Interpedicular approach in percutaneous sacroplasty for treatment of sacral vertebral body pathologic fractures.

For this technique, bone needle is introduced into the S1 vertebral body through the interpedicular route by penetrating the central spinal canal at the level of S3-4 and passing through the vertebral body of S2-3 parallel to the anterior border of sacrum. With the interpedicular approach, two sacral vertebral bodies can be injected in one session and lower sacral body injection also is available. interpedicular technique is a safe, practical, and effective technique for the treatment of sacral vertebral body pathologic fractures.

Advanced MRI findings in patients with breast hamartomas.

PURPOSE: Although it has been stated that breast hamartomas are rare tumors, radiologists frequently encounter them in their daily practices. Fat, glandular and fibrous tissues all produce a mass of disorganized but mature specialized cells. Because hamartomas do not have specific diagnostic histological features, the clinical and radiological findings are important in their diagnosis. The aim of this study is to present the advanced magnetic resonance imaging (MRI) findings of breast hamartomas. MATERIALS AND METHODS: Eight patients with breast hamartomas were examined using MRI techniques in addition to ultrasonographic and/or mammographic findings. RESULTS: Each of the lesions examined showed a gradual enhancement pattern in its time-signal intensity curve on dynamic contrast-enhanced MRI. On MR spectroscopy, water and lipid peaks were detected that resembled normal breast tissue. The diffusion features of the lesions were variable due to the different ratios of the tissue elements constituting them on diffusion-weighted imaging (DWI). CONCLUSION: Advanced MRI findings may clarify diagnoses by providing additional information following sonography, especially in lactating or pregnant women, in whom mammographic examination is not preferred.

A heart transplant recipient lost due to Pneumocystis jiroveci pneumonia under trimethoprim-sulfamethoxazole prophylaxis: case report.

Infections in solid-organ transplant recipients are the most important causes of morbidity and mortality. A primary goal in organ transplant is the prevention or effective treatment of infection, which is the most common life-threatening complication of long-term immunosuppressive therapy. A 21-year-old woman who underwent heart transplant 3 years previous owing to dilated cardiomyopathy was referred to our hospital with symptoms of high fever and cough. The patient's history revealed that she had received a trimethoprim-sulfamethoxazole double-strength tablet each day for prophylactic purposes. On chest radiograph, pneumonia was detected, and in broncho-alveolar lavage sample, Pneumocystis jiroveci cysts were found. After diagnosing P. jiroveci pneumonia, trimethoprim-sulfamethoxazole was initiated at 20 mg/kg/d including intravenous trimethoprim in divided dosages every 6 hours. On the sixth day of therapy, she died in intensive care unit. In solid-organ transplant recipients, although antipneumocystis prophylaxis is recommended within the first 6 to 12 months after transplant, lifelong prophylaxis is also used in several settings. In addition, the physician should keep in mind that P. jiroveci pneumonia may develop in solid organ recipients, despite trimethoprim-sulfamethoxazole prophylaxis.

Diffusion-weighted images differentiate benign from malignant thyroid nodules.

PURPOSE: To reveal the possible role of diffusion-weighted images (DWI) in the differential diagnosis of benign and malignant thyroid nodules by comparing the results of fine-needle aspiration cytology (FNAC). MATERIALS AND METHODS: In an 18-month period (December 2005 to May 2007), 27 cases with benign thyroid nodules with a total of 52 benign nodules, nine cases with thyroid gland malignancy, and 24 healthy control cases were included in the study. Cases that were indicated to undergo to FNAC examination and sent by a clinician for biopsy to the radiology unit were included in the study to assess the cytopathologic confirmation of the clinic, ultrasonographic, and magnetic resonance imaging (MRI) findings. RESULTS: The mean apparent diffusion coefficient (ADC) values of thyroid nodules were 2745.3 +/- 601.1 x 10(-6) mm(2)/s (1605-3899 x 10(-6)mm(2)/s) in the benign group and 695.2 +/- 312.5 x 10(-6)mm(2)/s (165-1330 x 10(-6)mm(2)/s) in the malignant group. Normal thyroid tissues had mean ADC values of 1344.1 +/- 276.4 x 10(-6) mm(2)/s (1015-1764 x 10(-6)mm(2)/s). The ADC values of three subgroups were significantly different (P = 0.0001). A reduced ADC was observed in most types of malignant tumors due to the consequent decrease of the extracellular extravascular space. CONCLUSION: Our preliminary results showed that ADC values of nodules may provide useful data about the nature of a thyroid nodule.

Incontinentia pigmenti: a case report and literature review.

Incontinentia pigmenti (IP) is a rare, X-linked dominant disorder that presents at or soon after birth with characteristic cutaneous signs. The eyes and central nervous system are the next most commonly affected systems. We aimed to describe the ophthalmological, neurological and radiodiagnostic findings of a patient with IP and bilateral retinal detachment. Clinical and laboratory findings of a four-month-old female baby who did not have light fixation and had neurological maturation retardation are presented. Characteristic skin lesions of IP were noted especially at the extremities, bilaterally. On neurological examination, motor and mental maturation were retarded and axial hypotonia was noted. Bilateral retinal detachment was the cause of absent eye fixation noted during ophthalmologic examination, and the detachments were also documented by ultrasonography and magnetic resonance imaging (MRI). Otologic examination was normal. Focal left frontal lobe atrophy, corpus callosum hypoplasia and prominence of right hemisphere were also noted on MRI. MR spectroscopy revealed negative lactate peak at the involved left frontal lobe. Bilateral retinal detachment is a probable finding in IP and patients with neurological symptoms should be investigated for associated sight-threatening ocular pathologies.

Microstructural changes in uterine leiomyomas and myometrium: a diffusion-weighted magnetic resonance imaging study.

Although morphological and histopathological changes in uterine leiomyomas have been investigated in detail, the microstructural disruptions could not be studied in the living organism. Diffusion-weighted magnetic resonance imaging (DWI) is a novel tool to assess microstructural changes in vivo. The aim of this study was to investigate and characterize the diffusional property of leiomyomatous tissues with DWI. Sixteen females with a total of 21 leiomyomas were imaged with a 1.5-tesla clinical MR scanner. DWI images of leiomyomas, adjacent myometrial and myometrial tissues of healthy controls were obtained and quantified using apparent diffusion coefficient (ADC) maps. Mean ADC values of these groups were 1,201, 1,684, 1,661 mm(2)/s x 10(-6), respectively. ADC values in leiomyomas were significantly lower than those observed in the myometrium (p < 0.001). Cut-off values produced 91% sensitivity and 100% specificity. As ADC values implied the presence of cytotoxic edema in leiomyomas, the technique was found to be promising in observing temporal variations in leiomyomas and to monitor even the most subtle effects of therapeutic interventions.

Neuroimaging findings in hyperargininemia.

In hyperarginenemia, there is a defect in argininase enzyme, which is a catalyzer of urea cycle. Though the pathogenesis of neuronal damage in hyperargininemia is not clear, high serum and cerebrospinal fluid arginine levels can be directly related with neuronal damage. In this study, our aim was to assess brain magnetic resonance images and magnetic resonance spectroscopy (MRS) patterns of two siblings with hyperarginenemia. We acquired single voxel MRS from the white matter to show the myelination pattern and to figure out any abnormal peak of metabolite stored due to enzymatic defect. We observed mild cerebral and cerebellar atrophy and infarct at bilateral posterior putamen and insular cortex localization on conventional images and elevated choline/creatine ratios and abnormal peak at 3.8 ppm, most likely representing arginine deposition. To the best of our knowledge, this is the first article revealing the brain MRS pattern of hyperargininemia. We reported the clinical and imaging findings of patients and discuss the correlation.

Isolated preauricular pits and tags: is it necessary to investigate renal abnormalities and hearing impairment?

We investigated the incidence and co-existence of hearing impairment and renal abnormalities in healthy children with preauricular tags and pits. Study population consists of 13,740 primary school children from routine health check. Thirty-five children with preauricular tags and pits were noted. Control group consisted of 91 patients without pits and tags, who underwent renal ultrasound and were scheduled to pediatric outpatient clinic. Urinalysis, renal ultrasound, otoacoustic emission were performed in both the groups. The prevalence of renal abnormality (1/36; 2.7%) and hearing impairment (1/36; 2.7%) in patients with preauricular tags and pits was similar to that of control group (3/91; 3.2% and 4/91; 4.3%) (P = 0.87, P = 0.64, respectively). According to our results, it is not necessary to investigate hearing or urinary abnormality in patients with preauricular tag or pit, unless there is an association of a syndrome or family history of hearing or renal impairment.

Magnetic resonance spectroscopy features of normal-appearing white matter in patients with acute brucellosis.

We aimed to evaluate whether the subtle metabolic cerebral changes are present in normal-appearing white matter on conventional MRI, in patients with acute brucellosis, by using MR spectroscopy (MRS). Sixteen patients with acute brucellosis and 13 healthy control subjects were investigated with conventional MRI and single-voxel MRS. Voxels were placed in normal-appearing parietal white matter (NAPWM). N-Acetyl aspartate (NAA)/creatine (Cr) and choline (Cho)/Cr ratios were calculated. There was no significant difference between the study subjects and the control group in NAA/Cr ratios obtained from NAPWM. However, the Cho/Cr ratios were significantly higher in patients with acute brucellosis compared to controls (p=0.01). MRS revealed metabolic changes in normal-appearing white matter of patients with brucellosis. Brucellosis may cause subtle cerebral alterations, which may only be discernible with MRS. Increased Cho/Cr ratio possibly represents an initial phase of inflammation and/or demyelination process of brucellosis.

1H magnetic resonance spectroscopy of the normal testis: preliminary findings.

PURPOSE: The purpose of this study was to determine the pre- and postpubertal 1H magnetic resonance spectroscopic characteristics of the normal testis to establish baseline values for further clinical studies. MATERIALS AND METHODS: The subjects consisted of male volunteers, of whom 19 were prepubertal with ages between 7 and 13 years and 24 were postpubertal with ages between 19 and 39 years. Their testes were evaluated at 1.5 T with magnetic resonance spectroscopy; in addition, testis volumes were measured. Major metabolite peaks were identified and their ratios were calculated. Metabolite differences of testis between pre- and postpubertal age were analyzed. RESULTS: Major constituents of spectra were 3.21 ppm choline and 0.9-1.3 ppm lipid peaks. At the echo time (TE) spectrum of 31 ms, choline/lipid ratios ranged from 0.35 to 8.30 (mean=1.87) in postpubertal males and from 0.06 to 5.45 (mean=0.88) in prepubertal males (P<.013). At the TE spectrum of 136 ms, choline/lipid ratios ranged from 0.66 to 15.42 (mean=4.09) in postpubertal males and from 0.05 to 4.91 (mean=0.9) in prepubertal males (P<.016). CONCLUSIONS: Choline/lipid ratio was higher in the postpubertal period. The existence of higher choline peak in that age group should be due to the initiation of spermatogenesis. The decrease in the lipid peak may represent the effect of testosterone on testicular tissue or may be due to histochemical changes initiated by puberty. The significant decrease in choline/lipid ratio noted after puberty could represent the presence of spermatogenesis. This hypothesis should be evaluated by further studies on postpubertal subjects with impaired spermatogenesis.

Diffusion-weighted imaging evaluation of subtle cerebral microstructural changes in intrauterine fetal hydrocephalus.

OBJECTIVE: Hydrocephalus is an important etiological factor in neurological decline. With the advent of fetal ultrasound, fetal hydrocephalus is now more frequently detected than in the past. Ultrasonography (USG) provides information on general morphology, but microstructural changes that may play a prognostic role are beyond the resolution of that technique. These changes may theoretically be revealed by diffusion-weighted magnetic resonance imaging (DW-MRI). In this study, our preliminary findings of DW-MRI on the hydrocephalic fetuses are presented. MATERIALS AND METHODS: Twelve fetuses with fetal USG diagnosis of hydrocephalus were investigated using a 1.5-T MR scanner. In addition to conventional techniques, DWI was performed. It was obtained using a single-shot echo-planar imaging sequence (TR/TE: 4393/81 ms; slice thickness: 5 mm; interslice gap: 1 mm; FOV: 230 mm; matrix size: 128x256; b values: 0 and 1000 s/mm2). Apparent diffusion coefficient (ADC) values were measured in the white matter of the periventricular frontal and occipital lobes, basal ganglia, thalamus, centrum semiovale and cerebrospinal fluid in the lateral ventricle. These values were compared with the normal prenatal ADC values from a radiological study published in the literature. RESULTS: All fetuses had moderate or severe bilateral supratentorial ventricular dilatation that was compatible with hydrocephalus. On conventional T1- and T2-weighted imaging, cerebral parenchyma had normal signal pattern and ADC values were significantly lower than those reported for fetuses with normal brain. These values were lower in hydrocephalic fetuses with statistical significance (P<.05-.01). CONCLUSION: DWI is a sensitive technique to investigate cerebral microstructure. The reduction in cerebral blood flow and alterations in cerebral energy metabolism in cases with hydrocephalus have been shown before. Changes in cerebral blood flow and energy metabolism, as a consequence of cerebral compression, may occur in hydrocephalus. Elevated ventricular pressure may cause cerebral ischemia. The anaerobic glycolysis seen in the hydrocephalic brain tissue by increasing the lactate concentration and intracellular fluid flux may be the reason for the reduced ADC values in hydrocephalic fetuses. However, long-term prospective trials on the correlation of ADC values and neurological outcome are necessary to exploit the full benefit of that novel technique.

[Dynamic contrast-enhanced magnetic resonance imaging findings of mass lesions of the pontocerebellar angle]. / Pontoserebellar köse tümörlerinde dinamik kontrastli manyetik rezonans görüntüleme bulgulari.

OBJECTIVES: The differential diagnosis of mass lesions of the pontocerebellar angle is not always possible by conventional magnetic resonance imaging (MRI). In this study, we investigated the role of dynamic contrast-enhanced MRI in the differential diagnosis of acoustic neurinoma, meningioma, and paraganglioma. PATIENTS AND METHODS: Twelve patients (8 females, 4 males; mean age 47.5 years; range 8 to 71 years) whose diagnoses were acoustic neurinoma (n=3), paraganglioma (n=5), and meningioma (n=4) were evaluated by simultaneous conventional and dynamic contrast-enhanced MRI. Prior to postcontrast T1-weighted images, dynamic MRI was obtained. On these images, maximum contrast enhancement (Cmax) and time to peak enhancement (Tmax) were calculated at 15 different time points. Time-signal intensity curve patterns of the lesions were compared. RESULTS: According to the four main time-signal intensity curve patterns described in the literature, acoustic neurinomas, meningiomas, and paragangliomas exhibited type C, type A-B, and type A curve patterns, respectively. CONCLUSION: Our results suggest that dynamic contrast MRI may have an additional but limited role in the differential diagnosis of extra-axial intracranial tumors such as those of the pontocerebellar angle.

[Chondroradionecrosis in two patients with laryngeal carcinoma]. / Larenks karsinomlu iki hastada kondroradyonekroz.

Postradiotherapy necrosis in the larynx is a rare but serious complication. It must be differentiated from tumor recurrence with radiological and histopathological studies. Herein, we presented two patients with stage II and stage IV larynx carcinoma who developed chondroradionecrosis following radiotherapy. The first patient did not accept surgical treatment and was treated with curative radiotherapy at a dose of 70 Gy. The other one received adjuvant radiotherapy at a dose of 46 Gy following total laryngectomy and bilateral functional neck dissection. The two patients were evaluated with computed tomography and magnetic resonance imaging, respectively. Pathologic examination of multiple biopsies taken from both cases showed coagulation necrosis without malignancy. The first patient had grade IV radionecrosis according to the Chandler classification and underwent total laryngectomy because of non-functional larynx. Histopathologically, there were no malignant cells, but widespread fibrosis and coagulation necrosis. The other patient was treated with conservative treatment and local debridement.

Magnetic resonance spectroscopic characteristics of glutaric aciduria type II.

Magnetic resonance spectroscopy (MRS) of a 12-year-old female patient with glutaric aciduria type II was compared with data obtained from four healthy age- and sex-matched volunteers. In the clinically active phase, conventional magnetic resonance imaging showed mild ventricular dilatation. Frontal lobe choline/creatine (Cho/Cr) ratio (1.98) was higher than the ratios reported for the comparison participants (1.64 [SD 0.21]). The N-acetylaspartate/creatine (NAA/Cr) ratio (1.95) was lower than normal limits (2.66 [SD 0.23]). After successful riboflavin treatment and dietary restriction for proteins, the NAA/Cr ratio was within the normal range (2.44) and Cho/Cr ratio was below the normal range (1.15), suggesting riboflavin-responsive multiple acyl-coA dehydrogenase deficiency. An elevated Cho/Cr ratio and decreased NAA/Cr ratio is consistent with a demyelinating process in the active phase of glutaric aciduria type II. MRS helps to monitor the progress of the disease and the efficacy of treatment by revealing changes in NAA/Cr and Cho/Cr ratios.

Unilateral reverse ocular bobbing caused by tuberous sclerosis.

A female aged 12 months with developmental delay and left-sided reverse ocular bobbing (rapid deviation of the eye upward and a slow return to the horizontal position) was observed. At birth, an upper left gingival mass, pathologically diagnosed as a benign granular cell tumour, was removed. On computed tomography (CT), left middle cerebral pedincular and midpontine lesions were seen. Magnetic resonance imaging revealed additional white matter hamartomas, corticosubcortical tubers, and subependymal nodules. The patient was re-examined at 36 months. Her general developmental quotient was equivalent to 23 months of age. Third cranial nerve functions and auditory brainstem response were normal. Her abnormal eye movements were still present. Reverse bobbing is usually observed in patients who are unconscious and who have significant pontine pathology and disruption of the reticular formation. This case is the first tuberous sclerosis-related ocular bobbing case to our knowledge and is interesting as the causative lesion was relatively mild, and ocular horizontal movements were preserved.

Clinical outcomes of neonatal hypoxic ischemic encephalopathy evaluated with diffusion-weighted magnetic resonance imaging.

PURPOSE: Detection of early phase neurological deficit in babies with hypoxic-ischemic encephalopathy (HIE) is the most important step to determine the appropriate preventive treatment methods. Diffusion-weighted imaging (DWI) is the most sensitive radiological modality to detect ischemic changes in the brain, in their earliest phase. Herein, we present the results of our study about the role of DWI in the diagnosis and determining the prognosis of HIE in neonates. MATERIALS AND METHODS: The study included 36 cases (4 preterm, 32 term babies) who were diagnosed with HIE within 24 hours of birth and classified according to modified Sarnat staging. They were examined for the presence of neurological sequelae at 3 and 6 months of age with electroencephalography (EEG), visual evoked potential (VEP), brainstem auditory evoked potential (BAEP), and Denver II developmental screening tests. All 36 patients underwent conventional magnetic resonance (MR) imaging and DWI within the first 24 hours of birth; survivors underwent repetitive imaging exams at the end of the first week and then after a month. RESULTS: Seventeen stage I cases (47%), 12 stage II cases (33%), and 7 stage III cases (20%) were detected. DWI obtained within the first 24 hours showed high sensitivity (100%) in detecting the permanent neurological sequelae but with very low specificity (20%). The negative predictive value of DWI in this period was 100%; however, in DWI obtained at the end of the first month, not only its sensitivity was preserved, but its specificity reached 80%. The negative predictive value of DWI in this period was preserved and the positive predictive value improved. The importance of DWI in detecting sequelae at the end of the first month was also demonstrated by McNemar (p=0.250) and Kappa (Kappa=0.719) tests. There was no difference between conventional MR imaging and DWI in detecting sequelae at the end of first month. CONCLUSION: DWI is superior to other imaging modalities in detecting ischemia; not only because of its high sensitivity in the early phase, but also because of its high sensitivity and specificity in the late phase. Moreover, with its high negative predictive value, DWI can be used for excluding the possibility of sequelae development in the early phase of HIE cases for medico-legal purposes.

The incidence of atopy in adults with recurrent secretory otitis media: screening with Phadiatop.

OBJECTIVES: This is a preliminary report of a relatively new method, Phadiatop, in screening atopic adult patients with recurrent secretory otitis media (SOM). The sensitivity and specificity, and its use in atopic adult patients with recurrent SOM were evaluated. PATIENTS AND METHODS: Eighty-four patients (54 females, 30 males; mean age 36.7; range 19 to 62 years) who were diagnosed as recurrent SOM were included in the study. The patients were evaluated with respect to history, laboratory tests, skin-prick test, and total IgE. Patients with at least one positive skin-prick test result and/or a high total IgE level with a positive history were considered to be in atopic status. RESULTS: According to certain criteria, atopy was detected in 31 of 84 patients. Negative Phadiatop values were found in all non-atopic patients as well as in one atopic patient. Among 31 patients having atopy, 30 patients showed positive Phadiatop values (specificity 1.00, sensitivity 0.97, positive predictive value 1.00, negative predictive value 0.98). CONCLUSION: These results indicate that Phadiatop is an effective test to detect atopy in patients with recurrent SOM.

Computed tomography virtual laryngoscopy: comparison between radiological and otolaryngological evaluations for laryngeal carcinoma.

OBJECTIVES: We evaluated the utility of computed tomography virtual laryngoscopy (CTVL) in identifying endolaryngeal lesions in laryngeal tumors. PATIENTS AND METHODS: Virtual laryngoscopic images were obtained from axial CT scans of 21 patients with known laryngeal carcinoma. Findings from rigid telescopic videolaryngoscopy (RTV) and CTVL images were evaluated and compared with reference to operative records. RESULTS: Lesions localized in the base of the tongue, pyriform sinus, aryepiglottic folds, and arytenoids were well visualized by both RTV and CTVL. The two techniques were not found effective in identifying lesions of the ventricular bands, ventricular cavities, and the anterior commissure. Virtual laryngoscopy was superior to RTV in the visualization of the subglottic area and vocal cords. CONCLUSION: Virtual laryngoscopy is a noninvasive and reliable technique that provides visualization of endolaryngeal surfaces and tumor extension. It may be beneficial in staging larynx carcinoma and planning the most appropriate surgical procedure.