Pars plana vitrectomy combined with pan-retinal photocoagulation, Ahmed glaucoma valve implantation, and/or phacoemulsification for complicated neovascular glaucoma treatment / Vitrectomia pars plana combinada com fotocoagulação panretiniana, implantação da válvula Ahmed para glaucoma e/ou facoemulsificação para tratamento de glaucoma neovascular complicado

ABSTRACT Purpose: To present long-term results of pars plana vitrectomy combined with pan-retinal endolaser photocoagulation, Ahmed glaucoma valve implantation, and/or phacoemulsification in patients with complicated neovascular glaucoma. Methods: The study comprised 15 eyes from 15 patients with neovascular glaucoma as a complication of diabetic retinopathy and owing to ischemic central retinal vein occlusion. There was a vitreous hemorrhage n all of the patients. Furthermore, 8 of the cases showed varying degrees of hyphema. All subjects received an intravitreal injection of bevacizumab three days before surgery. In 12 phakic patients, phacoemulsification, pars plana vitrectomy, and Ahmed glaucoma valve implantation were performed. Pars plana vitrectomy and Ahmed glaucoma valve implantation were performed in 3 pseudophakic patients. Perioperative and postoperative complications, intraocular pressure values, and best-corrected visual acuity scores were also recorded. Results: The mean follow-up was 24.4 ± 14.56 months. The mean preoperative intraocular pressure was 50.06 ± 7.6 mmHg. At 1 day, 7 days, and 1-, 3-, 6-, 12-month, and last visit following surgery, the mean intraocular pressure was 11.06 ± 8.22, 12.66 ± 7.27, 13.8 ± 7.73, 18.64 ± 7.05, 19.28 ± 4.61, 16.28 ± 1.68, and 16.92 ± 2.12 mmHg, respectively (p=0.001 for every follow-up visit). The mean visual acuity on the most recent appointment was 1.18 ± 0.42 logMar (p=0.001 for each subsequent visit). As postoperative early complications, varying degrees of hyphema and fibrin reactions were recorded. During follow-up, one patient developed phthisis bulbi. In 4 cases, Ahmed glaucoma valve revision surgery was required. Conclusions: In patients with complicated neovascular glaucoma, combined surgical procedures are safe, effective, and preferable both in terms of controlling high intraocular pressure and providing reasonable visual abilities.

RESUMO Objetivo: Apresentar nossos resultados de longo período de vitrectomia pars plana combinada com fotocoagulação panretiniana com endolaser, implantação da válvula Ahmed para glaucoma e/ou facoemulsificação em pacientes com glaucoma neovascular complicado. Métodos: Foram incluídos no estudo 15 olhos de 15 pacientes com glaucoma neovascular como complicação da retinopatia diabética e devido à oclusão isquêmica da veia central da retina. Todos os casos tiveram hemorragia vítrea. Além disso, 8 dos casos apresentaram diferentes graus de hifema. A injeção intravítrea de bevacizumabe foi administrada em todos os casos 3 dias antes da cirurgia. Facoemulsificação, vitrectomia pars plana e implantação da válvula Ahmed para glaucoma foram realizadas em 12 pacientes fáquicos. A vitrectomia pars plana e a implantação da válvula Ahmed para glaucoma foram realizadas em 3 pacientes pseudofáquicos. Complicações perioperatórias e pós-operatórias, valores de pressão intraocular e valores de melhor acuidade visual corrigida pré-operatório e pós-operatório foram registrados. Resultados: O acompanhamento médio foi de 24,4 ± 14,56 meses. A média da pressão intraocular pré-operatória foi de 50,06 ± 7,6 mmHg. Em 1 dia, 7 dias e 1,3,6,12 meses, e última visita após cirurgia, a média da pressão intraocular foi de 11,06 ± 8,22, 12,66 ± 7,27, 13,8 ± 7,73, 18,64 ± 7,05, 19,28 ± 4,61, 16,28 ± 1,68 e 16,92 ± 2,12 mmHg, respectivamente (p=0,001 para cada visita de acompanhamento). A média da acuidade visual na última visita foi de 1,18 ± 0,42 logMar (p=0,001 para cada visita de acompanhamento). Vários graus de reações de hifema e fibrina foram registrados como complicações precoces pós-operatórias. Phthisis bulbi foi desenvolvido em um caso durante o acompanhamento. A cirurgia de revisão da válvula Ahmed para glaucoma foi necessária em 4 casos. Conclusões: Os procedimentos cirúrgicos combinados que realizamos são seguros, eficazes e preferenciais, tanto em termos de controle da alta pressão intraocular quanto fornecimento de habilidades visuais razoáveis em pacientes com glaucoma neovascular complicado.

Acute reversible bilateral hearing loss after retrobulbar anesthesia.

This is the first reported case who had bilateral reversible hearing loss after regional anesthesia (RA) without a procedural sedoanalgesia. Furthermore, 20% lipid emulsion infusion (LEI) was first used in the treatment of a patient with hearing loss as an indicator of impending brainstem anesthesia. The ophthalmologist had performed a retrobulbar block without any difficulties to a 55-year-old the patient who undergone pars plana vitrectomy. A combination of lidocaine and bupivacaine was injected slowly through a 23G, 1.5-inch needle. Few minutes later, the patient experienced sudden bilateral hearing loss and, subsequently, mental confusion and mild respiratory distress. Local anesthetic toxicity to the predominantly brainstem was the diagnosis. Consequently, 20% LEI was administered, and his hearing loss gradually improved within a few hours. Prompt intervention is crucial in case of severe systemic complications of RA. LEI might be beneficial to halt the deepening of brainstem toxicity.

Different Cases, Different Manifestations of Post-COVID-19 Retinal Artery Occlusion: A Case Series.

Coronavirus disease 2019 (COVID-19) is a procoagulant disease that increases the risk of clinically evident thrombotic complications. Herein we present 3 cases with different retinal artery occlusions that emerged soon after the diagnosis of COVID-19. The first patient had central retinal artery occlusion (CRAO) that resulted in visual loss in one eye. The second patient had inflammatory peripheral retinal artery occlusion, vasculitis, and uveitis which did not affect vision. The third patient presented with CRAO following the progression from orbital cellulitis to orbital apex syndrome. Interestingly, CRAO progressed to internal carotid artery occlusion in this case within days and resulted in monocular visual loss. Variations in the underlying pathophysiology and the characteristics of individual immune responses in patients with COVID-19 may be factors that determine differences in clinical manifestations. This article aims to describe different presentations of COVID-19-related retinal artery occlusions and discuss possible pathophysiological aspects.

Pars plana vitrectomy combined with pan-retinal photocoagulation, Ahmed glaucoma valve implantation, and/or phacoemulsification for complicated neovascular glaucoma treatment.

PURPOSE: To present long-term results of pars plana vitrectomy combined with pan-retinal endolaser photocoagulation, Ahmed glaucoma valve implantation, and/or phacoemulsification in patients with complicated neovascular glaucoma. METHODS: The study comprised 15 eyes from 15 patients with neovascular glaucoma as a complication of diabetic retinopathy and owing to ischemic central retinal vein occlusion. There was a vitreous hemorrhage n all of the patients. Furthermore, 8 of the cases showed varying degrees of hyphema. All subjects received an intravitreal injection of bevacizumab three days before surgery. In 12 phakic patients, phacoemulsification, pars plana vitrectomy, and Ahmed glaucoma valve implantation were performed. Pars plana vitrectomy and Ahmed glaucoma valve implantation were performed in 3 pseudophakic patients. Perioperative and postoperative complications, intraocular pressure values, and best-corrected visual acuity scores were also recorded. RESULTS: The mean follow-up was 24.4 ± 14.56 months. The mean preoperative intraocular pressure was 50.06 ± 7.6 mmHg. At 1 day, 7 days, and 1-, 3-, 6-, 12-month, and last visit following surgery, the mean intraocular pressure was 11.06 ± 8.22, 12.66 ± 7.27, 13.8 ± 7.73, 18.64 ± 7.05, 19.28 ± 4.61, 16.28 ± 1.68, and 16.92 ± 2.12 mmHg, respectively (p=0.001 for every follow-up visit). The mean visual acuity on the most recent appointment was 1.18 ± 0.42 logMar (p=0.001 for each subsequent visit). As postoperative early complications, varying degrees of hyphema and fibrin reactions were recorded. During follow-up, one patient developed phthisis bulbi. In 4 cases, Ahmed glaucoma valve revision surgery was required. CONCLUSIONS: In patients with complicated neovascular glaucoma, combined surgical procedures are safe, effective, and preferable both in terms of controlling high intraocular pressure and providing reasonable visual abilities.

Genotype-phenotype correlations in ocular manifestations of Marinesco-Sjögren syndrome: Case report and literature review.

PURPOSE: This study aims to present a family with two children with MSS who presented with different ophthalmic features. We also aim to review MSS patients' ocular manifestations to provide a basis for future clinical trials and improve MSS patients' ophthalmologic care. CASE DESCRIPTION: Both patients presented with global developmental delay, microcephaly, cerebellar ataxia, and myopathy. The older sibling had developed bilateral cataracts at the age of six. Her 2 years younger sister interestingly showed bilateral hyperopic refractive error without cataracts yet. Mendeliome sequencing unraveled a novel homozygous frameshift mutation in the SIL1 gene (SIL1, NM_022464.5, c.1042dupG, p.E348Gfs*4), causing MSS. A systematic literature review revealed that cataracts appear in 96% of MSS cases with a mean onset at 3.2 years. Additional frequent ocular features were strabismus (51.6%) and nystagmus (45.2%). CONCLUSION: SIL1-related MSS is associated with marked clinical variability. Cataracts can develop later than neuromuscular features and cognitive signs. Since cataract is a relatively late finding, patients may refer to ophthalmologists for other reasons such as refractive errors, strabismus, or nystagmus. Molecular genetic testing for SIL1 is essential to facilitate early diagnosis in patients with suspected MSS.

Evaluating the brainstem in children with breath-holding spells.

OBJECTIVE: Breath-holding spells (BHSs) are a non-epileptic paroxysmal phenomenon characterized by frequent apnea episodes, loss of consciousness, and changes in skin tone and postural tone triggered by negative stimuli of childhood. The pathophysiology of the disease remains unclear; autonomic dysregulation caused by delayed myelination is believed to play a role. In this study, we aimed to evaluate the brainstems of children with BHS using diffusion tensor imaging (DTI) and investigate the etiology of this phenomenon. METHODS: The study group consisted of 16 children with a history of severe breath-holding episodes (accompanied by loss of consciousness and tonic contraction due to prolonged anoxic response) and 18 age-, gender-, and handedness-matched controls. All children underwent systemic, neurologic, and cardiologic evaluation, including complete blood count, blood biochemistry, serum iron and ferritin level, serum vitamin B12 level, electrocardiogram, and electroencephalograms. Magnetic resonance imaging was performed using a 1.5-Tesla Siemens Aera scanner (Siemens, Germany). RESULTS: Evaluation of brainstem (midbrain, pons, and medulla oblongata) volumes revealed no statistically significant differences between the BHS patient and control groups. In a voxel-wise analysis of DTI data, the BHS patient group had significantly lower fractional anisotropy (FA) values than the control group in the bilateral midbrain and medulla, right corticospinal tract, bilateral corpus callosum body and splenium, and left corpus callosum genu. In contrast, there were no significant differences in FA values in the pons, cerebellum, left corticospinal tract, and right corpus callosum genu. CONCLUSION: Based on our findings, we think that patients with BHS should be treated with an approach similar to other neurodevelopmental diseases and that this study may help elucidate the pathophysiology and establish the groundwork for future studies on its treatment.

Corneal tattooing for esthetic purposes in patients with corneal opacities.

Purpose: This study evaluated corneal tattooing for esthetic purposes in patients with corneal opacification. Methods: Eight eyes of eight patients were included in the study (four males and four females). Corneal tattooing was achieved by stromal puncture in five patients, femtosecond laser-assisted corneal tattooing in two patients, and femtosecond laser-assisted corneal tattooing and stromal needling (combined procedure) in one patient. In six of the patients, the entire cornea was stained black; in one patient, the center of the cornea (3 mm) was stained black and the periphery was stained dark brown; and in the last patient, the corneal periphery was stained dark brown. Patient satisfaction was evaluated on the first day after surgery and at the last visit as follows: Very satisfied (4), satisfied (3), moderately satisfied (3), and not satisfied (1). Results: The patients ranged in age from 11-80 years. The mean satisfaction score of the patients was 4 and 3.5 on the first postoperative day and at the last visit, respectively. No complication occurred during or after surgery. Conclusion: Corneal tattooing for esthetic purposes was successful in both blind eyes and seeing eyes.

An analysis of 109 fetuses with prenatal diagnosis of complete agenesis of corpus callosum.

BACKGROUND: Agenesis of the corpus callosum (ACC) is the most frequent commissural malformation of the brain. It continues to be an important cause of the pregnancy termination associated with the central nervous system (CNS). OBJECTIVE: The aim of the study is to provide a comprehensive assessment of fetuses with diagnosis of complete ACC, as well as postnatal neurodevelopmental outcomes. METHODS: The data of 75,843 fetuses were screened for evaluation of complete ACC between 2003 and 2017, and a total of 109 cases with complete ACC were included in the study. ACC was considered isolated when no additional anomalies were detected, and ACC was considered complex when additional anomalies were present. RESULTS: The prevalence of complete ACC was 9.4 per 10,000 live births, and the incidence was ranged from 1.8 to 16.6 per 10,000 person-years. Patients with isolated ACC had a significantly higher survival when compared with patients with complex ACC (97.4%, n = 38/39 vs. 68.8%, n = 22/32, P = 0.001).The most important cause of death were congenital heart disease and/or respiratory failure during neonatal period. Developmental and intellectual disabilities were significantly higher in the complex ACC cases (P < 0.001). Postnatal neurodevelopmental outcomes were completely normal in 79.4% of cases with isolated ACC. CONCLUSIONS: Isolated complete ACC is usually associated with a favorable outcome. The most important prognostic factors are the presence or absence of associated congenital anomalies.

Assessment of ganglion cell complex, macular thickness, and optic disc parameters in keratoconus patients.

PURPOSE: Keratoconus (KC) is bilateral noninflammatory corneal disorder characterized by progressive corneal thinning, protrusion, and scarring. The purpose of this study was to evaluate ganglion cell complex(GCC), macula thickness(MT) and optic head disc parameters in keratoconus patients. METHODS: A hospital based prospective clinical case series was performed in Inonu University School of Medicine. 52 eyes of 52 keratoconus patients and 50 eyes of 50 normal patients were enrolled. RESULTS: There is no statistically significant in MT between groups. GCC in nasal superior, temporal superior and temporal inferior 9 mm from macula were found statistically significant decrease in keratoconus group (p<0,05). In optic disc analysis fifth and the eleventh clock-hour quadrants of peripapiller retina nerve fiber layer and cup area ratio were found statistically significant decrease in keratoconic eyes (p<0,05). CONCLUSION: We thought that structural retinal changes seem in keratoconus eyes; keratoconus pathogenesis may affect not only cornea but also retina and optic nerve head.

Pepper spray inhalation-induced acute polyneuropathy mimicking Guillain-Barre syndrome.

Peripheral neuropathy is the most common reaction to toxic chemical substances in the nervous system. Toxic neuropathies are often misdiagnosed because there are no easily available specific or biologic tests for the diagnosis. Guillain-Barre syndrome is the most common cause of acute flaccid paralysis in children and adolescents. Clinical signs of the disease are often at the beginning of the distal symmetric weakness and areflexia progresses rapidly. Although capsaicin is widely used in the treatment of so many diseases, especially of neuropathic pain, cancer and osteoarthritis, it is known to be toxic in many systems such as the eye, skin, respiratory, and circulatory systems. Although there is inadequate information about its long-term effects, it has also been reported that in large quantities there is increased risk of toxicity and prolonged exposure can lead to death. In our case, we present acute polyneuropathy mimicking Guillain-Barre syndrome after exposure to pepper spray because it is noteworthy and interesting.

Periferik nöropati sinir sisteminin toksik kimyasal maddelere karsi verdigi en sik görülen reaksiyonudur. Tani için özgün ya da biyolojik testlerin kolaylikla bulunmamasi ve maruziyetin bilinmemesi nedeni ile toksik nöropatiler siklikla yanlis tani alirlar. Guillain-Barre sendromu çocuk ve ergenlerde akut flask paralizinin en sik nedenidir; klinik bulgulari hastaligin baslangicinda distalde olup siklikla hizli ilerleme gösteren simetrik güçsüzlük ve arefleksidir. Agri, kanser, osteoartrit vb. birçok hastalik tedavisinde kullanim alani bulan kapsaisinin basta göz, deri, solunum ve dolasim sistemi olmak üzere birçok sistemde toksik etki gösterdigi, hatta ölüme götüren hastalik süreçlerini tetikledigi bilinmektedir. Uzun dönemdeki etkileri ile ilgili yeterli bilgi bulunmamakla birlikte, yüksek miktarlarda ve uzamis maruziyet durumunda toksik risklerin arttigi ve ölüme yol açabilecegi de bildirilmektedir. Olgumuzda biber gazi maruziyeti sonrasi Guillain-Barre sendromunu taklit eden polinöropati olgusu ilgi çekici olmasi nedeni ile sunulmustur.

Comparison between high-flow nasal oxygen cannula and conventional oxygen therapy after extubation in pediatric intensive care unit.

Akyildiz B, Öztürk S, Ülgen-Tekerek N, Doganay S, Görkem SB. Comparison between high-flow nasal oxygen cannula and conventional oxygen therapy after extubation in pediatric intensive care unit. Turk J Pediatr 2018; 60: 126-133. The aim of this study was to compare the efficiency, safety, and outcomes of the high-flow nasal oxygen cannula (HFNC) and conventional oxygen therapy (COT) after extubation in children. A randomized controlled trial was conducted in a 13 bed pediatric intensive care unit. One-hundred children who underwent extubation were eligible for the study. Patients were divided into HFNC (n=50) and COT (n=50) groups. Basal variables including heart rate (HR), noninvasive blood pressure, respiratory rate (RR), SpO < sub > 2 < /sub > , SpO < sub > 2 < /sub > /FiO < sub > 2 < /sub > (SF) ratio, and end tidal CO < sub > 2 < /sub > (EtCO < sub > 2 < /sub > ) were obtained initially and recorded at 15, 30, and 45 minutes and at 1, 6, 12 hours, 24 and 48 hours after extubation. SF ratio and SpO < sub > 2 < /sub > increased during the first hour in the HFNC group (p=0.005 and p=0.03, respectively). HR and RR decreased during follow-up in the HFNC group (p=0.001 and p=0.048, respectively). There was no statistically significant difference for PCO < sub > 2 < /sub > after extubation between the two groups. PCO < sub > 2 < /sub > (p=0.008) and EtCO2 (p=0.018) values at 24-h were different between two groups. At follow-up, HR decreased only in the HFNC group (p=0.001) and was different at 12 and 48 hours (p=0.047 and p=0.01, respectively). Initial modified radiologic atelectasis scores (m-RAS) were higher for the HFNC group and decreased steadily (p=0.001). Extubation failure rates were 4% and 22% for the HFNC and COT groups, respectively (p=0.007). In conclusion, HFNC is better than COT, especially for the restoration of the respiratory and radiologic parameters. Although more expensive, the use of HFNC may have more advantages to reduce the risk of extubation failure in critically ill children compared with COT.

A Rare Case of Blebharitis: Phthiriasis Palpebrarum.

A six-year-old male patient was admitted to our hospital due to itching and scalding crusts that persisted 10-15 days in both eyes. Upon biomicroscopic examination, 5-6 semi-translucent, yellowish brown living lice attached to the upper eyelashes and a large number of eggs were observed. Following application of pilocarpine hydrochloride (Pilomann 2%, Bausch-Lomb) and topical proparacaine hydrochloride (Alcaine 0.5%, Alcon), the paralyzed parasites and eggs were manually removed by pulling with forceps. The lice were identified as adult forms of pubic louse, Pthirus pubis, and its eggs. The patient was treated with pilocarpine hydrochloride, which was applied thrice a day combined with pure vaseline. One week later, no lice or eggs were seen on the eyelashes.

Cerebral Sinus Venous Thrombosis and Prothrombotic Risk Factors in Children: A Single-Center Experience From Turkey.

BACKGROUND: Cerebral sinus venous thrombosis (CSVT) is a rare cerebrovascular disease that may be life-threatening, especially in children. OBJECTIVE: The purpose of this study was to assess the clinical presentation, radiologic imaging, underlying conditions, treatment, and outcomes of children with CSVT. PATIENTS AND METHODS: In total, 23 consecutive children aged between 1 month to 18 years with CSVT, who were followed-up in Erciyes University Children's Hospital, were retrospectively enrolled in the study from January 2000 to December 2016. RESULTS: The median age of the 23 children (13 female patients, 10 male patients) at initial diagnosis was 60 months (1 to 204 mo). The most common clinical manifestation was headache/irritability (n=9). The most common site of the CSVT was the transverse sinus (n=16). The most common prothrombotic risk factor was protein C deficiency (n=4). Underlying risk factors were detected in 15 patients. Genetic risk factors such as protein C deficiency, infections, trauma, malignancies, autoimmune hemolytic anemia, neurometabolic disorders, asphyxia, and cardiac malformations were common risk factors. Six children died. Multiple sinus involvement and parenchymal hemorrhages were seen in 4 and in 3 of the 6 children who died, respectively. CONCLUSIONS: Protein C deficiency seemed to be relatively high in the presented children. Multiple sinus involvement and additional parenchymal hemorrhages represent poor prognostic features.

Brain susceptibility changes in neurologically asymptomatic pediatric patients with Wilson's disease: evaluation with quantitative susceptibility mapping.

Background Wilson's disease (WD) is a copper metabolism disorder that causes hepatolenticular degeneration. It is important to diagnose WD before central nervous system involvement. Purpose To demonstrate the early susceptibility changes associated with the copper accumulation in the brain of neurologically asymptomatic pediatric patients with WD using quantitative susceptibility mapping (QSM). Material and Methods Twelve patients with neurologically asymptomatic WD (mean age = 13.7 ± 3.3 years) and 14 age-matched controls were prospectively examined using a 1.5-T clinical scanner. Routine magnetic resonance (MR) sequences and a three-dimensional multi-echo spoiled gradient echo (GRE) sequence were used and QSM maps were reproduced. The quantitative susceptibility of corpus striatum, thalamus, substantia nigra, and pons were analyzed with the region of interest analysis on QSM maps. The susceptibility values of two groups were statistically compared using a two-sample t-test. Results Conventional MR images of the patients and control group were similar. However increased magnetic susceptibility in the thalamus, pons and left posterior putamen were observed in the patients compared to the control group ( p < 0.05). Conclusion We observed statistically increased susceptibility values in the brains of neurologically asymptomatic patients with WD although the conventional MR images were normal. This might be compatible with early brain impairment, before neurological symptoms occur.

Evaluation of symmetrical increased echogenicity of bilateral caudothalamic grooves detected on cranial ultrasonography by comparing with susceptibility-weighted imaging.

OBJECTIVE: To assess symmetrical increased echogenicity of bilateral caudothalamic grooves (SIEBCG) detected on newborn cranial ultrasonography (CUS) using magnetic resonance susceptibility-weighted imaging (SWI). MATERIALS AND METHODS: A total of 14 newborns (8 girls; 12 premature with mean gestational age of 30 weeks and 5 days, 2 mature) who were detected to have SIEBCG on routine serial CUS and underwent cranial magnetic resonance imaging (MRI) were recruited for the study. The cranial MRI examinations including SWI acquired on the same day of SIEBCG detection and serial CUS to assess the progress of SIEBCG lesions in the following 6 month period were retrospectively evaluated and compared for the presence of germinal matrix hemorrhage. RESULTS: On SWI, solely one patient (7, 1%) had signal alteration on caudothalamic groove compatible with grade 1 germinal matrix hemorrhage. Two patients (14, 2%) had parenchymal (on cerebellar and parietal white matter) millimetric hemorrhagic foci. Seven patients (50%) had signs of presumptive hypoxic insult including hyperintense dots on centrum semiovale and periventricular white matter in five, and increased signal intensity on the globus pallidi in two, on T1-weighted images. Four patients (28, 6%) had normal findings. Of these, 10 patients became normal on follow-up CUS at postterm-equivalent age, whereas four were missing. CONCLUSION: Symmetrical increased echogenicity of bilateral caudothalamic grooves seen on newborn CUS may be the indicator of other pathologies as ischemic insult or focal parenchymal hemorrhage. In the presence of SIEBCG, further examination with SWI should be performed.

A Case of Child Physical Abuse With a Rolling Pin Insertion, Resulting in Bladder and Rectal Perforation.

Visceral injuries are not uncommon in nonaccidental trauma and often require emergent operative intervention. However, sometimes it can be difficult to assess the extent of injury. In this report, we present a case of child physical abuse resulting in bladder and rectal perforations, which was initially referred to our hospital as acute abdomen with intraperitoneal free fluid on ultrasonography. An exploratory laparotomy revealed the perforations and surgical repair was performed. The patient was evaluated by the Hospital Child Protective team and it was revealed that bladder and rectum perforations were due to insertion of rolling pin into the rectum by the stepmother. The child was discharged home uneventfully with a temporary colostomy. We believe that this is the first reported case in the English literature of inflicted perforation of the rectum and bladder through insertion of a rolling pin.

Relationship between Doppler findings and fetal brain apparent diffusion coefficient in early-onset intra-uterine growth restriction.

OBJECTIVE: The aim of the study is to assess the relationship between uteroplacental Doppler sonography findings and cerebral diffusion measured by diffusion-weighted magnetic resonance imaging (DWI) in fetuses with early-onset intrauterine growth restriction (IUGR). MATERIALS AND METHODS: The study included 54 pregnant women with fetal IUGR and 15 healthy controls (n: 15). Fetuses with IUGR were classified into four groups based on Doppler findings: group 1 (n = 12), umbilical artery (UA) pulsatility index (PI) > 95pc; group 2 (n = 11), UA PI >95 pc and middle cerebral artery PI < 5pc; group 3 (n = 21), absent end-diastolic (A-EDF) in UA; group 4 (n = 10), reversed EDF in UA. After Doppler evaluation, DWI was performed in all patients within hours. The groups were compared with respect to apparent diffusion coefficient (ADC) levels. FINDINGS: In cases with fetal IUGR, significant decreases were detected in ADC values of periatrial white matter (PAWM) (p = .01), frontal white matter (FWM) (p = .038), thalamus (p = .004), and basal ganglia (p = .013) compared to controls. In Doppler subgroup analysis adjusted for gestational age, ADC values of FWM, thalami, and pons were significantly lower in group 4 than control group (p = .02, p = .02, and p = .037, respectively). In PAWM, ADC values were significantly lower in group 4 than control and Group 1 (p = .004). No significant differences with regard to ADC values in basal ganglia, cerebellum was found between Doppler groups and control. CONCLUSIONS: In fetuses with IUGR, ADC values as measured by DWI decreases. The critical Doppler finding that is associated with reduced diffusion in some brain areas (FWM, PAWM, thalami, pons) is reverse end-diastolic flow in umbilical artery. Further prospective studies with larger sample size are needed to introduce cerebral ADC values in the management of IUGR.

Magnetic Susceptibility Changes in the Basal Ganglia and Brain Stem of Patients with Wilson's Disease: Evaluation with Quantitative Susceptibility Mapping.

OBJECTIVES: Wilson's disease (WD) is characterized with the accumulation of copper in the liver and brain. The objective of this study is to quantitatively measure the susceptibility changes of basal ganglia and brain stem of pediatric patients with neurological WD using quantitative susceptibility mapping (QSM) in comparison to healthy controls. METHODS: Eleven patients with neurological WD (mean age 15 ± 3.3 years, range 10-22 years) and 14 agematched controls were prospectively recruited. Both groups were scanned on a 1.5 Tesla clinical scanner. In addition to T1- and T2-weighted MR images, a 3D multi-echo spoiled gradient echo (GRE) sequence was acquired and QSM images were derived offline. The quantitative measurement of susceptibility of corpus striatum, thalamus of each hemisphere, midbrain, and pons were assessed with the region of interest analysis on the QSM images. The susceptibility values for the patient and control groups were compared using twosample t-test. RESULTS: One patient with WD had T1 shortening in the bilateral globus pallidus. Another one had hyperintensity in the bilateral putamen, caudate nuclei, and substantia nigra on T2-weighted images. The rest of the patients with WD and all subjects of the control group had no signal abnormalities on conventional MR images. The susceptibility measures of right side of globus pallidus, putamen, thalamus, midbrain, and entire pons were significantly different in patients compared to controls (P < 0.05). CONCLUSION: QSM method exhibits increased susceptibility differences of basal ganglia and brain stem in patients with WD that have neurologic impairment even if no signal alteration is detected on T1- and T2-weighted MR images.

Imaging Evaluation Of Pediatric Orbital Pathologies.

The orbital pathologies commonly detected during the childhood period substantially differ from the lesions that arise in adult orbit. The advance in imaging modalities including computed tomography (CT) and particularly magnetic resonance imaging (MRI) might enable the radiologists and clinicians who would be involved in either medical or surgical care of orbital pathologies, to confidently establish a definite diagnosis prior to histopathologic examination. The purpose of this pictorial assay is to present relatively common paediatric orbital pathologies with regard to CT and MRI findings.