A comparison of radiographic evidence of frontal sinusitis in middle-turbinate sacrificing versus middle-turbinate sparing approaches to the sella.

BACKGROUND: Initial descriptions of endoscopic approaches to the sella and pituitary involved resecting the middle turbinate (MT) to help improve access and visualization. Modifications of these procedures to preserve the MT have since been described, one rationale being to reduce the incidence of frontal sinusitis. The objective of this study was to establish the incidence of postoperative frontal sinusitis in MT sparing (MTsp) and MT sacrificing (MTsc) approaches to the sella. OBJECTIVE: A retrospective cohort study that compared radiographic evidence of frontal rhinosinusitis or frontal recess obstruction after skull base surgery in patients who underwent MTsc and MTsp endonasal approaches to the sella. METHODS: Consecutive retrospective review of pre- and postoperative magnetic resonance imaging from two institutions in geographic proximity but with different approaches to the sella. Mucosal thickening in the frontal sinus was measured and graded by a radiologist blinded to patient cohorts. RESULTS: Seventy-five patients, based on sample size calculations, were included at each site. Baseline demographics and indications for surgery were not significantly different between the groups. No difference was seen between the groups in the overall grade of radiographic frontal sinusitis seen on postoperative imaging. A total of 8 patients (10%) in the MTsc group had measured mucosal thickening, which was increased from their preoperative scan versus 15 in the MTsp group (20%) (p = 0.10). New mucosal thickening of >1 mm was found in three patients in the MTsc group and eight patients in the MTsp group (p = 0.21); the only patient with postoperative complete frontal sinus opacification was in the MTsp group. CONCLUSIONS: The choice of MTsc versus MTsp in endonasal endoscopic approach to the sella does not seem to make a difference in the incidence of postoperative radiographic frontal sinusitis.

Cluster Headache as the Index Event in MS: A Case Report.

We report a 42-year-old woman who presented with cluster headache (CH) in association with other neurological symptoms as the index event of new onset multiple sclerosis (MS). Her initial symptoms were left-sided headache with ipsilateral lacrimation and nasal congestion associated with ipsilateral facial numbness. A subsequent similar headache attack was also associated with ipsilateral arm ataxia and gait ataxia. She had many additional short headache attacks without focal neurological symptoms. Her cluster-like headache attacks have not recurred since intiation of dimethyl fumarate. Our patient illustrates that cluster-like headache attacks can occur as a first symptom of MS, in our patient in association with other neurological symptoms. A striking finding in our patient was a large demyelinating lesion in the brachium pontis ipsilateral to the headaches, although additional supratentorial demyelinating lesions were also present. Although CH associated with MS is rare, our patient and the two other reported patients with MS and CH with similar ipsilateral brachium pontis lesions suggest that the lesions in this location may have played a role in the generation of the cluster-like attacks.

Successful use of Solitaire FR for stroke in a pediatric ventricular assist device patient.

Acute ischemic stroke (AIS) remains a devastating and relatively common complication after pediatric ventricular assist device (VAD) placement, with a reported incidence of 29%. We describe an 8-year-old cardiomyopathy patient who had received a HeartWare device, complicated by AIS, and successful treatment with a Solitaire FR device with complete recanalization. This is the first report of the use of this device in a VAD patient and the first reported use in a pediatric patient with middle cerebral artery AIS.

Frontal sinus cells: identification, prevalence, and association with frontal sinus mucosal thickening.

BACKGROUND: Frontal sinus cells (FSCs) are thought to be a potential cause of narrowing of frontal recess outflow. It remains unclear if FSCs are associated with frontal sinus mucosal thickening and chronic rhinosinusitis. The goal of the current study is to determine the prevalence of FSCs and their association with frontal sinus mucosal thickening. METHODS: All adult patients undergoing computed tomography (CT) scans of the paranasal sinuses at our institution between February and October 2010 were reviewed. All CT scans were evaluated for the presence of FSC (types 1-4) and association with frontal mucosal thickening. The secondary outcome measure was to examine interrater agreement between two raters who independently evaluated all CT scans. RESULTS: Analysis of 399 CT scans was performed with 71 scans excluded. The proportion of patients with FSC type 1 was 26%, 6.4% was type 2 cells, 2.1% was type 3 cells, and 0% was type 4 cells. The odds ratio of mucosal thickening for type 1 FSCs was 15.9 (95% CI, 9.8-25.7), type 2 was 13.7 (95% CI, 6.7-27.8), and type 3 was 9.5 (95% CI, 3.0-30.2). Interrater agreement for the evaluation of mucosal thickening was high (kappa, 0.69-0.76; p = 0.001). Agreement for the presence or absence of FSCs was moderate (kappa, 0.392; p = 0.001). CONCLUSION: There is a significant association of frontal sinus mucosal thickening with the presence of FSCs. Independent raters have moderate agreement when identifying the presence and type of FSCs.

Imaging characteristics of an unusual, high-grade angiocentric glioma: a case report and review of the literature.

Angiocentric gliomas have recently been reclassified as a separate central nervous system tumor. Few cases have been reported, and most of those correspond to slow-growing, low-grade neoplasms in very young pediatric patients. Here we describe magnetic resonance imaging findings (including diffusion imaging, spectroscopy and tractography) in an unusual higher-grade neoplasm with pathologic features suggestive of an angiocentric glioma in a 15-year-old male. The tumor had mild heterogeneous enhancement on magnetic resonance imaging, and a low apparent diffusion coefficient (9.9 × 10(-4) mm(2)s(-1)), consistent with an intermediate-to-high cellularity tumor. Spectroscopic imaging showed elevated choline/phosphocreatine and choline/N-acetyl aspartate ratios, suggesting an unusually aggressive tumor. We conclude that angiocentric glioma should not be excluded from consideration at primary diagnosis, particularly in teenaged patients nearing adulthood.

Lung contusion in children--early computed tomography versus radiography.

OBJECTIVE: To investigate, in children, the correlation between the extent of lung contusion as detected on early radiologic examination (chest radiograph [CXR] and/or thoracic computed tomography [TCT]) and subsequent clinical outcome measures. DESIGN: Retrospective chart review study with blinded assessment of thoracic imaging. SETTING: A university-affiliated, level 1 designated pediatric trauma center. INTERVENTIONS: None. PATIENTS: Patients (1-18 yrs) who, between April 2000 and October 2005, were diagnosed with lung contusion were eligible for study entry. The medical records of those patients who underwent early (within the first 24 hrs of admission) thoracic imaging (CXR and/or TCT) were reviewed. A pulmonary contusion score (PCS) was assigned to each thoracic image according to the extent of contusion injury by two investigators blinded to each others score and the clinical details of the patient. RESULTS: Seventy-four patients were included in the study. Twenty patients had undergone CXR only, whereas 54 had undergone both CXR and TCT. The mean PCS on CXR was 3.9 +/- 3.6 compared with 6.5 +/- 3.49 on TCT (p < .001). In eight patients (15%) who underwent TCT and CXR, the CXR failed to demonstrate a lung contusion. The PCS derived from CXR examination correlated positively with lower Pao2/Fio2 (r = -.36, p = .019), higher ventilation index (r = .35, p = .014), and longer length of ventilation (r = .28, p = .019). No such correlation was seen with TCT-derived PCS. CONCLUSIONS: The severity of lung contusion determined by CXR, but not TCT, correlates with impairment of oxygenation, CO2 exchange, and duration of ventilatory support.

Effect of autologous platelet adhesives on dermal fat graft resorption following reconstruction of a superficial parotidectomy defect: a double-blinded prospective trial.

BACKGROUND: Dermal fat grafts are used to reconstruct facial contour defects but may undergo variable resorption. Application of autologous platelet adhesive may improve outcomes. The primary objective was to compare resorption of dermal fat grafts for parotidectomy defects, between patients receiving autologous platelet adhesive versus controls. METHODS: This was a double-blinded prospective cohort at a tertiary care center. Volumetric analyses of dermal fat graft measured by MRI scans. Resorption was determined by comparing 1- and 6-month MRIs in each patient. Complications, Frey's Syndrome, and patient satisfaction were also assessed. RESULTS: Twelve patients completed the study. A significant reduction in graft resorption was seen in the treatment group (57% vs. 31%, p = .01). Three patients in the control group developed fat liquefaction. Patient perceived significant differences in scar and contour. CONCLUSION: Application of autologous platelet adhesives improved graft viability and patient satisfaction at 6 months.

Coma with diffuse white matter hemorrhages in juvenile diabetic ketoacidosis.

Cerebral edema is the most common neurologic complication of diabetic ketoacidosis in children. A minority of young patients with intracerebral crises in diabetic ketoacidosis present with cerebrovascular accidents. We report 2 adolescent patients with diabetic ketoacidosis who presented with coma and diffuse white matter hemorrhages in the absence of either cerebral edema or cerebrovascular accidents. These 2 cases illustrate a novel clinical and neuropathologic description of diffuse white matter hemorrhages, possibly related to a cytotoxic process as the underlying mechanism. These case descriptions emphasize that pediatric patients with diabetic ketoacidosis and coma can present with pathology not related to either cerebral edema or cerebrovascular accidents.