MRI diagnosis of Takayasu arteritis in a young woman.

Takayasu arteritis is a rare type of chronic, granulomatous vasculitis, characterized by inflammation of blood vessels of large caliber, such as the aorta, and its branches. Clinical presentation varies, depending on the severity of symptoms. Onset may be gradual, however at times, presentation may be acute, and life threatening. Herein, we present the case of a 29-year-old female, 3 months post-op, following a right carotid artery stenting procedure. The patient presented with nonspecific symptoms of malaise, arthralgia, and blurry vision. Clinical presentation and imaging findings were consistent with Takayasu's Arteritis.

The Role of Magnetic Resonance Imaging (MRI) in Diagnostics of Acoustic Schwannoma.

BACKGROUND: Acoustic neuromas are also called vestibular schwannoma, acoustic neurinoma, vestibular neuroma, and acoustic neurofibroma. These are tumors that evolve from Schwann cell sheath and can be either intracranial or extra-axial. They usually occur adjacent to the cochlear or vestibular nerve. Anatomically, acoustic neuromas tend to occupy the cerebellopontine angle. About 20% of internal carotid artery (ICA) tumors are meningiomas and may occur elsewhere in the brain. Bilateral acoustic neuromas also tend to be exclusively in individuals with type 2 neurofibromatosis. OBJECTIVE: The aim was to asses the role of MRI in evaluation of cerebellopontine angle acoustic schwannomas, the role of the cyber knife treatment in eliminating the tumor with a maximum protection of healthy tissue. METHODS: MRI, GE 1.5 Tesla unit and standard protocol: Pre-contrast MRI images of the temporal bones and posterior fossa were obtained using Ax 3D Fiesta T2W Hi-resolution; Ax 3D T1 Fat-Suppressed, Thin-slice (2mm) Coronal T2W, Sag 3D FiestaT2W Hi-resolution images. Post-contrast images were obtained using Ax 3D T1 Fat-Suppressed Cor 3D T1 Fat-suppressed sequences. FLAIR sequence axial). CASE REPORT: A woman 62 years of age, reported sudden tinnitus, dizziness, hearing loss in her left ear. After one years she began to experience vertigo, headache. RESULTS: MRI of brain temporal bone with contrast show acoustic schwannoma measuring 20x9 mm on the left cerebellopontine angle extending into and enlarging the left IAC, solid enhancing component is seen the acoustic meatus and peripheral contrast cystic component in the left cerebellopontine angle, after cyber knife treatment MRI result was the solid component of the mass, filling the left internal acoustic canal shows marked post-contrast enhancement and is measured 10x5x4mm, cystic component of it filling the left cerebellopontine angle cistern is enlarged to 25x19x12mm), it extends down till the left lateral aspect of medullary cistern, abutting the CN-XII at its entrance to left hypoglossal canal. After 5 month control show, a 15mm long and 5mm thick neoplastic soft-tissue in the left internal acoustic canal, with post-contrast enhancement, measured up to 12mm at the level of porus acusticus but cystic component of the mass in left cerebellopontine angle cistern is no longer visible in this MRI exam. CONCLUSION: The sensitivity of MRI for correctly diagnosing acoustic schwannoma was 100 % and specificity was 92.86 % with a positive predictive value of 94.12 % and accuracy of 96.67 %. MRI is considered as an excellent noninvasive investigation for pontocerebral angle Schwannoma's.

CT angiographic demonstration of a mesenteric vessel "whirlpool" in intestinal malrotation and midgut volvulus: a case report.

Although the color Doppler ultrasonography diagnosis of intestinal malrotation with midgut volvulus, based on the typical "whirlpool" appearance of the mesenteric vascular structures is well-defined in the peer-reviewed literature, the combination of both the angiographic illustration of these findings and the contemporary state-of-the-art imaging techniques is lacking. We report the digital subtraction angiography and multidetector computed tomography angiography findings of a 37-year-old male with intestinal malrotation.

Iliocaval arteriovenous fistula following lumbar disc surgery: endovascular treatment with a Stent-graft.

Arteriovenous (AV) fistulae, pseudoaneurysms, and lacerations may occur during disc surgery. AV fistula after lumbar disc surgery is rare. Early diagnosis and treatment of vascular complications associated with disc surgery is essential due to their high mortality and morbidity rates. We report a case report who was presented with fistulous shunt between right common iliac artery and inferior vena cava fifteen days after operation for herniated discs at L4-L5 and L5-S1 levels. Treatment was transcatheter covered stent placement at the fistulous site of right common iliac artery using a self expandable stent-graft. We suggest use of minimally invasive interventional techniques in the management of suitable vascular injuries following lumbar disc surgery.

Is uterine artery embolization prior to myomectomy for giant fibroids helpful?

PURPOSE: To determine whether uterine artery embolization (UAE) prior to myomectomy is more effective than myomectomy alone. MATERIALS AND METHODS: The study included 15 consecutive infertile women with uterine fibroids > 10 cm (Group I) that underwent UAE with spherical particles using a microcatheter technique and a unilateral femoral approach between March 2005 and January 2007. The day after embolization all cases underwent myomectomy since the protocol for large fibroids in our hospital is myomectomy only. The control group was composed of 15 patients who underwent myomectomy only (Group II). Group II was established based on fibroid size (14 +/- 3 cm). Operating time, estimated blood loss and transfusion, complications, and hospital stay were calculated by retrospective chart reviews, and comparisons were made between the groups with Student's t-test. RESULTS: Mean operating time was 138 min in Group I and 240 minutes in Group II (P < 0.01). Mean estimated blood loss was 250 ml in Group I and 690 ml in Group II (P < 0.01). There was no need for transfusion in Group I, while transfusion was needed in 2 cases (13%) in Group II. Mean hospital stay in Group I was 5 days versus 8 days in Group II. Complications, including subsequent hysterectomy, were seen in 2 cases and bowel-bladder injuries in 1 case in Group II (a total of 20%), while no complications were observed in Group I. One of the cases in Group I later conceived and gave birth to a healthy child. CONCLUSION: UAE prior to myomectomy is more effective than myomectomy alone.

Role of MRI in Diagnosis of Ruptured Intracranial Dermoid Cyst.

INTRODUCTION: Intracranial dermoid cystic tumors account for <1% of all intracranial masses. CASE REPORT: A 52-year-old male, having headaches, nausea and is presented with a history of 2 episodes of new onset seizures. On presentation, the patient had a normal physical exam, including a complete neurological and cranial nerve exam. METHODS: Precontrast MRI; TSE/T2Wsequence in axial/coronal planes; 3D - HI-resolution T1W sagittal; FLAIR/T2W axial; FLAIR/T2W, Flash/T2W oblique coronal plane, GRE/T2W axial. Post-contrast TSE/T1W sequence in axial, coronal and sagittal planes. Diffusion weighted and ADC mapping, postcontrast: TSE/T1W sequence in axial, coronal and sagittal planes. RESULTS: Subsequent MRI of the brain revealed an oval and lobulated 47x34x30mm (TRxAPxCC) non-enhancing T1-hyperintense mass in right cavernous sinus, with compression of surrounding mesial temporal lobe and right anterolateral aspect of mesencephalon. Findings are consistent with ruptured dermoid cyst, given the evacuated sebum content at its lower half. Sebum particles in millimetric sizes are seen within right Sylvian fissure, anterior horns of lateral ventricles and to a lesser extent within left Sylvian fissure, right parietal sulci, cerebral aqueduct, and basal cisterns. No restricted diffusion is seen, eliminating the possibility of epidermoid. A shunt catheter is evident traversing between right lateral ventricle and right parietal bone; besides, slit-like right lateral ventricle is noted (likely secondary to over-draining shunt catheter). CONCLUSION: Intracranial dermoid cysts are benign rare slow-growing tumors that upon rupture, however, widespread presence of T1 hyperintense droplets and leptomeningeal enhancement can be noted-making MRI the best imaging modality for diagnosis of this rare entity.

Magnetic Resonance Imaging of a Case of Central Neurocytoma.

BACKGROUND: The purpose of this study is to investigate the MRI features of central neurocytoma. CASE REPORT: A 45 year old man with 3 months of worsening daily headaches. These headaches were diffuse, lasted for several hours, and mostly occurred in the morning. She was initially diagnosed and treated for migraines but later he had epileptic attack and diplopia and neurolog recomaded MRI. METHODS: precontrast MRI; TSE/T2Wsequence in axial/coronal planes; 3D-Hi-resolution T1W sagittal; FLAIR/T2W axial; FLAIR/T2W and Flash/T2W oblique coronal plane (perpendicular to temporal lobes) GRE/T2W axial plane for detection of heme products. Post-contrast TSE/T1W sequence in axial, coronal and sagittal planes. Diffusion weighted and ADC mapping MRI images for EPI sequence in axial plane. RESULTS: A 23x12mm heterogeneous mass within aqueductus cerebri, with calcified and hemorrhagic foci and extending downwards till fourth ventricle. It's originating from the right paramedian posterior aqueductal wall (tectum), and also extending to and involving the tegmentum of mesencephalon at its right paramedian aspect. CSF flow obstruction secondary to described aqueductal mass, with resultant triventricular hydrocephalus). Marked transependymal CSF leak can be noted at periventricular white matter, secondary to severe hydrocephalus. After IV injection of contrast media, this mass shows mild-to-moderate heterogenous speckled enhancement. CONCLUSION: MRI is helpful in defining tumor extension, which is important in preoperative planning. Although IN is a relatively rare lesion, it should be considered in the differential diagnosis of intraventricular lesions in the presence of such typical MR findings. However, a definitive diagnosis requires immunochemical study and electron microscopy.

Implications of post-gadolinium MRI results in 13 cases with posterior reversible encephalopathy syndrome.

BACKGROUND: There is a relative lack of definitive information about the contrast-enhancement characteristics of lesions in posterior reversible encephalopathy syndrome (PRES). OBJECTIVE: Evaluation of contrast-enhanced MRI findings in PRES with a special emphasis on pathophysiology of post-gadolinium behavior of these lesions. MATERIALS AND METHODS: Contrast-enhanced 1.5 T MRI findings and relevant clinical data of the patients were retrospectively reviewed on 13 cases (six males, seven females; age range: 22-78; mean age 47). Although fluid attenuated inversion recovery (FLAIR) and diffusion-weighted MR images were considered for identification of the entity, primarily post-contrast T1-weighted MR images were searched for traces of enhancement in the lesions. RESULTS: No definitely enhancing lesion was identified in the MR images obtained in 6-48 h after onset of symptoms (mostly headaches, seizures and cortical visual field deficits) in this series. Severity of disease indicated by small hemorrhages, confluence of lesions or progression to cytotoxic edema did not seem to alter this result. Typical lesion characteristics were consistent with vasogenic edema on FLAIR and diffusion MR images. Acute elevation of blood pressure on chronic hypertensive background was responsible in four, eclampsia in three, uremia with blood pressure fluctuations in three, and cyclosporine-toxicity in three cases. CONCLUSION: Although occasional enhancing brain lesions have been reported in the literature on PRES, contrast-enhancement of lesions may be a factor of scan timing and underlying etiology. Prospective studies with larger series on PRES are required for better evaluation of contrast-enhancement in MRI with respect to scan timing, which in turn may help understand its pathophysiology better.

A case of tuberculous pyomyositis that caused a recurrent soft tissue lesion localized at the forearm.

We present the case of a 20-year-old male who had a non-traumatic soft tissue lesion (4 x 3 cm) with recurrent discharge at his right posteromedial antebrachial muscles; the patient underwent surgery twice, and antibiotic therapy was administered, but no cure was achieved with these treatments. The patient underwent surgery at our medical center. There was no history of pulmonary, gastrointestinal, or genitourinary tuberculosis (TB). Due to suspected pulmonary, genitourinary, and gastrointestinal TB, radiography and computed tomography scans were performed, and these studies disclosed no evidence of a primary origin. The erythrocyte sedimentation rate and the results of purified protein derivate testing were normal. We also detected submandibular lymphadenopathy (LAP) (2 x 3 cm) localized at a submandibular site in our patient 4 months after his first visit to our clinic. Smears were stained with Ehrlich Ziehl Neelsen (EZN) stain and culture were grown for Mycobacterium tuberculosis complex (MTC); the samples used for these assays had been obtained by incisional biopsy of the forearm lesion and by aspiration of the submandibular lymph node, and they were found to be MTC-positive. Then, a culture for MTC, derived from an induced sputum sample, was found to be positive, despite the negative results obtained with a sputum smear subjected to EZN staining. According to these results, the primary focus of the tuberculous pyomyositis and the submandibular LAP was the lungs. The lesion and submandibular LAP were both treated successfully by the administration of antituberculous chemotherapy.

Intrahepatic arterioportal fistula and its treatment with detachable balloon and transcatheter embolization with coils and microspheres.

BACKGROUND: Although intrahepatic arterioportal fistula (APF) due to acquired or congenital causes are infrequent, they are listed among the causes of portal hypertension. PURPOSE: The aim of this study was to present the results of intrahepatic APF treatment with embolotherapy in six cases. MATERIAL AND METHODS: Transarterial detachable balloon and coil embolization was used on six consecutive cases with traumatic intrahepatic APF from 1989 to 2003. Six-month follow-up angiography was obtained in every case. RESULTS: Successful disconnection of hepatic arterial and portal system was achieved in five cases. At least symptomatic improvement was achieved in one. CONCLUSION: Transcatheter embolization may be the first line of treatment for intrahepatic APF.

MR cholangiopancreatography of a case with a biliary tract variation and postoperative biliary duct injury.

Because of the increasing frequency of surgical procedures such as hepatic resection, partial liver transplantation, and laparoscopic cholecystectomy, the number of patients requiring biliary imaging has increased. In this report, magnetic resonance cholangiopancreatography findings of a case with an aberrant right posterior hepatic duct draining directly into the gallbladder, which was overlooked prior to laparoscopic cholecystectomy, is presented and the importance of magnetic resonance cholangiopancreatography in the evaluation of congenital biliary anomalies and iatrogenic bile duct injury is discussed.

Prevalence of dual left anterior descending artery variations in CT angiography.

PURPOSE: We aimed to evaluate the frequency and features of dual left anterior descending artery (LAD) variants using computed tomography (CT) angiography. METHODS: A total of 1337 consecutive coronary CT angiography examinations performed between April 2010 and December 2013 were retrospectively evaluated for the presence of dual LAD. CT examinations were performed with either 64- or 320-row multidetector CT scanners. All CT angiography images were evaluated for the presence and morphologic features of dual LAD subtypes. RESULTS: Fifty-six dual LAD variations (4%) were identified in this study population. Type 1 was the most common type of dual LAD (n=48), while Type 3 (n=3) and Type 4 (n=2) were infrequent and Type 2 was not detected. Additionally, we detected previously unclassified dual LAD variations in three cases. CONCLUSION: Dual LAD may be a relatively more common variant than described in the medical literature, which is mostly based on catheter angiography studies. Coronary CT angiography seems markedly efficacious for detecting and documenting the anatomical details of dual LAD subtypes, as well as showing other associated cardiocoronary anomalies.

Computed tomography-guided percutaneous drainage of splenic abscesses.

OBJECTIVE: The aim of the study is to evaluate the role of computed tomography (CT)-guided percutaneous drainage in the management of solitary splenic abscesses. MATERIALS AND METHODS: Sonography and CT were used in the initial diagnosis of splenic abscess in patients with vague left upper quadrant pain and/or fever. Solitary splenic abscesses of nine male patients whose ages varied between 21 and 27 years (mean age: 24.7 years) were percutaneously drained under CT guidance. Puncture with 18-gauge Chiba needles and coaxial guidewire technique was used for insertion of six or eight French pigtail catheters. Antibiotics in accordance with the microbiological results were also given adjuvant to drainage. Follow-up examinations were performed by sonography, daily for the first week and weekly for the next 7 weeks, and by CT at the end of first, fourth and eighth weeks. RESULTS: All patients tolerated the intervention well, except for one complicating with splenic rupture and hemorrhage, who underwent emergency splenectomy. The remaining eight patients recovered within 4 weeks without any splenic sequela. A mean of 3.9 days was needed before removing the drainage catheter based on regression criteria. DISCUSSION AND CONCLUSION: CT-guided percutaneous drainage of splenic abscesses may be proven effective and is superior to splenectomy in selected cases, as it preserves host immunity.

Percutaneous treatment of a primary pancreatic hydatid cyst using a catheterization technique.

Primary pancreatic hydatid cysts are rare and its percutaneous treatment and catheterization technique has, to the best of our knowledge, not been published in literature. A 33-year-old male patient who presented with abdominal pain was evaluated by ultrasonography (US) and computed tomography examinations. Both examinations revealed a cyst in the neck of the pancreas. After the administration of albendazole chemoprophylaxis, the patient underwent diagnostic puncture showing high pressure spring water which harbored the scoleces and was treated percutaneously by the catheterization technique. In this technique, first the cyst was punctured, the fluid content aspirated, the radiocontrast material injected to see possible fistulisation, and then re-aspirated. The 20% hypertonic saline solution was injected and re-aspiration was performed to the best of our abilities, followed by the insertion of a catheter for drainage of the remaining non-aspiratable fluid content. At follow-up examination, the cyst was not visible on US after 6 months. There was no evidence of cyst recurrence or dissemination after 18 months at serologic and imaging follow-up.

Osteopetrosis and congenital hypothyroidism complicated by slipped capital femoral epiphysis.

OBJECTIVE: To describe a 13-year-old girl with unilateral slipped capital femoral epiphysis (SCFE), who presented with an acute onset limp during follow-up for congenital hypothyroidism and osteopetrosis. METHODS: We present a case report detailing the patient's history as well as clinical, laboratory, and imaging findings and discuss the related literature. RESULTS: The patient had been diagnosed elsewhere with congenital hypothyroidism, and levothyroxine therapy was initiated when she was 20 days of age; however, adherence to the treatment was irregular. Both her weight and her height were below the 5th percentile, her breast development and pubic hair were consistent with Tanner stage 1, and she had mental retardation and atypical facies. Her gait was antalgic; no muscle atrophy or shortness in the affected leg was present. On laboratory investigation, thyroid function tests were concordant with primary hypothyroidism. Her bone age was estimated as 8 years. Dual-energy x-ray absorptiometry revealed increased bone mineral density. Radiographic studies disclosed striking opacity of the bones of the pelvis and sclerosis at the skull base. Computed tomography of the affected left lower limb showed a fragmented appearance of the capital femoral epiphysis and thickening and irregularities of the physis line on the left, consistent with SCFE. CONCLUSION: We underscore the possible facilitator role of osteopetrosis in the pathogenesis of SCFE, suggest the need to consider SCFE in the differential diagnosis when a lower extremity abnormality is detected in patients with congenital hypothyroidism or delayed puberty (or both), and emphasize this association with osteopetrosis.

A new syndrome associated with absence of lower lid lacrimal punctum, ptosis, elevation deficiency of both eyes and mild facial dysmorphism.

A considerable volume of literature has been published on the association of lacrimal outflow dysgenesis with developmental anomalies or systemic syndromes. We report three affected individuals in a consanguineous family those are associated with bilateral ptosis, upper ocular movement limitation, and absence of the lacrimal punctum. T our knowledge, this is the first article reporting the association of bilateral ptosis, facial dysmorphism, upper ocular movement limitation, and absence of the lacrimal punctum in a hereditary form. As a sole example, these findings may be accepted as a new syndrome with autosomal recessive pattern because of consanguinity.

Percutaneous treatment of hepatic hydatid cyst in pregnancy: long-term results.

PURPOSE: To present the long-term results of percutaneous treatment of hepatic hydatid cyst in pregnancy. MATERIAL AND METHODS: Six pregnant patients (age range 19-28 years; mean age 23 years) with six hepatic hydatid cysts underwent percutaneous treatment without albendazole prophylaxis. Puncture, aspiration, injection and reaspiration (PAIR technique) were used to treat the cysts. Hypertonic saline solution was used as cytotoxic agent. Follow-up was mainly by sonography every 2 weeks during pregnancy, every third month post-partum for the first year, every 6 months for the second year, and once a year thereafter. The mean follow-up time was 57.5 months. RESULTS: Before the treatment, average hydatid cyst volume was 2,145 ml that was reduced to 145 ml post-treatment at the time of delivery. The first five cases of the study had solid appearance of the cyst remnant (indicating complete cure) in 22 months. Cystobiliary fistula was suspected in the sixth case three months after delivery. After confirmation of the cystobiliary fistula with cystography, a percutaneous catheter was placed into the postresidual cavity and a nasobiliary catheter was placed into the common bile duct after syphincterotomy. The fistula was closed in 2 weeks. This patient has a follow-up time of 1 year so far without any problem. No mortality, morbidity, fetal loss, abdominal dissemination, or tract seeding was observed among our cases. CONCLUSION: Percutanous treatment of hydatid cysts in pregnancy is an efficient and safe procedure in cases where percutaneous treatment is indicated.

Impact of catheter arteriography on the serum level of asymmetric dimethylarginine, an endogenous inhibitor of nitric oxide synthase.

The purpose of this study was to investigate the instantaneous impact of catheter arteriography on blood asymmetric dimethylarginine (ADMA) levels in accordance with patient- and procedure-related variables. Sixty-eight patients (16 women, 52 men; mean age, 45.6 +/- 20.1 years; range, 20-79 years) referred for cerebral or peripheral catheter arteriography were recruited for the study. Pre- and postarteriography arterial blood ADMA levels were determined by high-performance liquid chromatographic technique. Type of nonionic iodinated contrast media used, duration of procedure, patient gender, and patient age were noted and evaluated as possible factors that could influence serum ADMA levels in arteriography procedures. Prearteriography ADMA levels decreased significantly after arteriography in general (pre, 1.16 +/- 0.96 micromol/L; post, 1.08 +/- 0.80 micromol/L; p = 0.002). Males tended to have lower postarteriography serum ADMA levels (p = 0.005). Serum ADMA levels tended to get lower after peripheral arteriography procedures (p = 0.005) and when iohexol, 350 mg I/ml, was used as the contrast agent (p = 0.017). In conclusion, ADMA level does not seem to be subject to acute elevation after catheter arteriography; on the contrary, its level may decrease in general. Moreover, a reduction in serum ADMA level may be expected, especially in male patients, in patients who undergo a peripheral arteriography procedure, or when iohexol, 350 mg I/ml, is used as the contrast agent.

Right renal vein aplasia associated with diverted renal venous drainage through lower pole.

We report a unique anomalous renal venous drainage on a 25-year-old man who had congenital absence of the right renal vein and an aberrant venous drainage through the lower pole of the kidney into the inferior vena cava. To our knowledge, this anomaly has not been previously reported in the peer-reviewed literature. State-of-the-art imaging findings are presented.

Obstructive uropathy caused by testicular vein compression: multidetector-row computed tomography findings.

Although the right testicular vein and ureter follow a close course at the level of the third lumbar vertebra, it is unusual for the right testicular vein to be a cause of ureteral obstruction. Previously, conventional computed tomography (CT) has been used for establishing this anatomic relation. A case of hydronephrosis in a man secondary to right testicular vein compression diagnosed with multidetector-row CT findings is described.