Lung ultrasound score in the decision of patent ductus arteriosus closure in neonates.

PURPOSE: We aimed to investigate the role of lung ultrasound (LUS) score in the closure of hemodynamically insignificant patent ductus arteriosus (PDA) and the clinical findings of the patients before and after closure. METHODS: The study groups (107 preterm neonates under 34 gestational weeks) were classified as hemodynamically significant PDA (group 1), hemodynamically insignificant PDA with closure therapy (group 2), hemodynamically insignificant PDA without closure therapy (group 3), and no PDA group (group 4) based on the echocardiography. 6- and 10-region LUS scores were compared for each group. RESULTS: There was a significant difference between groups 1 and 3 on first, third, and seventh days. In contrast, groups 1 and 2 had similar LUS scores on the first, third, and seventh days. There was a negative correlation between LUS scores on the first and third days and gestational age, birth weight, the first- and fifth-minute APGAR scores, and there was a positive correlation between aortic root to left atrium ratio, and PDA diameter/weight ratio. CONCLUSION: We observed that LUS scores in patients with hemodynamically insignificant PDA treated with closure therapy were similar to in patients with hemodynamically significant PDA. Thus, LUS score can have role in PDA closure in preterm neonates. However, more comprehensive studies are needed.

Prolonged Bleeding After Dental Extraction Due to Decreased Serum Level of Von Willebrand Factor Caused by Untreated Profound Hypothyroidism.

BACKGROUND: Delayed diagnosis of hypothyroidism may result in atypical presentations. Here, we report a case with decreased serum level and activity of von Willebrand factor due to untreated profound hypothyroidism. OBSERVATION: A 9-year-old girl, presented with prolonged gingival bleeding after dental extraction. Clinical findings of the case were consistent with hypothyroidism, and the laboratory workup results revealed decreased serum level and activity of von Willebrand factor associated with profound hypothyroidism. Restoration of euthyroidism normalized the coagulation parameters. CONCLUSION: Delayed diagnosis of hypothyroidism may lead to atypical presentations such as bleeding diathesis. Profound hypothyroidism should be considered in the differential diagnosis of acquired von Willebrand disease to avoid undue treatment.

Gemcitabine-associated digital necrosis in metastatic breast cancer.

INTRODUCTION: Gemcitabine is a nucleoside analog antimetabolite used in various malignancies, including metastatic breast cancer. Objective response rates in its use as a single agent in the treatment of metastatic breast cancer are not to be underestimated. Cutaneous, hematological, pulmonary, and vascular side effects are well-known side effects. Venous thromboembolism may occur with antineoplastics, such as platinum compounds. Arterial thromboembolism is rare in cancer, almost rare with chemotherapy. Here, we present a metastatic breast cancer patient who had digital necrosis due to arterial occlusion with gemcitabine monotherapy. CASE REPORT: A 54-year-old metastatic breast cancer female patient had digital ischemia and necrosis in the left hand's fifth finger after the second course of single-agent gemcitabine as the fourth line setting. Gemcitabine was discontinued, and medical treatment was started. Thrombus was detected in the left subclavian artery digital angiography. Balloon angioplasty and stenting were applied. However, digital amputation had to be performed since tissue necrosis had not regressed despite radiological interventions and medical treatment. MANAGEMENT AND OUTCOME: Gemcitabine was discontinued. Low molecular weight heparin and acetylsalicylic acid were started. The distal phalanx was amputated due to necrosis during follow-up. Gemcitabine was permanently stopped. DISCUSSION: Gemcitabine-related vascular events, including arterial thrombosis, may also occur in cancer patients, especially those with higher tumor burden. Therefore, predisposing factors for hypercoagulability and vascular occlusion should be questioned in more detail even before starting antineoplastics which are known to have a lower risk for thrombosis, such as gemcitabine monotherapy.

Mutation Spectrum of ß-Thalassemia in Some Ethnic Groups of North Maharashtra, India.

Beta-thalassemia is the most common inherited single-gene disorder in the world, caused by more than 200 known mutations in the HBB gene. In India, the average prevalence of ß-thalassemia carriers is 3-4%. Several ethnic groups have a much higher prevalence, about 8% in the tribal groups, according to the 2011 census. The study's main goal is to identify common ß-thalassemia mutations and the frequencies of different haplotypes in various communities in North Maharashtra. Nashik district had the highest prevalence of ß-thalassemia (34%), followed by Ahmednagar (29%), Jalgaon (16%), Dhule (14%), and Nandurbar (7.0%). Prevalence of ß-thalassemia was highest in the schedule caste community (SC) (48%), followed by (17%) in Muslims, (14%) in other backward classes (OBC), (13%) in Schedule Tribe (ST), and (8.0%) in the general population The six most common ß-thalassemia mutations detected in this study are IVS 1 > 5 (G→C), Cd 15(G→A), Cd 41/41 (-TCTT), Cd 8/9(+G), IVS 1 > 1(G→T) and Cap + 1(A > G). Among these mutations, IVS 1 > 5 (G > C) was the most common type of mutation found in ß-thalassemia patients in the North Maharashtra population. Type-I haplotype was the most prevalent among all communities. Nashik and Ahmednagar districts were highly affected by ß-thalassemia. Among different ethnic groups, the SC and Muslim communities were the worst affected with a higher proportion of ß-thalassemia and increased frequency of mutations.

Retrograde Guidewire-Assisted Remodeling Technique: A Novel Technique for Endovascular Recanalization of Occluded Arterial Origins in Critical Limb Ischemia.

PURPOSE: The main objective of this study is to describe the retrograde guidewire-assisted remodeling technique (REGART), a novel technique, and assess its feasibility, safety, and effectiveness in the recanalization of ostial arterial occlusions without a visible stump in the critical limb ischemia (CLI). MATERIALS AND METHODS: A retrospective review of 387 patients who underwent endovascular treatment (EVT) for peripheral artery disease between January 2020 and June 2021 was performed. Among these, 23 patients (14 males [60.8%]) with a mean age of 64.2 (range: 55-72) years who underwent REGART were included. Patient demographics, procedural details, and outcomes were noted. RESULTS: The technical success rate was 95.6% (22/23). The angiographic success rate was 86.3% (19/22). The procedure-related complication rate was 21.7% (5/23), with 4 (17.4%) major complications and 1 (4.3%) minor complication. CONCLUSION: In the CLI, results of this trial suggest that REGART is feasible, effective, and with acceptable safety in the catheterization of occluded artery origins without a visible stump when conventional anterograde and retrograde techniques fail. Thus, the target occluded artery can be recanalized while preserving other arterial origins by minimizing dissection risk through subintimal balloon angioplasty at the bi-trifurcation level.

Antiapoptotic Effects of Hydroxychloroquine on Hypoxic-Ischemic Injury in Neonatal Rat Brain: May Hydroxychloroquine Be an Adjuvant Theraphy?

OBJECTIVE: Hydroxychloroquine (HCQ) has immunomodulatory, antithrombotic, cardiovascular, antimicrobial, and antineoplastic effects. In this study, we aimed to investigate the antiapoptotic and immunomodulator effects of intraperitoneal HCQ on hypoxic-ischemic (HI) injury in newborn rats. STUDY DESIGN: Wistar albino rats, 7 to 10 days old, were randomly divided into three groups: hypoxic-ischemic encephalopathy (HIE) group, HIE treated with HCQ group, and Sham group. Left common carotid artery ligation and hypoxia model were performed in HIE and HCQ groups. The HCQ group was treated with 80 mg/kg intraperitoneal HCQ every 24 hours for 3 days, while Sham and HIE groups were given physiological saline. After 72 hours, rats were decapitated and brain tissues were stained with hematoxylin and eosin, TUNEL, and IL-1ß for histopathological grading and neuronal cell injury. RESULTS: Neuronal apoptosis was statistically lower in all neuroanatomical areas in the HCQ group compared with the HIE group. IL-1ß-stained areas were similar in both HCQ and HIE groups but significantly higher compared with the Sham group. Histopathological grading scores were found to be lower in the HCQ group on the left parietal cortex and hippocampus region. CONCLUSION: In this study, we have shown for the first time that HCQ treatment decreased apoptosis in HI newborn rat model in both hemispheres. HCQ may be a promising adjuvant therapy in neonatal HIE. KEY POINTS: · HCQ decreased neuronal apoptosis in the ischemic penumbra of the rat brain.. · HCQ attenuates hypoxia-ischemia-induced brain injury in neonatal rats.. · HCQ has no anti-inflammatory effect on HI injury..

Comparison of clinical outcomes of autologous bone graft versus pronator quadratus pedicled vascularized bone graft in the treatment of scaphoid nonunion.

We aimed to compare the union rate and clinical outcome of autologous bone graft versus pronator quadratus vascularized pedicled muscle flap in treatment of scaphoid nonunion. Forty patients with a diagnosis of scaphoid nonunion who underwent unilateral pseudarthrosis surgery were included in this study. Notably, the scaphoid nonunion was unilateral, and the contralateral wrist was asymptomatic with normal function, per the physical and radiological examinations. Pronator quadratus vascularized pedicled muscle flap was used in 16 patients (group 1), and autologous bone graft was used in 24 patients (group 2). Patients were compared used Scapholunate angles, Natrass carpal height ratio and Mayo wrist score pre and postoperatively. Fifteen of the 16 (93.3%) patients in group 1 and 19 of the 24 (79.2%) patients in group 2 achieved bone union. Four of twelve patients in group 2 with avascular necrosis (AVN) and one of eight in group 1 with AVN were not able to achieve union. The group 2 (34%) had higher nonunion rate than group 1 (12%) in AVN patients. The scapholunat angle was significantly decreased and the Natress ratio was significantly increased postoperatively compared to the preoperative measurement in both group. There was no statistically significant difference in the postoperative measurement. The postoperative Mayo wrist score showed no statistically significant differences between both groups. The pronator quadratus vascularized pedicled muscle flap was superior to non-vascularized bone grafting in the treatment of scaphoid nonunion with AVN. However, management of the patients without avascular necrosis is not requiring the vascularized pedicled muscle flap technique.

Measuring the Optic Nerve Sheath Diameter with Ultrasound in Acute Middle Cerebral Artery Stroke Patients.

BACKGROUND: Measurement of the optic nerve sheath diameter (ONSD) with ultrasound enables non-invasive and indirect assessment of increased intracranial pressure (ICP). Although most of the studies were employed with traumatic brain injury patients, it's increasingly popular in acute ischemic stroke (AIS) studies. OBJECTIVES: Evaluating whether using ONSD as a follow-up measurement would help monitor the thrombolytic therapy (TT) effectiveness and determine the high-risk patients for malignant middle cerebral artery (MCA) syndrome. METHODS: This prospective observational study was conducted between August 1, 2019, and February 1, 2020, in a tertiary hospital. Forty-four patients were eligible. We determined the TT moment as the time when the first ocular ultrasound measurement would be made (time 0). Also, we decided on the 24th h after the treatment as the time to perform the second ocular ultrasound measurement (time 24). The National Institute of Health Stroke Scale (NIHSS), the Glasgow Coma Scale (GCS), and the Alberta Stroke Program Early Computed Tomography (ASPECT) scores were evaluated blindly at the time-0 and the time-24. The cut-off value of ONSD was 0.55 mm. RESULTS: There was no difference in ONSD results before and after the TT (p = 0.414). But, patients with an equal or higher value than cut-off had an increased risk for complications such as malignant-MCA, bleeding, seizure, etc. (p = 0.05). Malignant-MCA was observed in four patients with higher ONSD values. At the time-24, NIHSS decreased, GCS and ASPECT scores increased. Finally, ONSD was positively correlated with the NIHSS and negatively correlated with the GCS at the time-24. CONCLUSIONS: Monitoring ONSD values in both the emergency department and the intensive care unit may be useful in the early diagnosis of MCA stroke complications and the follow-up of TT's effectiveness.

A new predictor of bleeding based on ultrasonographic features in percutaneous liver mass biopsy

Background/aim: An ultrasound-guided liver mass biopsy is a method frequently used in determining the diagnosis and treatment plan.The aim of this study was to evaluate the potential new predictors of bleedingbased on ultrasonographic features in liver mass biopsies, which are frequently applied in routine clinical practice. Materials and methods: The images and data of patients aged over 18years,who underwent an imaging-guided percutaneous liver mass biopsy between January 2018 and December 2019 with various indications, were retrospectively reviewed. Liver size, liver steatosis status, parenchyma appearance, and mass vascularity on Doppler ultrasonography before the procedure, and hemoglobin (Hb) values before and after the procedure were recorded. Results: A total of 176 patients were included in the study. Ninety-six patients were male (54.5%) and 80 were female (45.5%). The mean age of the patients was 64 ± 12.3 years. The mean hemoglobin values of the patients were 11.5 ± 1.9 gr/dL before the procedure and 11.4 ± 1.5 gr/dL after the procedure. While 144 of the patients had less than 10% hemoglobin decrease (81.8%), 32 had more than 10% decrease (8.2%). In 56 patients, a heterogeneous and coarse granular pattern was observed in the liver parenchyma (31.8%). The decrease in the Hb rate was significantly higher in patients with heterogeneous and coarse granular liver parenchyma (8.7%) than in patients with normal parenchyma (6.6%) (P = 0.036). Conclusion: In our study, it was shown for the first time in the literature that the ultrasonographic appearance of the liver (heterogeneous and coarse granular parenchyma) may also be one of the parameters that can help to predict the risk of bleeding.

Doppler ultrasonography criteria of superior mesenteric artery stenosis.

PURPOSE: The techniques mostly used for the diagnosis of superior mesenteric artery (SMA) stenosis are computed tomography angiography (CTA), and magnetic resonance angiography. We aimed to evaluate color-coded Doppler Ultrasonography (CDUS) for the detection of SMA stenoses and to determine Doppler criteria. METHODS: We identified retrospectively 65 patients with CTA images of SMA stenosis and examined them with CDUS for the Doppler measurement of SMA peak systolic flow velocity (PSV), end-diastolic velocity (EDV), and mesenterico-aortic ratio (MAR). Results were analyzed with receiver-operating characteristic curve analysis. RESULTS: The optimal threshold values for determining 50%-69% SMA stenoses were PSV >280 cm/s, EDV >45 cm/s, and MAR >3.6. For identifying 70%-99% SMA stenoses, they were PSV >395 cm/s, EDV >74 cm/s, and MAR >3.6. CONCLUSION: CDUS is a convenient method with high accuracy for identifying SMA stenosis. PSV yielded better results than EDV and MAR.

A Case of Familial Hemophagocytic Lymphohistiocytosis Type 4 With Involvement of the Central Nervous System Complicated With Infarct.

BACKGROUND: Familial hemophagocytic lymphohistiocytosis (HLH) is a fatal disease affecting infants and very young children. Central nervous system involvement of HLH can cause catastrophic results. METHOD: We present a case with cranial involvement of familial HLH type 4 who showed diffuse infiltration of white matter complicated with intracranial thrombosis. A 5-year-old girl from a consanguineous couple presented with fever and pancytopenia, and was referred to our hematology unit. Examination revealed fever, lymphadenopathy, and hepatosplenomegaly. Ultrasound examination revealed hepatosplenomegaly and free intra-abdominal fluid. HLH was revealed on bone marrow aspiration biopsy. Defective natural killer and T lymphocyte cytotoxicity using degranulation tests was determined. In the genetic analysis, syntaxin gene mutation was found. On T2-weighted and T2-fluid-attenuated inversion recovery magnetic resonance imaging (MRI), diffuse hyperintense signal changes of cerebral white matter, indicating white matter demyelination, were observed. A second brain MRI showed an acute infarct involving the left temporooccipital region. Immunosuppressive therapy according to the HLH 2004 protocol was started. The infarct resolved but white matter lesions were stable on the brain MRI that was performed 1 month later. Brain MRI taken 4 months after the first examination showed stable cerebral white matter lesions, but hyperintense signal changes appeared in the cerebellar white matter and were regarded as progression. The patient died because of infection despite immunosuppressive therapy. CONCLUSIONS: Physicians managing patients with HLH must be vigilant about the possibility of central nervous system involvement including stroke.

Successful Treatment of Classic Kaposi Sarcoma With Long-Pulse Neodymium-Doped Yttrium Aluminum Garnet Laser: A Preliminary Study.

BACKGROUND: Kaposi sarcoma (KS) is a systemic disease that can present with cutaneous lesions with or without internal involvement, mostly caused by infection with human herpesvirus-8. The treatment options include surgical excision, cryotherapy, radiotherapy, intralesional chemotherapy, laser, and elastic stockings for the prevention of lymphedema. OBJECTIVE: This article presents 7 cases with classic KS treated with the long-pulse neodymium:yttrium-aluminum-garnet (Nd:YAG) laser. METHODS: Forty-nine lesions of 7 KS patients (5 stage 1, 2 stage 2A) were treated with Nd:YAG laser with a spot size of 4 to 6 mm and a fluence of 180 J/cm increased by 10 J/cm in the neighboring area to a maximum of 260 J/cm. The pulse sequencing was 1.5, and delay time was 5 milliseconds. Sessions were continued at 4-week intervals for 2 to 4 sessions. RESULTS: All patients exhibited clinical and histological improvement. One session was sufficient for small lesions, whereas coalescing and multicentric lesions required up to 4 sessions. All the lesions healed in 2 to 4 weeks, with the only complication being mild atrophic scars. CONCLUSION: With the advantage of penetrating into deeper sites than other lasers, long-pulse Nd:YAG is an efficient and safe local treatment alternative especially for papulonodular and deeper lesions located on bony structures.

A split-face, investigator-blinded comparative study on the efficacy and safety of Q-switched Nd:YAG laser plus microneedling with vitamin C versus Q-switched Nd:YAG laser for the treatment of recalcitrant melasma.

BACKGROUND: High recurrence has previously been reported in the treatment of melasma with low-fluence 1,064-nm Q-switched neodymium-doped yttrium aluminium garnet (QS-Nd:YAG) laser. On the other hand, the efficacy and safety of the QS-Nd:YAG laser plus microneedling with vitamin C have not been evaluated in patients with mixed-type melasma. MATERIAL AND METHODS: Sixteen patients with recalcitrant dermal- or mixed-type melasma were included in the study. One side of patients' face was treated with QS-Nd:YAG laser plus microneedling with vitamin C (Group A) and the other side with QS-Nd:YAG laser alone (Group B) for four sessions at four-week intervals. Melasma Area Severity Index (MASI) scores and clinician's evaluation of clinical response were assessed monthly. RESULTS: Group A had a significantly lower mean MASI score and better treatment response than Group B according to clinician's evaluation. According to MASI scores, in Group B, two patients had a good response while 12 were unresponsive to treatment. Good or very good improvement was reported by 10 patients in Group A and three patients in Group B. Adverse effects and recurrence rates were similar in Groups A and B (31.3 and 43.8%, respectively). DISCUSSION: QS-Nd:YAG increases the blood circulation in the dermis, thereby enhancing the mechanical effect of microneedling to promote the penetration of vitamin C. CONCLUSION: Vitamin C application with microneedling immediately after treatment with QS-Nd:YAG laser is a promising adjunctive method for the treatment of recalcitrant melasma.

Erbium:yttrium aluminum garnet laser versus Q-switched neodymium:yttrium aluminum garnet laser for the treatment of xanthelasma palpebrarum.

BACKGROUND: Several lasers have been used for the treatment of xanthelasma palpebrarum (XP), such as Q-switched neodymium:yttrium aluminum garnet (QSNd:YAG) and erbium:yttrium aluminum garnet (Er:YAG) laser. Up to now, a comparative study among these laser options in the treatment of XP has not been reported. OBJECTIVE: The aim of this study was to compare the clinical efficacy and response rates of QSNd:YAG and Er:YAG in the treatment of XP. METHODS: Sixty patients with a total of 102 XP lesions were randomly and equally divided into two groups. The first group was treated with QSNd:YAG at a fluence of 10 joule/cm2, 10 Hz and 2 mm spot size, and the second group was treated with Er:YAG at 200-300 millijoule, 4 Hz and 2 mm spot size. RESULTS: In the Er:YAG group, the percentage of patients who required 3 or 4 sessions and wound healing time were higher compared to those of the QSNd:YAG group. Furthermore, the percentage of patients who had an improvement score of 4 was higher in the Er:YAG than that in the QSNd:YAG group. CONCLUSION: Er:YAG is an efficient, successful and minimally invasive method without long-lasting adverse effects.

Salicylic acid peeling combined with vitamin C mesotherapy versus salicylic acid peeling alone in the treatment of mixed type melasma: A comparative study.

INTRODUCTION: Melasma is a distressing condition for both dermatologists and patients. We evaluated the effectiveness of salicylic acid (SA) peel and vitamin C mesotherapy in the treatment of melasma. MATERIALS AND METHODS: Fifty female patients were divided into two groups. All patients were treated with 30% SA peel every two weeks for two months. In addition, after SA peeling Group A was intradermally administered 10 vitamin C on the melasma lesion at 1-cm intervals. All patients were followed up for 6 months, during which the recurrence rates were evaluated. Digital photographs of the melasma site were taken and patients' Melasma Area and Severity Index (MASI) scores were assessed. After the treatment, the patients were asked to complete the melasma quality of life questionnaire (MelasQoL) to evaluate their satisfaction with the treatment. All the adverse effects were noted. RESULTS: The MelasQoL and MASI scores of patients in both groups significantly decreased after the treatment. Apart from a burning sensation, no adverse event was observed and all patients tolerated the treatment well. DISCUSSION: SA peel combined with vitamin C mesotherapy is a safe and effective alternative for the treatment of melasma with no significant side effects and minimal downtime.

Bilateral Half-Head Comparison of 1% Anthralin Ointment in Children with Alopecia Areata.

BACKGROUND/OBJECTIVES: Alopecia areata (AA) is one of the most difficult skin diseases to manage well. In children, anthralin is commonly used for the treatment of AA. Available research consists of a limited number of uncontrolled trials that assessed the effectiveness of anthralin in promoting hair growth in patients with AA. The objective of this study was to validate the clinical effectiveness of short-contact anthralin 1% ointment in children with AA. METHODS: Thirty children with chronic, severe, treatment-refractory, extensive AA were treated with 1% anthralin ointment. One side of the scalp was treated with anthralin for 12 months and the other side was left untreated. Outcomes were evaluated according to the Severity of Alopecia Tool (SALT) score. RESULTS: The mean time to first response in terms of new hair growth was 3 months and the mean time to maximal response was 9 months. In the first 12-month period, 10 patients (33.4%) achieved complete response to treatment and 11 patients (36.6%) had a partial response. Of the 11 patients with partial response at the end of the first year, 6 achieved a complete response before the end of the study. Total SALT scores for the entire scalp decreased from the end of the first year to the end of the 2-year period. No serious adverse events were observed. CONCLUSION: Anthralin 1% is an effective therapy for AA and should be continued at least 9 months. At 9 months of topical anthralin therapy, the patients with at least a 50% reduction in their pretreatment SALT scores should continue the same treatment for at least 1 year. Anthralin is safe in children with chronic, severe, treatment-refractory, extensive AA.

Efficacy and safety of mascara dyeing as an adjunct to Alexandrite and Nd:YAG laser applications for removing thin and white-colored facial and axillary hair.

INTRODUCTION: There is no satisfactory and efficient method for long-term removal of white-colored and thin hair. METHODS: We conducted a randomised clinical trial of hirsute patients with excessive white and/or thin hair on the face and/or axilla. In Group I (n: 16), the facial hair on one side of the face was painted with a black eyelash mascara immediately before Nd:YAG laser and the other half was only treated by Nd:YAG. In Group II (n: 20), the axillary hair on one side was painted with the mascara before the Alexandrite laser with the other side being only treated by Alexandrite. RESULTS: The terminal hair counts on the painted facial and axillary sides were significantly lower than those on the control sides throughout the study except for the first month. The decrease in the terminal hair count was significant from the beginning of treatment to the second and sixth months on the painted and control facial sides and to the first and sixth months on the axillary sides. CONCLUSION: Hair coloring with black eyelash mascara is a simple, efficient and safe adjunct to Alexandrite and Nd:YAG laser applications to enhance their clinical efficacy in eliminating white and thin facial or axillary hair.

Aneurysm rupture from blunt abdominal trauma after endovascular repair.

We present a case of aneurysm rupture from severe blunt abdominal trauma due to fight in a patient who had endovascular aneurysm repair. The patient presented to the emergency service with computed tomography evidence of an endoleak and a large retroperitoneal hematoma. The contrast abdominal computed tomography demonstrated a type Ib endoleak, increase in the aneurysm diameter and hematoma in the retroperitoneum. The patient has been taken under interventional procedure for endovascular aneurysm repair revision under urgent condition. Type Ib endoleak was treated by placement of a covered iliac extension limb, but a second leakage from graft body was found in control computed tomography images and open surgical conversion was necessary. Operative findings included a type III endoleak from graft body, defect on fabric. It was seen that the aneurysm sac anterior and posterior parts were ruptured. Upon reviewing the literature, we found that it was an interesting case as the first rupture case which had been developed after severe blunt abdominal trauma during the follow-up period of a patient on which endovascular aneurysm repair procedure had been performed and progressed in this manner.

Spontaneous Epidural Pneumocephalus.

Spontaneous epidural pneumocephalus is a rare condition. The authors reported a 35-year-old male patient with tinnutus, dull headache, and swelling on his head. Patient had a history of head trauma and skull fracture from when he was 5 years old. Cranial computed tomography revealed increase in pneumatization of right mastoid air cells and large epidural air in temporoparietal region. Inner table of right temporal bone got thinner, causing communication of mastoid air cells with epidural space. Epidural air had septations and exerted mass effect on the right parietal lobe with minimal midline shift. Thinning of also right parietal bone caused extension of epidural air into the right parietal subcutaneous tissue and hence subcutaneous swelling. There was no obvious fracture line. Spontaneous epidural pneumocephalus is extremely rare condition that may cause severe complications. There are several etiologic factors. Head trauma can be the eliciting factor in the authors' patient. It is important to be familiar with its presentation and imaging findings to make early diagnosis and treatment.