A 52-Year-Old Man With Progressive Weakness and Incontinence.

Here we report a challenging case of a 52-year-old man presenting with subacute constipation, urinary retention, impotence, absent Achilles reflexes, and hypoesthesia in S2-S5 dermatomes. We review the clinical decision-making as the symptoms evolved and diagnostic testing changed over time. Once the diagnosis is settled, we discuss the sign and symptoms, additional diagnostic tools, treatment options and prognosis.

Staging of hip avascular necrosis: is there a need for DWI?

BACKGROUND: No comprehensive study has been performed to stage avascular necrosis of the hip using diffusion-weighted imaging (DWI). PURPOSE: To determine apparent diffusion co-efficient (ADC) alterations in hip avascular necrosis (AVN) and to determine variations of ADC values according to stages of disease. MATERIAL AND METHODS: The study is approved by our institutional review board and local ethical committee. Written informed consent was present for each subject. Thirty-five femoral heads of 21 cases affected by AVN were included in the study. Control group consisted of both femoral heads of 10 healthy volunteers. The hips affected by AVN were staged according to Ficat and Arlet classification system from I to IV. All cases underwent to routine hip magnetic resonance imaging (MRI) and DWI performed with a single-shot fast spin echo sequence at a b value of 600 s/mm(2). The ADC values were calculated automatically by placing ROIs on AVN lesions in affected patients and both femoral heads of control group. The median ADC value obtained from femoral heads of control group and that from AVN lesions were compared by Mann-Whitney U test. The median ADC values of AVN lesions at different stages were compared by Kruskal-Wallis test. RESULTS: The median ADC value of normal bone measured in control group was 185.5 ± 133.2 x 10(-6) mm(2)/s. The median ADC value measured in hip avascular necrosis lesions was 988.0 ± 332.7 x 10(-6) mm(2)/s. ADC values in hip AVN lesions were statistically significantly higher than normal bone marrow (P<0.01). The median ADC values of hips with avascular necrosis at stage I, II, III, IV were 817.5 ± 172.1 x 10(-6) mm(2)/s, 902.0 ± 181.0 x 10(-6) mm(2)/s, 1200.0 ± 363.2 x 10(-6) mm(2)/s and 1024.0 ± 324.0 x 10(-6) mm(2)/s, respectively. There was no statistically significant difference among AVN lesions at stages I, II, III and IV (P>0.05). CONCLUSION: Although DWI is a promising imaging tool that provides valuable diagnostic information in hip AVN, it fails to distinguish between different stages, and therefore is of limited value.

In-bore MRI-guided prostate biopsy in a patient group with PI-RADS 4 and 5 targets: A single center experience.

PURPOSE: To determine the diagnostic yield of magnetic resonance imaging (MRI) guided in-bore biopsy in patients with high likelihood multiparametric MRI (mpMRI) findings, regarding overall and clinically significant prostate cancer (csPCa) detection rates and concordance of biopsy and radical prostatectomy (RP) Gleason scores (GS). METHODS: This retrospective study consisted of 277 Prostate Imaging Reporting and Data System (PI-RADS) assessment category 4 and 5 targets in 246 patients (mean age, 65.7 years; median prostate specific antigen value, 7.75 ng/mL) who had undergone in-bore biopsy at our institution between 2012 and 2020. Eighty-one patients who underwent RP were eligible for the concordance analysis of biopsy and RP specimen GS. RESULTS: Overall PCa detection rates were 80.5 % per patient (198/246) and 78 % per target (216/277) and 83.5 % and 67.4 % in primary (biopsy naive) and secondary (at least one negative prior biopsy) settings. csPCa was found in 63 % overall, 66 % of patients (132/200) in the primary, and 50 % of patients (23/46) in the secondary biopsy settings (p < 0.001). The prostate cancer detection rate was 68 % and 92 % in PI-RADS 4 and 5, respectively (p < 0.001). In the radical prostatectomy subcohort, 27.2 % of patients were upgraded, 8.6 % of patients were downgraded from needle biopsy. Significant complications occurred in 1.2 % of patients. CONCLUSIONS: MRI-guided in-bore prostate biopsy has a high detection rate of csPCa in primary and secondary biopsy cohorts. Biopsy results were satisfactory in terms of the number of positive cores, cancer percentage in positive cores, and concordance of GS in needle biopsy and RP specimen.

[Transcatheter aortic valve implantation: the first applications and early results in Turkey]. / Transkateter aort kapak yerlestirme: Türkiye'deki ilk uygulamalar ve erken sonuçlar.

OBJECTIVES: The objective of this study was to evaluate the first applications and results of transcatheter aortic valve implantation (TAVI) in Turkey, which is a new technology for the treatment of aortic valve stenosis. STUDY DESIGN: We performed TAVI in eight severely symptomatic patients (5 women, 3 men; mean age 81.6 ± 6.7 years; range 71 to 95 years) between May 1 and December 31, 2009. All the patients had severe aortic stenosis (mean valve area 0.6 cm², systolic peak/mean gradients 80.5 ± 22.1/50.0 ± 16.1 mmHg). Two patients had severe coronary artery disease that required intervention during TAVI. All the patients presented a high surgical risk (EuroSCORE 31.1 ± 9.8 and STS score 12.8 ± 7.9). The Edwards Sapien bioprosthetic valve was implanted through the transfemoral approach in seven patients, and transapical approach in one patient. RESULTS: All prosthetic valves were of appropriate size, were implanted in appropriate locations, and functioned perfectly. Two patients with severe coronary stenosis underwent successful simultaneous percutaneous coronary intervention before TAVI. Following TAVI, the mean aortic valve area increased to 1.5 ± 0.1 cm² (p < 0.01), and systolic/mean gradients decreased to 27.6 ± 9.6/14.6 ± 5.8 mmHg (p < 0.01). One patient underwent permanent pacemaker implantation due to persistent atrioventricular block, and two patients had transient atrioventricular block. Two patients died; one on the first day following transapical implantation, and the other after six months of implantation. The mean NYHA functional class decreased from preoperative 3.8 ± 0.3, to 1.1 ± 0.3 after a mean follow-up of 3.5 ± 2.5 months (range 1 to 8 months) (p < 0.01). CONCLUSION: Early results of TAVI are successful in patients with inoperable aortic valve stenosis due to high surgical risk. The results of randomized studies with longer follow-up will clarify widespread use of this technique.

Accuracy of Sampling PI-RADS 4-5 Index Lesions Alone by MRI-guided In-bore Biopsy in Biopsy-naive Patients Undergoing Radical Prostatectomy.

BACKGROUND: Targeting multiparametric magnetic resonance imaging (MP-MRI)-suspicious regions alone in biopsy-naive patients is not common practice, since it may miss clinically significant prostate cancer (PCa). OBJECTIVE: To investigate the accuracy of in-bore MRI-guided biopsy of Prostate Imaging Reporting and Data System (PI-RADS) 4 and 5 index lesions alone in biopsy-naive patients undergoing radical prostatectomy (RP). DESIGN, SETTING, AND PARTICIPANTS: A total of 170 patients underwent MRI-guided in-bore biopsy for PI-RADS 4 and 5 index lesions alone between 2013 and 2018, of whom 136 patients were diagnosed with PCa. Fifty-two patients without prior biopsy who underwent RP were included in this study. MP-MRI findings, biopsy results, and whole-mount step-section specimen evaluation were retrospectively analyzed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Continuous variables were reported as mean (standard deviation) or median (range). Differences in parametric variables were calculated by Student t test. RESULTS AND LIMITATIONS: Overall International Society of Urological Pathology grade group (GG) up- and downgrading rates were 23.0% and 7.6% per patient and 24.5% and 6.5% per focus, respectively. Ten of 12 biopsy-detected GG 1 foci were upgraded in the final pathology. In 30 patients, a total of 43 different tumor foci were identified outside the sampled index lesion. Average biopsied and nonbiopsied tumor volumes were found to be 2.02 and 0.45 cm³, respectively (p < 0.001). The index lesion was the largest focus of tumor in all patients' final histopathological examination; upgrading was identified in only one nonbiopsied focus in a single patient. Limitations include retrospective design and nonstandard indications of in-bore MRI biopsy. CONCLUSIONS: In-bore MRI-guided biopsy of PI-RADS 4-5 index lesions alone in biopsy-naive patients is a safe and accurate diagnostic modality allowing appropriate patient selection for individualized treatment. PATIENT SUMMARY: In-bore magnetic resonance imaging-guided prostate biopsy of suspicious lesions alone allows accurate risk stratification of patients and reduces the detection of insignificant prostate cancer.

Crossing Y-Solitaire thrombectomy as a rescue treatment for refractory acute occlusions of the middle cerebral artery.

BACKGROUND: Mechanical thrombectomy using a stent retriever has become the standard of care for acute large-vessel occlusions in the anterior circulation. Clots that are refractory to single stent retriever thrombectomy remain a challenge for neurointerventionalists. OBJECTIVE: To assess the efficacy and safety of double stent retriever (crossing Y-Solitaire) thrombectomy as a rescue treatment for acute middle cerebral artery (MCA) occlusions that are refractory to single stent retriever thrombectomy. METHODS: We retrospectively reviewed the databases of our hospitals to identify patients who presented with an acute MCA occlusion and were treated with crossing Y-Solitaire thrombectomy. The angiographic (Thrombolysis in Cerebral Infarction (TICI) scale) and clinical outcomes (National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) scores) and complications were assessed. RESULTS: Ten patients were included in the study. The median initial NIHSS score and Alberta Stroke Program Early CT Score (ASPECTS) were 19.0 and 9.6, respectively. Crossing Y-Solitaire thrombectomy was performed as a rescue technique after unsuccessful single Solitaire thrombectomy passes in all cases. Successful recanalization (TICI 2b/3) was achieved in 8 (80%) patients. We observed asymptomatic reperfusion hemorrhages in 2 (20%) patients. No procedural related complications were seen other than reversible vasospasms in 5 (50%) patients. Sixty percent of the patients had a mRS score of between 2 and 0 at 90 days after the procedure. There was no mortality. CONCLUSION: Crossing Y-Solitaire thrombectomy seems to be an effective and safe alternative rescue technique to treat refractory MCA bifurcation occlusions that are refractory to standard thrombectomy procedures.

The value of diffusion-weighted imaging in the diagnosis of Marchiafava-Bignami disease: apropos of a case.

Marchiafava-Bignami disease (MBD) is characterized by demyelination and necrosis of corpus callosum encountered in chronic alcoholic patients. Etiology is the deficiency of vitamin B complex. Magnetic resonance imaging (MRI) in MBD typically reveals focal lesions of high T2 and FLAIR signal intensity in the corpus callosum. We here present a 42-year-old male alcoholic diagnosed as MBD on the basis of MRI and diffusion-weighted imaging (DWI) features. The patient totally recovered following appropriate vitamin B complex replacement therapy, despite reduced diffusion in the initial setting. This case report emphasizes on the important role played by MRI and DWI in the early diagnosis and follow-up of this potentially fatal disease.

Diffusion-weighted imaging of the appendicular skeleton with a non-Carr-Purcell-Meiboom-Gill single-shot fast spin-echo sequence.

OBJECTIVE: The objective of our study was to prospectively evaluate the signal-to-noise ratio (SNR) improvement in diffusion-weighted imaging (DWI) of the appendicular skeleton with the use of a newly developed non-Carr-Purcell-Meiboom-Gill (non-CPMG) single-shot fast spin-echo (SSFSE) sequence and to evaluate its effect on apparent diffusion coefficient (ADC) measurements. SUBJECTS AND METHODS: DWI of the bone was performed in 32 patients with an echo-planar imaging (EPI)-based sequence followed by a non-CPMG SSFSE technique. SNR and ADC values were measured over a lesion-free right femoral head. A score was assigned for each set of images to assess image quality. When a bone lesion was present, contrast-to-noise ratio (CNR) and ADC were also measured. Paired Student's t tests were used for statistical analysis. RESULTS: The mean (+/- SD) SNR values were 9.89 +/- 2.20 and 81.68 +/- 4.87 for EPI and non-CPMG SSFSE DWI, respectively. SNR values associated with the non-CPMG SSFSE technique were found to be significantly higher than those measured with the EPI-based DWI technique (p < 0.01). Mean ADCs of the bone were 0.57 +/- 0.20 and 0.29 +/- 0.15 x 10(-3) mm2/s, respectively, for EPI and non-CPMG SSFSE DWI. Image quality scores were higher for the non-CPMG SSFSE DWI technique (p < 0.05) than for the EPI-based DWI technique. Overall lesion CNR was found to be higher in DWI performed with the non-CPMG SSFSE technique. CONCLUSION: The non-CPMG SSFSE technique provides a significant improvement over the currently used EPI-based DWI technique and has the potential to be a powerful tool in imaging the appendicular skeleton.

Evaluation of Peripheral Zone Prostate Cancer Aggressiveness Using the Ratio of Diffusion Tensor Imaging Measures.

Purpose: To evaluate the aggressiveness of peripheral zone prostate cancer by correlating the Gleason score (GS) with the ratio of the diffusion tensor imaging (DTI) measures. Materials and Methods: Forty-two peripheral zone prostate tumors were imaged using DTI. Regions of interest focusing on the center of tumor foci and noncancerous tissue were used to extract statistical measures of mean diffusivity (MD) and fractional anisotroy (FA). Measure ratio was calculated by dividing tumor measure by noncancerous tissue measure. Results: Strong correlations are observable between GS and MD measures while weak correlations are present between GS and FA measures. Minimum tumor MD (MDmin) and the ratio of minimum MD (rMDmin) show the same highest correlation with GS (both ρ = -0.73). Between GS ≤ 7 (3 + 4) and GS ≥ 7 (4 + 3), differences are significant for all MD measures but for some FA measures. MD measures perform better than FA measures in discriminating GS ≥ 7 (4 + 3). Conclusion: Ratios of MD measures can be used in evaluation of peripheral zone prostate cancer aggressiveness; however tumor MD measures alone perform similarly.

Spontaneous thrombosis of a traumatic posterior cerebral artery aneurysm in a child.

Traumatic posterior circulation aneurysms are rare, especially in children. They are typically associated with severe trauma and are thought to result from either direct osseous injury or stretching or compression of an artery against the tentorium. They may grow, rupture, or both. Although spontaneous thrombosis may occur, it rarely results in complete occlusion. We report the spontaneous and complete thrombosis of a large posterior cerebral artery aneurysm in a child who presented after minor head trauma. Five-year follow-up documents the complete occlusion of the aneurysm.

Self-expandable stent-assisted coiling of wide-necked intracranial aneurysms: a single-center experience.

BACKGROUND AND PURPOSE: Endovascular treatment of wide-necked aneurysms remains a therapeutic challenge. We conducted this study to evaluate the angiographic results and clinical outcome of patients treated with stent-assisted coiling by using a recently available self-expandable intracranial stent. METHODS: A retrospective review of all patients treated with self-expandable stent-assisted coiling between September 2002 and December 2003 was done. Treatment was attempted in 32 patients with 35 aneurysms. Four of the aneurysms were ruptured. All had either a dome-to-neck ratio less than 2 and/or a neck diameter of 5 mm or larger. Following stent placement, coiling was attempted in 33 of 34 aneurysms. The technical success of the procedure, procedure related complications, and the angiographic results were documented. RESULTS: In 34 of 35 aneurysms, stent deployment across the neck of the aneurysm was successful. Coiling was performed successfully in 30 of 33 aneurysms. In 20 aneurysms, immediate posttreatment angiography showed either total (17%) or satisfactory (50%) occlusion. Procedure-related mortality occurred in one patient (3.1%). Adverse events occurred in eight patients (25%); in three of them permanent neurologic deficit resulted (9.3%). In six patients, thrombus formation occurred within the stented segments during the procedure and reopro infusion was used. Follow-up angiography was available in 12 (40%) of 30 treated aneurysms. CONCLUSION: In our practice use of the self-expandable stent seemed to facilitate endovascular treatment of wide-necked intracranial aneurysms. Difficulty of deployment and stent thrombogenicity are the main drawbacks of the system.

Three-dimensional imaging and cone beam volume CT in C-arm angiography with flat panel detector.

We evaluated a new 3D angiography system with a flat panel detector (FPD) for its capabilitiy to acquire volume sets during a single rotation scan and to reconstruct high spatial resolution three-dimensional and cross sectional images, namely cone beam volume computed tomography (CBVCT) images. Present status of the technique, advantages and potential applications are discussed.

Endovascular treatment of peripheral vascular lesions with stent-grafts.

PURPOSE: To evaluate our results of stent-graft implantation for the endovascular treatment of peripheral vascular lesions. MATERIALS AND METHODS: Seventeen patients underwent repair of iatrogenic, traumatic, or spontaneous vascular lesions by means of endovascular stent-grafts. The study cases consisted of 10 cardiac catheterization-induced femoral arteriovenous fistulas (AVFs) located between the deep femoral artery and the femoral vein, one iatrogenic AVF between the common iliac artery and vein, one penetrating trauma-induced AVF between the superficial femoral artery and vein, two penetrating trauma-induced pseudoaneurysms in the axillary and popliteal arteries, and three spontaneous or atherosclerosis- related iliac artery aneurysms. Balloon-expandable or self-expandable stent-grafts were used in all 17 cases. RESULTS: All the stent-grafts were deployed successfully. In catheterization-induced femoral AVFs, complete closure of the fistulas was immediately accomplished in 9 of the 10 cases. Blood flow within the pseudoaneurysms of the axillary artery and the popliteal artery, and aneurysms of the iliac arteries were stopped. Partial closure was achieved in two patients with traumatic iliac and femoral AVFs. For the patients who reported subsided complaints, mean follow-up for 24 months with clinical examination and color Doppler ultrasound revealed patency of the stented segments. CONCLUSION: Our results suggest that endovascular treatment of various types of peripheral vascular lesions with stent-grafts is a low-risk procedure, which appears to be less invasive than surgery.

Simple bone cyst in spinous process of the c4 vertebra.

Simple bone cysts are common, benign, fluid-filled, cystic lesions that occur mostly in the metaphysis of the long bones and are rarely found in vertebrae. A case of a simple bone cyst in the spinous process of the fourth cervical vertebra in a 26-year-old woman is reported. According to the radiologic findings, the lesion was identified as a simple bone cyst, and the diagnosis was verified by surgical and histopathologic examinations.

A technique for improved quantitative characterization of intracranial aneurysms.

3D digital subtraction angiograms of two intracranial aneurysms were imported to a workstation for reconstruction and postprocessing into a format allowing delineation of 1) the extent to which the diameter of the parent artery is incorporated into the aneurysm ostium (percentage of parent artery involvement or neck angle) and 2) the aneurysm volume and surface area. For clear visualization, 3D surface-rendered objects of the reconstructed artery, neck angle, and aneurysm were created.

Moyamoya disease presented with migrainelike headache in a 4-year-old girl.

A 4-year-old girl was admitted to our department with the complaints of severe headache, nausea, vomiting, and photophobia. She had a 1-year history of migrainelike headache that occurred every 1 to 2 months. Her neurologic examination was normal, but T-weighted axial magnetic resonance imaging (MRI) of the brain showed flow void within the basal ganglia owing to parenchymal vascular collaterals. Magnetic resonance angiography and digital substraction carotid angiography showed both occlusion of the internal carotid artery in the supraclinoid portion and extensive parenchymal vascular collaterals. Because there was no evidence of risk factors for cerebral arterial occlusion and cerebral infarct or hemorrhage, she was diagnosed as having moyamoya disease. In any case of atypical migrainelike headache, a detailed investigation should be kept in mind to detect an underlying vascular disease such as moyamoya.

Endovascular stent-graft placement for the management of a traumatic axillary artery pseudoaneurysm-a case report.

A 24-year-old woman with a right infraclavicular gunshot wound developed an axillary artery pseudoaneurysm. She was successfully treated by using a 5 cm Hemobahn stent-graft with a diameter of 6 mm. Postimplantation arteriography revealed normal flow through the axillary artery without evidence of leakage of contrast medium. Five months after the procedure, stenoses developed within the stent-graft owing to intimal hyperplasia and were treated by balloon angioplasty. The patient has been followed up symptom-free for 6 months after the second procedure.

Assessment of t2-weighted coronal magnetic resonance images in the investigation of pituitary lesions.

Magnetic resonance imaging is the most important diagnostic method in the investigation of the pituitary lesions. Our aim is to determine whether T2-weighted coronal images may be helpful in the evaluation of the pituitary gland with suspected pituitary adenomas. One hundred and sixty-seven patients were examined prospectively with T2-weighted coronal and T1-weighted coronal images enhanced with intravenous contrast material. The images were evaluated for the presence, the size, the location, and the ancillary signs including sellar floor erosion or ballooning, infindibulary deviation, convexity of the superior border of the gland, diffuse enlargement of the gland, and the invasion of the cavenous sinuses on both images. In forty-six (28%) patients lesions were revealed on both sequences. In twenty-one (12%) patients the lesions that were revealed on the T1-weighted images were not detected on the T2-weighted images. Positive predictive value, negative predictive value, sensitivity, specificity, and diagnostic accuracy rates of T2-weighted coronal images on the detection of the presence of lesions were 100%, 17.4%, 68.7%, 100%, and 87.4%, respectively. Both T2-weighted coronal and T1-weighted coronal images enhanced with intravenous gadolinium-based contrast material are important in the diagnosis of pituitary adenomas. T2-weighted coronal images could be used as a screening tool for the primary evaluation of the pituitary gland.

Conspicuity of peripheral zone prostate cancer on computed diffusion-weighted imaging: comparison of cDWI1500, cDWI2000, and cDWI3000.

INTRODUCTION AND OBJECTIVE: Disadvantages associated with direct high b-value measurements may be avoided with use of computed diffusion-weighted imaging (cDWI). The purpose of this study is to assess the diagnostic performance of cDWI image sets calculated for high b-values of 1500, 2000, and 3000 s/mm(2). MATERIALS AND METHODS: Twenty-eight patients who underwent multiparametric MRI of the prostate and radical prostatectomy consecutively were enrolled in this retrospective study. Using a software developed at our institute, cDWI1500, cDWI2000, and cDWI3000 image sets were generated by fitting a monoexponential model. Index lesions on cDWI image sets were scored by two radiologists in consensus considering lesion conspicuity, suppression of background prostate tissue, distortion, image set preferability, and contrast ratio measurements were performed. RESULTS: Lesion detection rates are the same for computed b-values of 2000 and 3000 s/mm(2) and are better than b-values of 1500 s/mm(2). Best lesion conspicuity and best background prostate tissue suppression are provided by cDWI3000 image set. cDWI2000 image set provides the best zonal anatomical delineation and less distortion and was chosen as the most preferred image set. Average contrast ratio measured on these image sets shows almost a linear relation with the b-values. CONCLUSION: cDWI2000 image set with similar conspicuity and the same lesion detection rate, but better zonal anatomical delineation, and less distortion, was chosen as the preferable image set.