BRAIN MAGNETIC RESONANCE IMAGING CHARACTERISTICS IN DOGS AND CATS WITH CONGENITAL PORTOSYSTEMIC SHUNTS

Animals with a portosystemic shunt (PSS) often have neurologic abnormalities. Diagnostic imaging, including brain magnetic resonance (MR) imaging, is not performed routinely in these animals. In this study, brain MR images were obtained in 13 dogs and three cats with a PSS, and in 15 dogs and five cats that were neurologically normal and used as controls. All animals with a PSS had widened sulci. In addition, 10 out of 13 dogs with a PSS and one out of three cats with a PSS had hyperintense focal areas in the lentiform nuclei on T1-weighted (T1W) images, which did not enhance after intravenous gadolinium. Following surgical correction of the PSS, MR imaging examinations were repeated in one dog and one cat. The hyperintensity of the lentiform nuclei had decreased. This study indicates that MR imaging findings of widened sulci and hyperintensity of the lentiform nuclei on T1W images may be found in dogs and cats with a PSS.     

USE OF QUANTITATIVE HEPATIC SCINTIGRAPHY TO EVALUATE SPONTANEOUS PORTOSYSTEMIC SHUNTS IN 12 DOGS

Quantitative hepatic scintigraphy is a valid means for estimating total liver blood flow and relative portal hepatic perfusion. The Hepatic perfusion index (HPI) was determined for a group of 12 dogs with portosystemic shunts prior to and two days after corrective surgery. HPI values for the dogs prior to operation were significantly elevated (p<0.001) as compared with those for a group of normal dogs, indicating reduced effective portal hepatic perfusion in dogs with shunts. Dogs showing a favorable clinical response after surgery had a significant decrease (p<0.02) in HPI values after operation. One dog showing a poor clinical response after operation had an increase in HPI score after operation. Quantitative hepatic scintigraphy is a valuable diagnostic test for screening presumptive cases of portosystemic shunts and monitoring the response to surgical intervention.     

USE OF MAGNETIC RESONANCE ANGIOGRAPHY FOR DIAGNOSIS OF PORTOSYSTEMIC SHUNTS IN DOGS

A prospective study was conducted to determine the sensitivity and specificity of diagnosis of portosystemic shunts (PSS) and the accuracy of anatomically locating single congenital PSS in dogs using magnetic resonance angiography (MRA). MRA was performed on 10 normal dogs and 23 dogs with PSS. Sensitivity and specificity of MRA to diagnose any shunt among all dogs were 80% and 100%, respectively. Among dogs identified with PSS, sensitivity and specificity of MRA for diagnosis of multiple extrahepatic shunts were 63% and 97%, respectively, and for diagnosis of single congenital shunts were 79% and 100%, respectively. Using MRA, radiologists correctly identified shunts as extrahepatic or intrahepatic in 83% of patients and correctly identified the origin and insertion of the shunts in 57% and 97% of patients, respectively. Use of MRA is specific for diagnosis of PSS and is a sensitive indicator of anatomic location of single congenital portosystemic shunts.     

ANATOMY OF EXTRAHEPATIC PORTOSYSTEMIC SHUNTS IN DOGS AS DETERMINED BY COMPUTED TOMOGRAPHY ANGIOGRAPHY

Congenital extrahepatic portosystemic shunts are anomalous vessels joining portal and systemic venous circulation. These shunts are often diagnosed sonographically, but computed tomography (CT) angiography produces high‐resolution images that give a more comprehensive overview of the abnormal portal anatomy. CT angiography was performed on 25 dogs subsequently proven to have an extrahepatic portosystemic shunt. The anatomy of each shunt and portal tributary vessels was assessed. Three‐dimensional images of each shunt type were created to aid understanding of shunt morphology. Maximal diameter of the extrahepatic portosystemic shunt and portal vein cranial and caudal to shunt origin was measured. Six general shunt types were identified: splenocaval, splenoazygos, splenophrenic, right gastric‐caval, right gastric‐caval with a caudal shunt loop, and right gastric‐azygos with a caudal shunt loop. Slight variations of tributary vessels were seen within some shunt classes, but were likely clinically insignificant. Two shunt types had large anastomosing loops whose identification would be important if surgical correction were attempted. A portal vein could not be identified cranial to the shunt origin in two dogs. In conclusion, CT angiography provides an excellent overview of extrahepatic portosystemic shunt anatomy, including small tributary vessels and loops. With minor variations, most canine extrahepatic portosystemic shunts will likely be one of six general morphologies.     

ULTRASONOGRAPHIC DIAGNOSIS OF CONGENITAL PORTOSYSTEMIC SHUNTS IN DOGS: RESULTS OF A PROSPECTIVE STUDY

The aims of this study were to determine if accurate diagnosis of congenital portosystemic shunt was possible using two dimensional, grey-scale ultrasonography, duplex-Doppler, and color-flow Doppler ultrasonography in combination, and to determine if dogs with congenital portosystemic shunts have increased or variable mean portal blood flow velocity. Eighty-two dogs with clinical and/or clinicopathologic signs compatible with portosystemic shunting were examined prospectively. Diagnosis of congenital portosystemic shunt was subsequently confirmed in 38 of these dogs using operative mesenteric portography: 14(37%) dogs had an intrahepatic shunt and 24(63%) had an extrahepatic shunt. Ultrasonography had a sensitivity of 95%, specificity of 98%, and accuracy of 94%. Ultrasonographic signs in dogs with congenital portosystemic shunts included small liver, reduced visibility of intrahepatic portal vessels, and anomalous blood vessel draining into the caudal vena cava. Correct determination of intra - versus extrahepatic shunt was made ultrasonographically in 35/38 (92%) dogs. Increased and/or variable portal blood flow velocity was present in 21/30 (70%) dogs with congenital portosystemic shunts. In one dog with an intrahepatic shunt the ultrasonographic diagnosis was based partly on finding increased mean portal blood flow velocity because the shunting vessel was not visible. Detection of the shunting vessel and placement of duplex-Doppler sample volumes were facilitated by use of color-flow Doppler. Two-dimensional, grey-scale ultrasonography alone is sufficient to detect most intrahepatic and extrahepatic shunts; sensitivity is increased by additional use of duplex-Doppler and color-flow Doppler. Increased and/or variable portal blood flow velocity occurs in the majority of dogs with congenital portosystemic shunts.     

CHARACTERIZATION OF MULTIPLE ACQUIRED PORTOSYSTEMIC SHUNTS USING TRANSPLENIC PORTAL SCINTIGRAPHY

We describe the scintigraphic patterns observed in 14 patients with confirmed multiple portosystemic shunts imaged via transplenic portal scintigraphy. Parameters evaluated included presence of multiple anomalous vessels, presence of hepatofugal flow caudal to spleen, and/or to cranial margin of the kidneys, slow absorption resulting in longer spleen to heart transit time, and presence of biphasic or fragmented bolus. Twenty‐eight additional patients, 14 with a confirmed single portocaval and 14 with a portoazygos shunt, were used for comparison. Nine of 14 (64.3%) patients with multiple shunts had multiple vessels, five (35.7%) had a biphasic bolus, 13 (92.9%) had hepatofugal flow caudal to the cranial margin of the kidneys. In all single portocaval shunts, a single anomalous vessel was identified. None had hepatofugal flow caudal to the border of the kidneys. Among portoazygos shunts, 4/14 (28.6%) had flow caudal to the injection site. Six portoazygos and one portocaval shunts had biphasic bolus. Median transit time from spleen to heart was significantly longer (1.9 s) in patients with multiple shunts than in patients with a portocaval shunt (1.0 s), but not in patients with a portoazygos shunt (1.3 s). Although a distinct plexus of anomalous vessels is not detected in all patients with multiple shunts imaged using transplenic portal scintigraphy, findings of hepatofugal flow caudal to the margin of the kidneys, and longer transit time compared with single portocaval shunts were characteristic. Flow caudal to the splenic injection site but cranial to the kidneys and biphasic bolus can also be seen with a single congenital shunt.     

ULTRASONOGRAPHIC DIAGNOSIS OF PORTOSYSTEMIC SHUNTING IN DOGS AND CATS

The value of ultrasonography was evaluated in 85 dogs and 17 cats presented with a clinically suspected portosystemic shunt (PSS). A PSS was confirmed in 50 dogs and nine cats (single congenital extrahepatic in 42, single congenital intrahepatic in 11, and multiple acquired in six). Six dogs and one cat had hepatic microvascular dysplasia, and 29 dogs and seven cats had a normal portal system. Ultrasonography was 92% sensitive, 98% specific, and had positive and negative predictive values of 98% and 89%, respectively, in identifying PSS, with an overall accuracy of 95%. When a PSS was identified with ultrasonography, extrahepatic, intrahepatic, and multiple acquired PSS could be correctly differentiated in 53/54 patients (98%). The combination of a small liver, large kidneys, and uroliths had positive and negative predictive values of 100% and 51% for the presence of a congenital PSS in dogs. The portal vein/aorta (PV/Ao) and portal vein/caudal vena cava (PV/ CVC) ratios were smaller in animals with extrahepatic PSSs compared with animals with microvascular dysplasia, intrahepatic PSSs and those without portal venous anomalies (P<0.001). All dogs and cats with a PV/Ao ratio of < or = 0.65 had an extrahepatic PSS or idiopathic noncirrhotic portal hypertension. Dogs and cats with PV/Ao and PV/CVC ratios of > or = 0.8 and > or = 0.75, respectively, did not have an extrahepatic PSS. Reduced or reversed portal flow was seen in four of four patients with multiple acquired PSSs secondary to portal hypertension. The presence of turbulence in the caudal vena cava of dogs had positive and negative predictive values of 91% and 84%, respectively, for the presence of any PSS terminating into that vein.     

USE OF INTRAOPERATIVE MESENTERIC PORTOVENOGRAPHY IN CONGENITAL PORTOSYSTEMIC SHUNT SURGERY

A retrospective study of the use of intraoperative mesenteric portovenography (IOMP) in the surgical management of congenital portosystemic shunts in 100 dogs and cats was performed. Each portovenogram was scored using a subjective visual analogue scale (VAS) and was assessed for the presence of portal atresia or hypoplasia. VAS scores and portal hypoplasia assessments were obtained for portovenogram images obtained for each animal both before shunt manipulation (preligation) and following the temporary, complete ligation of the vessel (postligation). In each patient, surgical records were reviewed to ascertain the degree of shunt attenuation that was achieved at surgery. Hepatic portal vasculature was significantly different on postligation compared with preligation IOMP. Sixty-two percent of animals had apparent portal hypoplasia or atresia on their preligation IOMP. The majority of these (81%) had an improvement in portal vasculature on postligation IOMP. It was concluded that both preligation and postligation IOMP provided valuable information regarding the morphology of congenital portosystemic shunts. An accurate assessment of an animal's portal vasculature could only be made following the interpretation of a postligation portovenogram, and these findings significantly influenced the surgical management of the patient. Although individuals with high postligation VAS scores were more likely to achieve full shunt attenuation at surgery, there was no quantifiable relationship between IOMP findings and the degree of shunt attenuation achieved.     

COMPARISON OF PER-RECTAL PORTAL SCINTIGRAPHY USING 99mTECHNETIUM PERTECHNETATE TO MESENTERIC INJECTION OF RADIOACTIVE MICROSPHERES FOR QUANTIFICATION OF PORTOSYSTEMIC SHUNTS IN AN EXPERIMENTAL DOG MODEL

Per-rectal portal scintigraphy using tech-netium-99m pertechnetate (^99mTcO₄^-) was performed in 8 normal dogs before and after surgical creation of a portacaval shunt. Shunt fractions were calculated by computer assisted analysis of dynamic images (IMG) and compared to shunt fractions determined by mesenteric venous injection of radioactive microspheres (MIC). The mean pre-operative shunt fraction was 1.59% using IMG and 3.00% using MCI. The mean postoperative shunt fraction was 64.56% using IMG and 69.56% using MIC. There was excellent correlation between both methods (r² 0.94). Per-rectal portal scintigraphy is an easily performed, inexpensive method to diagnose and quantify portosystemic shunts in dogs.     

USE OF TRANSSPLENIC INJECTION OF AGITATED SALINE AND HEPARINIZED BLOOD FOR THE ULTRASONOGRAPHIC DIAGNOSIS OF MACROSCOPIC PORTOSYSTEMIC SHUNTS IN DOGS

We describe the use of ultrasonography‐guided percutaneous splenic injection of agitated saline and heparinized blood for the diagnosis of portosystemic shunts (PSS) in 34 dogs. Agitated saline mixed with 1 ml of heparinized autologous blood was injected into the spleen of 34 sedated dogs under sonographic guidance. The transducer was then sequentially repositioned to visualize the portal vein, the caudal vena cava, and the right atrium through different acoustic windows. It was possible to differentiate between intrahepatic and extrahepatic shunts depending on the entry point of the microbubbles into the caudal vena cava. Portoazygos shunts and portocaval shunts could be differentiated based on the presence of microbubbles in the caudal vena cava and/or the right atrium. In one dog, collateral circulation due to portal hypertension was identified. In dogs with a single extrahepatic shunt, the microbubbles helped identify the shunting vessel. The technique was also used postoperatively to assess the efficacy of shunt closure. All abnormal vessels were confirmed by exploratory laparotomy or with ultrasonographic identification of the shunting vessel. Ultrasound‐guided transsplenic injection of agitated saline with heparinized blood should be considered as a valuable technique for the diagnosis of PSS; it is easy to perform, safe, and the results are easily reproducible.     

USE OF CONTRAST HARMONIC ULTRASOUND FOR THE DIAGNOSIS OF CONGENITAL PORTOSYSTEMIC SHUNTS IN THREE DOGS

Contrast harmonic ultrasound was used to determine macrovascular and perfusion patterns in three dogs with congenital extrahepatic solitary portosystemic shunts (PSS). With coded harmonic angiographic ultrasound, the size and tortuosity of the hepatic arteries were subjectively increased. Single pulse intermittent low-amplitude harmonic perfusion imaging provided contrast enhancement time-intensity curves from regions of interest in the liver. Mean (+/- standard deviation) peak perfusion times of dogs with PSS were significantly shorter (p = 0.01; 7.0 +/- 2.0 s) than reported in normal dogs (22.8 +/- 6.8 s). The contrast inflow slope for the dogs with PSS (14.6 +/- 3.7 pixel intensity units [PIU] was significantly (p = 0.05) larger than reported for normal dogs (3.6 +/- 1.4 PIU/s). These results indicate that combined coded harmonic angiographic and contrast harmonic perfusion sonography can be used to detect increased hepatic arterial blood flow as an indicator of PSS in dogs.     

USE OF TRANSCOLONIC 123I-IODOAMPHETAMINE TO DIAGNOSE SPONTANEOUS PORTOSYSTEMIC SHUNTS IN 18 DOGS

Transcolonic ¹²³I-Iodoamphetamine is rapidly absorbed across the colonic mucosa and binds to amine receptors in the liver and lungs. During the first ten minutes following colonic administration, a simple ratio of lung counts to lung counts plus liver counts provides an accurate estimate of the fraction of portal blood that bypasses hepatic sinusoids in dogs with portosystemic shunts. Studies were performed on 24 dogs with suspect portosystemic shunt. Shunt fraction values for 18 dogs with surgically confirmed portosystemic shunt were obviously higher than published values for normal dogs, and also significantly higher than values for the other six dogs, later confirmed to lack shunts. Postoperative studies were repeated on ten dogs with single shunt vessels 1–2 days after shunt closure. Total shunt ligation resulted in normal postoperative shunt fraction, whereas partial shunt ligation resulted in persistant elevation of shunt fraction. Transcolonic iodoamphetamine scintigraphy is noninvasive, easy to perform, and provides an accurate method to diagnose dogs with portosystemic shunt.     

CONTRAST‐ENHANCED MAGNETIC RESONANCE ANGIOGRAPHY FOR DIAGNOSIS OF PORTOSYSTEMIC SHUNTS IN 10 DOGS

Computed tomography angiography, sonography, scintigraphy, and portography can be used to evaluate the portal vasculature to evaluate for a portosystemic shunt (PSS). Time‐of‐flight magnetic resonance angiography (TOF‐MRA) and contrast‐enhanced MRA (CE‐MRA) are other potentially useful techniques. The aim of this study was to evaluate CE‐MRA in 10 dogs suspected of having a PSS. Noncontrast MR images of the abdomen were obtained using a Siemens Symphony MR‐scanner (1.5 T) and a T1‐weighted FLASH‐3D sequence with a very short scan time (about 20 s). After injection of contrast medium, the initial sequence was repeated five times. The sequence with the best contrast medium filling of the portal vasculature was selected subjectively, subtracted from the initial survey image series, and a maximum intensity projection (MIP) of the subtraction data, in multiple views, was created. The cross‐sectional and MIP images were evaluated for abnormal portosystemic vasculature. A single PSS was identified and confirmed at surgery in all dogs. A portocaval shunt was found in five dogs, a portophrenic shunt in three dogs, a portoazygos shunt in one, and a central divisional intrahepatic shunt in one other dog. Based on our results, CE‐MRA is a useful tool for imaging abdominal and portal vasculature and for the diagnosis of a PSS.     

ACQUIRED PORTAL COLLATERAL CIRCULATION IN THE DOG AND CAT

We describe patterns of acquired portal collateral circulation in dogs and in a cat using multidetector row computed tomography angiography. Large portosystemic shunts included left splenogonadal shunts in patients with portal hypertension. Small portal collaterals were termed varices; these collaterals had several patterns and were related either to portal vein or cranial vena cava obstruction. Varices were systematized on the basis of the venous drainage pathways and their anatomic location, namely left gastric vein varix, esophageal and paraesophageal varices, gastroesophageal and gastrophrenic varices, gallbladder and choledocal varices, omental varices, duodenal varices, colic varices, and abdominal wall varices. As reported in humans and in experimental dog models, esophageal and paraesophageal varices may result from portal hypertension that generates reversal of flow, which diverts venous blood in a cranial direction through the left gastric vein to the venous plexus of the esophagus. Blood enters the central venous system through the cranial vena cava. Obstructions of the cranial vena cava can lead to esophageal and paraesophageal varices formation as well. In this instance, they drain into the azygos vein, the caudal vena cava, or into the portal system, depending on the site of the obstruction. Gallbladder and choledocal varices, omental varices, duodenal varices, phrenico-abdominal varices, colic varices, abdominal wall varices drain into the caudal vena cava and result from portal hypertension. Imaging plays a pivotal role in determining the origin, course, and termination of these vessels, and the underlying causes of these collaterals as well. Knowledge about these collateral vessels is important before interventional procedures, endosurgery or conventional surgery are performed, so as to avoid uncontrollable bleeding if they are inadvertently disrupted.     

USE OF 99MTCO TRANS-SPLENIC PORTAL SCINTIGRAPHY FOR DIAGNOSIS OF PORTOSYSTEMIC SHUNTS IN 28 DOGS

Ultrasound-guided percutaneous trans-splenic portal scintigraphy (TSPS) using 99mTcO4(-) has been used to image the portal venous system in normal dogs. Compared with per-rectal portal scintigraphy, it provides higher count density, consistent nuclear venograms of the splenic and portal vein, and significantly decreased radiation exposures. This paper describes the use of TSPS for the diagnosis of portosystemic shunts in 28 dogs. TSPS was performed injecting 70 +/- 28 MBq of 99mTcO4(-) (mean +/- SD) into the splenic parenchyma with ultrasound guidance. A dynamic acquisition at a frame rate of four frames/s for 5 min was initiated after placement of the needle and approximately 2s prior to injection. All dogs had diagnoses confirmed via exploratory laparotomy or ultrasonographic identification of the shunting vessel(s). Three studies (10.7%) were nondiagnostic because of intraperitoneal rather than intrasplenic injection of the radionuclide. Three pathways were recognized on the scintigraphic images: (1) portoazygos shunts--the 99mTcO4(-) bolus traveled dorsally, running parallel to the spine and entering the heart craniodorsally; (2) single portocaval or splenocaval shunts--the 99mTcO4(-) bolus ran from the area of the portal vein/splenic vein junction in a linear fashion toward the caudal vena cava entering the heart caudally; (3) internal thoracic shunt-the 99mTcO4 bolus traveled ventrally along the thorax and abdomen entering the cranial aspect of the heart. Single and multiple shunts were easily distinguished. There were no distinguishing features between single intra and extrahepatic portocaval shunts.     

HELICAL COMPUTED TOMOGRAPHIC PORTOGRAPHY IN TEN NORMAL DOGS AND TEN DOGS WITH A PORTOSYSTEMIC SHUNT

Contrast enhanced helical computed tomography (CT) of the liver and portal system is routinely performed in human patients. The purpose of this project is to develop a practical protocol for helical CT portography in the dog. Ten clinically normal dogs were initially evaluated to develop a protocol. Using this protocol, ten dogs with confirmed portosystemic shunts (PSS) were then evaluated. Each patient was anesthetized, and a test dose of sodium iothalamate (400 mg I/ml) at 0.55 ml/kg was injected. Serial images were acquired at the level of T12-13 or T13-L1. The time to maximum enhancement of the portal vein was determined. This time period was used as the period between the second injection (2.2 ml/kg) and the start of the helical examination of the cranial abdomen. Delay times for normal dogs ranged from 34.5 s-66.0 s (median: 43.5 s) or 1.41 s/kg-4.12 s/kg (median: 2.09 s/kg). For patients with a PSS, the delay times were 16.5-70.5 s (median: 34.5 s) or 1.47-19.17 s/kg (median: 3.39 s/kg). The aorta, caudal vena cava, portal vein, shunt vessels, and their respective branches were well visualized on the CT images. Clinical case results were surgically confirmed. The surgeons reported that the information gained from the CT portography resulted in a subjective decrease in surgical time and degree of dissection necessary compared with similar surgeries performed without angiographic information. We believe that helical CT portography in the dog will be a useful adjunct in the diagnosis of PSS. The use of helical CT portography may allow clinicians to give clients a more accurate prognosis prior to surgery and will allow patients with lesions that are not surgically correctable to avoid a costly and invasive procedure.     

COMPARISON OF TRANSCOLONIC 123I-IODOAMPHETAMINE AND PORTAL VEIN INJECTION OF 99mTc-MACROAGGREGATED ALBUMIN SHUNT FRACTION CALCU-LATIONS IN EXPERIMENTAL DOGS WITH ACQUIRED POR-TOSYSTEMIC SHUNTS

Shunt fraction was determined using transcolonic ¹²³I-iodoamphetamine (IMP) and portal vein injection of ^99mTc-macroaggregated albumin (MAA) in a group of eight dogs with chronic cirrhosis and acquired portosystemic shunts subsequent to total common bile duct ligation. Hepatic parenchymal damage was confirmed by alterations in liver function tests and liver histology. Seven of the eight dogs developed portal hypertension and had angiographic evidence of hepatofugal portal blood flow with multiple peripheral portosystemic anastomoses. Shunt fractions determined in the seven dogs with shunts varied from 39 to 100 using IMP and 45 to 93 using MAA. The remaining dog had normal portal pressure, a normal portal angiogram, and normal IMP and MAA scintigraphic studies. There was an excellent correlation between the two methods of shunt fraction calculation (R²= 0.98) and the line of regression was not significantly different from unity (IMP = 1.09 × MAA - 0.03).     

THREE-DIMENSIONAL HELICAL COMPUTED TOMOGRAPHIC ANGIOGRAPHY OF THE LIVER IN FIVE DOGS

The objective of this study was to develop a simple, safe, minimally invasive protocol to evaluate the hepatic vasculature. Five purpose-bred Beagle dogs underwent noncontrast-enhanced computed tomographic scan of the entire abdomen. A dynamic, nonincremental computed tomography scan at the level of T11 was then performed using a test bolus of contrast medium to determine time to peak opacification and to aid in the calculation of scan delay. The time to peak arterial enhancement ranged from 2.0 to 7.0 s, with a median of 2.0 s. The time to peak portal venous enhancement ranged from 23.0 to 46.0 s, with a median of 32.0 s. Scan delay for arterial opacification ranged from 0 to 5.0 s, with a median of 0 s. Scan delay for the portal phase of opacification ranged from 6.0 to 21.0 s, with a median of 17.0 s. Using this information, two separate computed tomographic studies were used to image the arterial and portal venous phases of circulatory opacification, respectively. The dogs were hyperventilated to prevent breathing motion during the scan, each of which required approximately 20 s. A power injector was used to inject diatrizoate meglumine (128 mg I/kg) through an 18-gauge cephalic vein catheter at a rate of 5 ml/s. Scanning was initiated after the appropriate scan delay to optimize the specific phase of vascular filling. Maximum intensity projections allowed clear delineation of the hepatic arteries and the portal venous system, while eliminating overlying structures that might interfere with image analysis. Time/density curves were generated, and the time needed for each study was recorded. Hepatic arteries and portal veins were clearly visualized in all dogs. Parenchymal opacification was also observed.