Acute hemiparesis and status epilepticus following endoscopic esophageal balloon dilation: is it really a stroke?

A 68-year-old gentleman was referred for elective upper gastrointestinal endoscopy on a background of dysphagia and esophageal candidiasis. A benign peptic stricture was noted, managed with balloon dilation without apparent immediate complication. At completion, however, the patient became confused and agitated, with no improvement despite the reversal of sedation. Two hours later, with all investigations for suspected complications including perforation, negative, he developed acute left-sided hemiparesis. Urgent computed tomography brain and angiogram were both normal. A diagnosis of acute ischemic stroke was made, and the patient was thrombolysed in the Intensive Care Unit. No improvement of the stroke was observed. Seven hours later, the patient developed generalized tonic-clonic seizures that required phenytoin infusion and subsequent intubation and ventilation. The following morning, magnetic resonance imaging brain did not reveal features of a stroke, but instead diffuse cortical and white matter edema in the right frontal lobe, consistent with atypical, unilateral Posterior Reversible Encephalopathy Syndrome (PRES). Signs and symptoms resolved rapidly over the course of several days, and after one month the patient made a complete clinical and radiological recovery. To our knowledge, this is the only case of PRES to arise in the setting of endoscopy and esophageal dilation.

Modic Type 1 Vertebral Endplate Changes: Injury, Inflammation, or Infection?

OBJECTIVE: In the 29 years since the initial description of Modic type 1 vertebral endplate changes there has been ongoing debate regarding their cause. Studies have attributed Modic type 1 vertebral endplate changes to traumatic injury to the vertebral endplate, localized action of proinflammatory mediators, and more recently low-grade bacterial infection. Can we reconcile these conflicting data about the underlying cause of Modic type 1 vertebral endplate changes? Are we now in a position to conclude whether Modic type 1 vertebral endplate changes are secondary to injury, inflammation, or infection? CONCLUSION: We argue that the processes are not disparate but are in fact closely linked, each potentially instigating a chain of events leading to the MRI findings of Modic type 1 vertebral endplate change. A method of delineating which process is predominantly at play in an individual patient is required so that tailored treatment options can be offered with huge potential benefit to individuals and society alike.

Prevalence and clinical significance of extravascular incidental findings in patients undergoing CT cervico-cerebral angiography.

INTRODUCTION: CT cervico-cerebral angiography (CTCCA) is now the first line diagnostic imaging modality for the majority of vascular pathologies of the head and neck with diagnostic value comparable to or better than traditional angiographic techniques. The aim of this study was to assess the prevalence, clinical significance and management of extravascular incidental findings detected on CTCCA. MATERIALS AND METHODS: A retrospective review of the CTCCA reports of 302 consecutive patients from 2009 to 2013 was undertaken. Extravascular incidental findings were classified, according to an adaptation of the CT colonography data and reporting system (CRADS), as EV1-EV4. EV1=no incidental findings, EV2=clinically insignificant incidental finding, EV3=incidental finding of intermediate clinical significance, EV4=highly clinically significant finding. Follow up of the electronic medical records of patients with EV3 or EV4 findings was undertaken to determine subsequent management. RESULTS: Potentially clinically significant findings were demonstrated in 14.2% of patients with 8.6% of patients having a highly clinically significant finding. 4 incidental findings were confirmed to be malignant lesions and 5 required acute intervention. In addition 19% of patients with highly clinically significant incidental findings did not receive appropriate follow up. DISCUSSION: This study has demonstrated the presence of clinically important incidental findings in a significant proportion of patients undergoing CTCCA with a significant minority of these patients not receiving follow up. A standardised method of reporting incidental findings, such as that used in this paper, would aid radiologists and referring physicians in recording and communicating these findings.