenous access. Transvenous embolizations were successful in both patients. Given multiple arterial tributaries, and large communicating hematomas into which these arteries bleed, transvenous access may be a useful approach for embolizing compound traumatic arteriovenous fistulae.

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Violent lateral blunt impacts to the chest, such as inflicted in broadside automobile collisions, can cause traumatic rupture of the thoracic aorta. Unfortunately, because this injury is among the least common in blunt chest trauma, and given that it is not caused by the expected "classic" frontal collision, its diagnosis is often delayed or altogether missed. In most of these events, quite unlike the classic isthmus rupture of deceleration accidents, the injury appears to be partial shearing of the distal aortic arch, probably just above the isthmus. The aortic injury is often part of a wounding pattern typical of a lateral collision, in which critical intra-abdominal injuries are located on the side of the patient that was on the receiving end of the impact. Findings in 13 such patients are presented and discussed. The point is also made that because seatbelts and air bags do not protect car occupants against broadside impacts, their mandatory use will not lower the rate of occurrence of aortic shearing in lateral collisions, and as a result the numerical prominence of these injuries compared with that of aortic isthmus ruptures in the statistics of road traffic collisions may be expected to increase.

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The high risk of exsanguinating hemorrhage in patients with pelvic ring disruption demands aggressive, yet balanced orthopedic and angiographic management as soon as patients are admitted to the emergency department. We present a perspective of our experience in two trauma centers and propose a logical approach to early prediction, diagnosis, and management of hemorrhage associated with pelvic fractures. Our method is based on knowledge of pelvic anatomy and an understanding of the mechanisms of injury and their wounding capacity, given that the mechanism of injury determines the type of pelvic ring disruption and that the probability of arterial hemorrhage is--to a great extent--a function of the type of pelvic fracture. The risks of diagnostic peritoneal lavage and of excessive radiologic studies of noncritical injuries are emphasized. The principles guiding arterial embolization and the application of external fixators are discussed.

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Compression of the celiac trunk by the median arcuate ligament of the diaphragm is an uncommon angiographic and surgical finding that rarely may be symptomatic. We retrospectively reviewed contrast-enhanced abdominal CT scans in five patients with severe ligamentous compression of the celiac axis, confirmed by surgery and/or angiography, and compared the findings with those of enhanced scans of 100 consecutive patients without known ligamentous compression. In all five patients with ligamentous celiac artery compression, CT showed effacement or narrowing of the celiac trunk by an anterior soft-tissue band. Dilated peripancreatic collateral vessels were seen in four cases, and poststenotic dilatation of the distal celiac trunk was seen in two cases. The normal appearance of the vasculature was seen in the majority (76%) of the 100 control subjects, but in eight patients the celiac origin was obscured on CT scans, and in 16 patients the celiac trunk appeared narrow or effaced. Our experience suggests that severe ligamentous celiac artery compression can be identified on CT. However, the isolated CT finding of effacement or obscuration of the celiac axis occurs sufficiently often in normal patients that it is not adequate evidence to establish the diagnosis of celiac artery compression.

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Shunts that decompress the portal vein are effective in the treatment of bleeding esophageal varices. Use of large-caliber portacaval shunts, however, results in the complete decompression of the portal system and the risk of subsequent development of hepatic encephalopathy. Use of small-caliber portacaval shunts results in mild portal hypertension and less frequent hepatic encephalopathy but may increase the risk of recurrent bleeding. Thirty-three patients underwent angiography after partial decompression portacaval shunting (median trans-shunt pressures, 8 mm Hg). Embolization of residual varices, noted in 13 patients, was performed. Results included one complication with no sequelae and no bleeding a mean of 13 months after the procedure was performed. Trans-shunt embolization of esophageal varices effectively prevents bleeding varices after partial portal decompression.

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The nature and severity of a bullet wound depend on the characteristics of the bullet and of the tissues through which it travels. In addition to the mass and velocity of the bullet, its orientation and whether it fragments or deforms affect the nature of the wound. Two major mechanisms of wounding are described: crushing and stretching of tissue. Understanding the mechanisms by which bullets disrupt tissue can help physicians to evaluate and treat wounds.

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Radiologists can contribute substantially to the evaluation and treatment of the patient with a gunshot wound. Plain films, CT, angiography, and sometimes MR imaging are used to localize the missile, determine what path it followed in the body, assess missile and bone fragmentation, and identify missile emboli. If the peritoneal cavity was entered by a bullet, a laparotomy is required. Missiles subject to magnetic forces can complicate MR imaging. Certain locations of missile fragments predispose to lead poisoning or lead arthropathy. Angiography is useful for both diagnosis and treatment. Both angiographic hemostasis and percutaneous foreign body removal may be used.

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Renal artery branch injury resulting from stab wounds of iatrogenic origin or street violence is an important cause of renal hemorrhage. Over a period of 10 years we accurately diagnosed the injury and successfully managed the associated hemorrhage in 15 patients by using angiography and percutaneous embolization techniques. Nine branch injuries in eight patients were due to street knifings and seven injuries were complications of invasive medical procedures (four from renal biopsy, two from nephrostolithotomy, and one from nephrostomy). All patients had gross hematuria at the time of angiographic evaluation. False aneurysms were present in six patients (one with associated frank extravasation), false aneurysm/arteriovenous fistula in three, false aneurysm/arteriocaliceal fistula in one, and isolated arteriovenous fistula in two. Frank extravasation without associated false aneurysm/arteriovenous fistula was present in two. One patient had two injuries, an upper-pole false aneurysm and a lower-pole false aneurysm/arteriovenous fistula. In the eight patients injured in street knifings, hematuria recurred after surgical exploration and treatment. None of the 16 injuries involved the main renal artery. Gelfoam was used for embolization of nine lesions and steel coils for four. Three others were treated with Gelfoam plus coils. Hemostasis was achieved in all and none required subsequent surgery. Renal tissue loss was small to moderate (less than 30%) in 12 patients and large (30-50%) in three patients. Transient postembolization hypertension occurred in one of the latter. We consider selective angiography/embolization to be an effective and safe means for diagnosing and treating wounds of the renal artery branches.

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Pelvic ring disruption is part of a complex wounding pattern that challenges our ability to diagnose and manage hemorrhage. The conventional methods of diagnosis and control of abdominopelvic bleeding--peritoneal lavage and exploratory laparotomy--should be replaced by exploratory abdominopelvic angiography and transcatheter embolization. Angiography should be performed as soon as possible after the patient is admitted to the emergency room, and shock should not delay transfer of the patient to the angiography suite.

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Embolotherapy for extremity vascular injuries is a relatively new, effective, and safe treatment modality in selected patients. The resultant hemostasis decreases the morbidity or even mortality that can result from uncontrolled hemorrhage. In addition, surgery may be postponed until the patient is stabilized, or avoided altogether. Prompt diagnosis of vascular injury and embolization when indicated also contributes to the proper management of associated osseous and soft tissue injuries.

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The formation of an iliac arteriovenous fistula caused by rupture of an atherosclerotic iliac artery aneurysm is unusual. We describe a case and review the previously reported 18 cases of spontaneous iliac arteriovenous fistula. The presence of a palpable abdominal mass associated with a thrill or bruit and unilateral leg symptoms of venous engorgement or arterial insufficiency, with or without acute onset of congestive heart failure, should result in a high index of suspicion of this entity. Prompt recognition and surgical closure of the iliac fistula are most important in successful management.

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Eighteen patients with surgically proved penetrating injuries to the thoracic aorta or brachiocephalic arteries were evaluated preoperatively with angiography. Fifteen injuries resulted from direct penetration of a vessel and three were concussion or blast injuries. Arteriography correctly showed vessel damage in 16 (89%), although one was identified only in retrospect. There were two false-negative examinations. False aneurysms were present in nine. Other findings included occlusion, wall irregularity, and an arterial-arterial fistula. Our results show that angiography is an accurate means of detecting penetrating injuries to the thoracic aorta or brachiocephalic arteries.

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