A case of an idiopathic massive osteolysis with skip lesions.

A patient with a 2-year history of pain in the left arm, and decreased strengths unrelieved by non-steroidal anti-inflammatory therapy, was being referred for repeating radiography. The radiologic examinations have demonstrated a unique pattern of non-contiguous osteolysis in the left elbow, proximal and distal radius, ulna, wrist, carpal bones, proximal and distal metacarpals and phalanges. Multi-site biopsies were being performed and confirmed the diagnosis of massive osteolysis. To our knowledge, this is the first case in which multifocal, non-contiguous osteolysis with skip lesions without associated nephropathy and without a hereditary pattern is being described in one extremity.

Pulmonary artery involvement and associated lung disease in Behçet disease: a series of 47 patients.

Pulmonary artery aneurysms (PAAs) are well known causes of mortality and morbidity in Behçet disease (BD). However, pulmonary artery involvement in BD is not limited to PAA; the other main type of pulmonary artery involvement is pulmonary artery thrombus (PAT), with or without associated PAA. In addition, other types of lung disease like nodules and cavities in the lung parenchyma are frequently associated with pulmonary artery involvement, and can be misinterpreted as being due to infection. We surveyed the clinical, radiologic, and laboratory characteristics and outcome of 47 BD patients with pulmonary artery involvement and the associated findings, all seen and followed at a single dedicated tertiary care center.We identified 47 (41 male, 6 female) patients in whom pulmonary artery involvement was diagnosed, who were registered in the multidisciplinary clinic at Cerrahpasa Medical Faculty between January 2000 and December 2007. Mean age at diagnosis was 29 ± 8 years, and mean disease duration to the onset of pulmonary artery involvement was 3.6 ± 4.8 years. Hemoptysis was the most common presenting symptom (79%) followed by cough, fever, dyspnea, and pleuritic chest pain. Thirty-four of 47 patients (72%) presented with PAA, including 8 with associated PAT. The remaining 13 patients (28%) had isolated PAT. Patients with isolated PAT in general have clinical features similar to patients with PAA. However, hemoptysis was less frequent and voluminous in patients with isolated PAT. Most (91%) of the patients had active disease outside the lungs when they presented with pulmonary artery involvement.Forty (85%) patients had nodules and 6 (13%) had cavities when first seen. Peripheral venous thrombosis was present in 36 of 47 (77%) patients, and intracardiac thrombi in 12 of the 36 (33%) patients. Nodules, cavities, and intracardiac thrombi were mainly present in the acute stages of pulmonary artery involvement.Pulmonary artery involvement is usually multiple, and involves mostly descending branches of the pulmonary artery. Pulmonary artery involvement may disappear, but arterial stenosis or occlusions usually develop at the same location. After a mean follow-up of 7 years, 12 of 47 (26%) patients were dead; patients with larger aneurysms were more likely to die. Sixteen of 47 (34%) patients were symptom free, and the remaining 40% had mild dyspnea (13/47) and/or small bouts of hemoptysis (8/47).Pulmonary artery pressure may be elevated, and may indicate a poor prognosis. Mediastinal lymphadenopathy and mild pleural and pericardial effusions may also be observed. Corticosteroids and immunosuppressive agents are the mainstays of treatment; however, refractory cases may require embolization, lobectomy, cavitectomy, and decortication.

Management of the thrombosed filter-bearing inferior vena cava.

Inferior vena cava (IVC) filter thrombosis is a complex problem. Thrombus within an IVC filter may range from an asymptomatic small thrombus to critical IVC occlusion that affects both lower extremities. The published experience of IVC thrombosis management in relation to filters is either anecdotal or limited to a small group of patients; however, endovascular treatment methods appear to be safe and effective in patients with IVC thrombosis. This review focuses on filter-related IVC thrombosis and its endovascular management.

Isolated bone marrow natural killer cell lymphoma with central nervous system involvement mimicking a cerebral infarct.

BACKGROUND: We describe the case of an isolated bone marrow natural killer (NK) cell lymphoma with central nervous system (CNS) involvement mimicking a cerebral infarct. CNS involvement in isolated bone marrow lymphoma has not been reported previously. CASE REPORT: A 49-year-old man with complaints of fever, confusion, and agitation was presented. A bone marrow biopsy was performed to investigate the etiology of bicytopenia which was consistent with NK-cell lymphoma. Brain MRI findings were suggestive of a subacute infarct. CONCLUSION: Even if pathological signal changes of the brain without contrast enhancement resembling infarct are detected in patients with lymphoma on the magnetic resonance imaging, CNS involvement of the lymphoma should be kept in mind in the differential diagnosis.

Spontaneous intracranial hypotension syndrome in a patient with marfan syndrome and autosomal dominant polycystic kidney disease.

Intracranial hypotension is typically manifested by orthostatic headache. The most frequent underlying factor is cerebrospinal fluid leakage. It has been suggested that dural structural weakness in some connective tissue diseases may be responsible for dural tears and diverticula and consequently leakage. We present a case of spontaneous intracranial hypotension associated with Marfan syndrome and autosomal dominant polycystic kidney disease. The patient was treated successfully with epidural autologous blood patch. Dural involvements of these hereditary connective tissue diseases are also discussed.

Female breast surface radiation exposure during FDG PET/CT examinations.

BACKGROUND: The combined positron emission tomography (PET) and computed tomography (CT) scanners have been developed in which CT data can be used for both anatomical landmarks and attenuation correction of PET images. However, this modality potentially introduces more radiation burden to patients compared to conventional PET scanning as a result of the added radiation exposure received from CT examination. The purpose of our study was to determine the breast radiation doses of combined PET/CT examination. MATERIAL AND METHODS: Patients' superficial breast doses were calculated using thermoluminescence dosimeters (TLDs) placed onto the surface of the breasts. TLDs were positioned before FDG injection and removed after 24 h. We also determined the average superficial and glandular breast radiation doses from the anthropomorphic dosimetric phantom imaged using similar CT protocol (low dose) to the patients' study. RESULTS: The mean superficial breast dose of the breast skin measured from the PET/CT studies was 14.42+/-2.41 mGy. The average superficial and glandular breast doses of the anthropomorphic phantom measured from the low-dose CT was 9.50 mGy and 5.94 mGy, respectively. CONCLUSION: This study showed that radiation exposure to the breasts during PET/CT was higher than the recommended doses. Therefore, combined PET/CT scanning must be used for essential indications, particularly in women of reproductive age and preferentially a low-dose CT protocol should be implemented to avoid overexposure in such patients.

Is early bladder activity in radionuclide cisternography an indirect sign of spontaneous intracranial hypotension or sequence of lumbar puncture?

Spontaneous intracranial hypotension (SIH) is characterized by severe postural headache and low cerebrospinal fluid (CSF) pressure. Radionuclide cisternography (RC) is of some value in diagnosing CSF leakage causing SIH. However, the sensitivity of RC is too low to demonstrate the site of leakage. In these cases, the early appearance of the radioactivity in the urinary bladder has also been used as an indirect finding in the diagnosis of SIH. The aim of this study was to evaluate the diagnostic reliability of early urinary bladder activity as an indirect sign of SIH. We investigated early bladder activity in 21 patients with suspicion of normal pressure hydrocephalus. Of the 21 subjects, 13 (62%) showed early bladder activity. We demonstrated that early bladder activity is observed in patients without CSF leakage such as normal pressure hydrocephalus. Therefore, this indirect finding of RC is not a reliable finding in diagnosing SIH.

Avoidance of misinterpretation of an FDG positive sacral insufficiency fracture using PET/CT scans in a patient with endometrial cancer: a case report.

Whole-body FDG PET is an important tool for imaging of cancer, including skeletal metastases. However, false-positive results can occur in benign diseases such as insufficiency fractures. We report a case of sacral insufficiency fracture in which increased FDG uptake was detected. Correlative CT images obtained by a combined PET/CT scanner excluded a possible false-positive interpretation by revealing the fracture lines at the site of increased FDG uptake.

Pain & resistance in patients with adhesive capsulitis during contrast material injection phase of MR arthrography.

BACKGROUND & OBJECTIVE: Adhesive capsulitis of the shoulder is a condition of unknown aetiology that results in the development of restricted active and passive glenohumeral motion. It has been reported that magnetic resonance (MR) imaging is useful in diagnosing adhesive capsulitis. We carried out this study to assess how pain and/or resistance during contrast material injection affects the diagnosis of adhesive capsulitis on magnetic resonance (MR) arthrography. METHODS: The study included MR arthrography examinations of 21 patients with a diagnosis of adhesive capsulitis. The control group consisted of 20 patients who presented clinically with rotator cuff tear. The pain (visual analog scale, VAS), resistance to injection and the amount of contrast material that could be injected during injection phase of MR arthrography was assessed and compared between groups. RESULTS: The patients in adhesive capsulitis group (mean VAS score 66.5+/-25.5) experienced more pain when compared with the control group (mean VAS score 34.9+/-27.7, P<0.001). A statistically significant difference (P<0.001) in terms of the amount of the injected fluid (4.3+/-2.6 ml for adhesive capsulitis group, and 10.9+/-4.1 ml for control group) was seen into the joint cavity. Resistance to injection was significantly more (P<0.001) in patients with adhesive capsulitis when compared to control group. INTERPRETATION & CONCLUSION: Experience of pain during injection, a decreased amount of contrast material injected and resistance to injection in patients during injection phase of MR arthrography may suggest adhesive capsulitis.

Pseudocoarctation.

Pseudocoarctation, also known as kinking or buckling of the aorta, is an uncommon anomaly. Its recognition is important, because it may be mistaken for true coarctation, aneurysm or mediastinal neoplasm. A case of pseudocoarctation associated with left cervical aorta is reported. The present case is unique in the demonstration of obvious tortuosity and kink formation of the cervical aorta and main branches without frank aneurysm formation. Magnetic resonance angiography as a noninvasive imaging modality was suggested for the definitive diagnosis of cervical aortic arch and its accompanying anomalies.

Intrathecal gadolinium-enhanced MR-cisternography in spontaneous intracranial hypotension associated with Behcet's syndrome.

We report a 32-year-old woman diagnosed with spontaneous intracranial hypotension (SIH) and Behcet's Syndrome. Suspicion of SIH was based on cervical MRI findings, and magnetic resonance (MR)-cisternography revealed dural leaks bilaterally at lumbar region. MR-cisternography is a recently performed technique and gaining importance in demonstration of CSF fistula.

Female breast radiation exposure during thorax multidetector computed tomography and the effectiveness of bismuth breast shield to reduce breast radiation dose.

OBJECTIVE: The purpose of our study was to determine the breast radiation dose when performing routine thoracic multidetector computed tomography (MDCT). We also evaluated dose reduction and the effect on image quality of using a bismuth breast shield when performing thoracic MDCT. MATERIAL AND METHODS: The dose reduction achievable by shielding the adult (18 years or older) female breasts was studied in 50 women who underwent routine thoracic MDCT. All examinations were performed with a 16-MDCT scanner (Sensation Cardiac 16; Siemens Medical Solutions). To compare the shielded/unshielded breast dose, the examination was performed with (right breast) and without (left breast) breast shielding in all patients. With this technique, the superficial breast doses were calculated. To determine the average glandular breast radiation dose, we imaged an anthropomorphic dosimetric phantom into which calibrated dosimeters were placed to measure the dose to breast. The phantom was imaged using the same protocol. Radiation doses to the breasts with and without the breast shielding were measured and compared using the Student t test. RESULTS: In the qualitative evaluation of the MDCT scans, all were considered to be of diagnostic quality. We did not see any differences in quality between the shielded and unshielded lung. The mean radiation doses to the breasts with the shield and to those without the shield were 8.6 +/- 2.33 versus 14.46 +/- 3.94 mGy, respectively. The breast shield enabled a 40.53% decrease in radiation dose to the breast. The difference between the dose received by the breasts with and that received by the breasts without bismuth shielding was significant, with a P value of less than 0.001. CONCLUSIONS: Bismuth in-plane shielding for routine thoracic MDCT decreased radiation dose to the breast without qualitative changes in image quality. The other radiosensitive superficial organs (eg, testes and thyroid gland) specifically must be protected with shielding.

Coronary calcium scoring with MDCT: the radiation dose to the breast and the effectiveness of bismuth breast shield.

OBJECTIVE: The purpose of our study was to determine the breast radiation dose during coronary calcium scoring with multidetector computerized tomography (MDCT). We also evaluated the degree of dose reduction by using a bismuth breast shield when performing coronary calcium scoring with MDCT. MATERIALS AND METHODS: The dose reduction achievable by shielding the adult (35 years or older) female breasts was studied in 25 women who underwent coronary calcium scoring with MDCT. All examinations were performed with a 16-MDCT scanner. To compare the shielded versus unshielded breast dose, the examinations were performed with (right breast) and without (left breast) breast shielding in all patients. With this technique the superficial breast doses were calculated. To determine the average glandular breast radiation dose, we imaged an anthropomorphic dosimetric phantom into which calibrated dosimeters were placed to measure the dose to the breast. The phantom was imaged using the same protocol. Radiation doses to the breasts with and without the breast shielding were measured and compared using the Student's t-test. RESULTS: The mean radiation doses with and without the breast shield were 5.71+/-1.1 mGy versus 9.08+/-1.5 mGy, respectively. The breast shield provided a 37.12% decrease in radiation dose to the breast with shielding. The difference between the dose received by the breasts with and without bismuth shielding was significant, with a p-value of less than 0.001. CONCLUSION: The high radiation during MDCT greatly exceeds the recommended doses and should not be underestimated. Bismuth in plane shielding for coronary calcium scoring with MDCT decreased the radiation dose to the breast. We recommend routine use of breast shields in female patients undergoing calcium scoring with MDCT.

Utilization of low-dose multidetector CT and virtual bronchoscopy in children with suspected foreign body aspiration.

BACKGROUND: Foreign body aspiration is common in children, especially those under 3 years of age. Chest radiography and CT are the main imaging modalities for the evaluation of these children. Management of children with suspected foreign body aspiration (SFBA) mainly depends on radiological findings. OBJECTIVE: To investigate the potential use of low-dose multidetector CT (MDCT) and virtual bronchoscopy (VB) in the evaluation and management of SFBA in children. MATERIALS AND METHODS: Included in the study were 37 children (17 girls, 20 boys; age 4 months to 10 years, mean 32 months) with SFBA. Chest radiographs were obtained prior to MDCT in all patients. MDCT was performed using a low-dose technique. VB images were obtained in the same session. Conventional bronchoscopy (CB) was performed within 24 h on patients in whom an obstructive abnormality had been found by MDCT and VB. RESULTS: Obstructive pathology was found in 16 (43.25%) of the 37 patients using MDCT and VB. In 13 of these patients, foreign bodies were detected and removed via CB. The foreign bodies were located in the right main bronchus (n = 5), in the bronchus intermedius (n = 6), in the medial segment of the middle lobe bronchus (n = 1), and in the left main bronchus (n = 1). In the remaining three patients, the diagnosis was false-positive for an obstructive pathology by MDCT and VB; the final diagnoses were secretions (n = 2) and schwannoma (n = 1), as demonstrated by CB. In 21 patients in whom no obstructive pathology was detected by MDCT and VB, CB was not performed. These patients were followed for 5-20 months without any recurrent obstructive symptomatology. CONCLUSIONS: Low-dose MDCT and VB are non-invasive radiological modalities that can be used easily in the investigation of SFBA in children. MDCT and VB provide the exact location of the obstructive pathology prior to CB. If obstructive pathology is depicted with MDCT and VB, CB should be performed either for confirmation of the diagnosis or for the diagnosis of an alternative cause for the obstruction. In cases where no obstructive pathology is detected by MDCT and VB, CB may not be clinically useful.

The effect of fluid intake on renal length measurement in adults.

PURPOSE: To evaluate whether oral fluid intake has an effect on renal length as determined with sonography. METHODS: We studied 524 adult patients who were referred to our ultrasound unit with complaints other than urinary tract symptoms. The mean age of the patients was 44 years (range 17-76). All of the measurements were performed with the patient in the prone position. The renal length of each kidney was measured by the same observer before and after oral fluid intake. Student's t-test was applied for the statistical significance of renal length measurements before and after hydration. Analysis of variance was performed for the effect of age and sex on the renal length measurements. RESULTS: The mean renal length on the right side was 106.2 +/- 5.5 mm and 107.5 +/- 5.7 mm on the left side before hydration. There was no statistically significant difference between right and left side renal length measurements. After hydration, the mean renal length was 113.5 +/- 6.1 mm on the right side and 114.6 +/- 6.6 mm on the left side. The mean increase in renal length after hydration was statistically significant (P < 0.001) and was 6.8% on the right side and 6.6% on the left side. Sex and age did not affect the measurements significantly. CONCLUSIONS: Oral fluid intake causes a statistically significant increase in renal length. This observation should be taken into consideration when renal length measurements are clinicallly important.