Porto-mesenteric vein thrombosis after laparoscopic sleeve gastrectomy. A case report.

INTRODUCTION AND IMPORTANCE: Porta-mesenteric vein thrombosis (PMVT) is a rare but fatal complication in patients who are undergoing bariatric surgery. In this report, we present a rare case of a PMVT after laparoscopic sleeve gastrectomy (LSG). CASE PRESENTATION: A 52-year-old male patient with a body mass index of 42 kg/m2 was admitted to our clinic for morbid obesity. Standart LSG was performed with 5 trocar technique. 15 days after LSG, the patient admitted to the emergency department with complaints of abdominal pain, nausea and vomiting. The patient was dehydrated. His C-reactive protein level was 138 mg/L. Abdominal computerized tomography with contrast was performed and showed thickening of a part of small bowel wall in 10 cm length. Also, major trombosis were detected in the superior mesenteric vein branches and portal vein. The patient was hospitalized and 2 × 10,000 IU/1.0 mL high dosage low moleculer weight heparin (LMWH) therapy was initiated. The patient's clinical signs recovered rapidly following treatment. CLINICAL DISCUSSION: In LSG, if the gastroepiploic venous arcus, which runs along the greater curvatura, and has a direct connection to the portal circulation is damaged, a local thrombus may form and move towards the portal system over time. Dehydration is another significant predisposing factor for PMVT. Some patients may develop life-threatening intestinal ischemia. Abdominal tomography with contrast plays a major role in diagnosis. CONCLUSION: PMVT should be considered as a serious complication after LSG in patients with abdominal pain. With early diagnosis and anticoagulant therapy, patients's clinical symptoms may improve quicly.

Brain MRI Findings in Patients in the Intensive Care Unit with COVID-19 Infection.

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Imaging Spectrum of TIPIC Syndrome : Validation of a new Entity with Vessel Wall Imaging.

PURPOSE: Acute neck pain can have non-vascular and vascular causes. Some patients present with distinct vascular and perivascular changes on imaging at the site of tenderness. This study aimed to evaluate the imaging findings of transient perivascular inflammation of the carotid artery (TIPIC) syndrome with an emphasis on vessel wall imaging using 3­Tesla (3-T) high-resolution (HR) magnetic resonance imaging (MRI). METHODS: Clinical data along with diagnostic and follow-up imaging of patients presenting to these hospitals with acute neck pain/tenderness and at least 1 imaging study using color Doppler ultrasound (CDU) and/or MRI including vessel wall imaging from September 2013 through September 2017 were retrospectively evaluated. A total of 15 patients with no other underlying cause of pain, findings meeting the imaging criteria for TIPIC syndrome and clinical recovery (spontaneous or with treatment) were included in the study. RESULTS: The mean patient age was 43.2 years. With CDU and precontrast MRI, perivascular inflammation (PVI) of the involved artery segment was evident in all patients. Contrast enhancement of the adventitia and PVI were noted on postcontrast HR vessel wall MRI in all patients. Of the patients five had co-existing plaques at the site of tenderness. Follow-up imaging demonstrated pronounced regression or complete resolution of the findings. CONCLUSION: Imaging is useful for the establishment of TIPIC syndrome diagnosis and to rule out other conditions. The use of CDU is usually sufficient for diagnosis and follow-up but in clinically doubtful and complicated cases, vessel wall imaging with HR-MRI is very valuable. Thorough knowledge of this entity among radiologists enables a prompt diagnosis, which accelerates the clinical management.

Cardiac Tamponade as a Life-Threatening Complication of Laparoscopic Antireflux Surgery: The Real Incidence and 3D Anatomy of a Heart Injury by Helical Tacks.

BACKGROUND: Cardiac tamponade (CT) is a dreadful complication of laparoscopic antireflux surgery (LARS) with unknown incidence, and preventive measures are yet to be defined. Incidence during LARS with respect to usage/configuration of graft deployment is analyzed. Three-dimensional (3D) analysis of tack distribution provided anatomical insight to prevent cardiac injury. MATERIALS AND METHODS: Data regarding the usage and configuration of graft deployment are retrieved from the prospective database. Grafting was "posterior" or "posterior + anterior." Incidence of CT in all hiatoplasties is calculated. Tomography is reconstructed in 3D, showing the spatial distribution of the tacks. Tacks are numbered in the surgical video. Corresponding numbering is applied to the tacks in any particular tomography slice, utilizing the 3D images as an interface. A numbering-blinded radiologist is asked to identify the offending and the nonoffending tacks as the cause of tamponade. Tack-to-pericardium distances are recorded. Tacks having no measurable distance from the pericardium are regarded as offensive. RESULTS: One CT occurred in 1302 consecutive LARS (0.076%). The incidence is 0% when "no" (379) or "posterior" (880) graft is used as opposed to 2.3% rate in "posterior + anterior" (43) grafting. The distribution of "offensive," "nonoffensive but nearest," and "safe" tacks followed a pattern. All offensive tacks belonged to the anterior graft fixation, which we referred as the critical zone. CONCLUSION: CT during LARS is rare, and associated with graft fixation anterior to the hiatal opening. Avoiding graft fixation to the critical zone may prevent cardiac injury.

The Pitfalls and Important Distances in Temporal Bone HRCT of the Subjects with High Jugular Bulbs - Preliminary Report.

BACKGROUND: High jugular bulb (HJB) may be detected unilaterally or bilaterally in temporal bone high resolution computerized tomography (HRCT). OBJECTIVES: In this retrospective study, we investigated the pitfalls and important surgical distances in patients with unilateral and bilateral HJB via temporal bone HRCT. MATERIAL AND METHODS: In this preliminary report, the study group consisted of 20 adult patients (12 male, 8 female), or 40 ears, all of which underwent temporal bone HRCT. We divided them into groups that consisted of bilateral HJB (14 ears), unilateral HJB (13 ears), and control (No HJB, 13 ears). The anotomical relationships of the sigmoid sinus, jugular bulb, and carotid artery with several landmarks in the temporal bone were studied via temporal bone axial and coronal HRCT. The shortest distances between certain points were measured. These measurements were analyzed in respect to pneumatization. Dehiscence on the jugular bulb (JB) and internal carotid artery (ICA) and the dominance of JB were also evaluated for all of the groups. RESULTS: In the axial sections of the temporal bone HRCTs, the sigmois sinus (SS)-external auditory canal (EAC) distance of the bilateral HJB group (14.00±1.17 mm) was significantly lower than that of the control group (16.46±2.14 mm). The JB-posteromedial points of the umbo on the ear drum (ED) distance of the bilateral HJB (6.28±1.72 mm) and the unilateral HJB groups (7.23±2.00 mm) were significantly lower than that of the control group (11.15±2.30 mm). In the coronal sections of the temporal bone HRCT, the JB-F distance of the bilateral HJB group (5.42±2.10 mm) was significantly lower than that of the control group (8.30±2.28 mm). As the mastoid pneumatisation and mastoid volume increased, the percentage of ICA-dehiscence and the percentage of JB-dehiscence increased. CONCLUSIONS: In subjects with well-pneumatised mastoids, the doctors should be aware of the increased risk of ICA-dehiscence and JB-dehiscence. These measurements should be done in greater series to yield more thorough knowledge.

Unilateral cerebellar hypoplasia with different clinical features.

Unilateral cerebellar hypoplasia (UCH) is a rare pathological condition characterized by the loss of volume in cerebellar hemispheres ranging from mild asymptomatic to severe symptomatic cases. As the designation of UCH remains problematic, the underlying etiopathogenesis also lacks explanation. We investigated the patients admitted to Departments of Child Neurology, Neurology, and Genetics between the years 1992 and 2010 and detected 12 patients with unilateral cerebellar volume loss, with the exclusion of all other cerebellar pathologies. The ages of patients ranged between 6 months to 55 years. Five patients had a delay in developmental milestones, and one of these was diagnosed with neurofibromatosis type 1. Two patients had epileptic seizures, one patient had peripheral facial paralysis as a component of Moebius syndrome, and four patients were incidentally diagnosed during etiological work-up for headache. The clinical outcomes of patients varied from healthy subjects to marked developmental impairment. Radiologically, five patients had severe disproportionate UCH, six had moderate disproportionate, and one had mild proportionate UCH. Cerebellar peduncles were affected in all, and vermis was partly hypoplastic in eight patients. Brainstem was involved in four patients, and seven patients showed involvement of white matter and/or corpus callosum. Imaging features supported that patients with severe disproportionate UCH also displayed additional cerebral and commissural changes, which were related to ischemic or vascular injuries, implying a prenatally acquired disruption. In the presence of such a wide spectrum of clinical and radiological features, a prenatally acquired lesion and, thus, a disruption seem to be more explanatory rather than a primary developmental process or malformation in the etiopathogenesis of unilateral cerebellar hypoplasia.

Midbrain-hindbrain involvement in lissencephalies.

OBJECTIVES: To determine the involvement of the midbrain and hindbrain (MHB) in the groups of classic (cLIS), variant (vLIS), and cobblestone complex (CBSC) lissencephalies and to determine whether a correlation exists between the cerebral malformation and the MHB abnormalities. METHODS: MRI scans of 111 patients (aged 1 day to 32 years; mean 5 years 4 months) were retrospectively reviewed. After reviewing the brain involvement on MRI, the cases were reclassified according to known mutation (LIS1, DCX, ARX, VLDLR, RELN, MEB, WWS) or mutation phenotype (LIS1-P, DCX-P, RELN-P, ARX-P, VLDLR-P) determined on the basis of characteristic MRI features. Abnormalities in the MHB were then recorded. For each structure, a score was assigned, ranging from 0 (normal) to 3 (severely abnormal). The differences between defined groups and the correlation between the extent of brain agyria/pachygyria and MHB involvement were assessed using Kruskal-Wallis and chi(2) McNemar tests. RESULTS: There was a significant difference in MHB appearance among the three major groups of cLIS, vLIS, and CBSC. The overall score showed a severity gradient of MHB involvement: cLIS (0 or 1), vLIS (7), and CBSC (11 or 12). The extent of cerebral lissencephaly was significantly correlated with the severity of MHB abnormalities (p = 0.0029). CONCLUSION: Our study focused on posterior fossa anomalies, which are an integral part of cobblestone complex lissencephalies but previously have not been well categorized for other lissencephalies. According to our results and the review of the literature, we propose a new classification of human lissencephalies.

Dilated perivascular spaces: an informative radiologic finding in Sanfilippo syndrome type A.

Mucopolysaccharidosis type IIIA, or Sanfilippo syndrome type A, is a lysosomal storage disorder caused by deficiency of heparan N-sulfamidase, resulting in defective degradation and subsequent storage of heparan sulfate. It is characterized by progressive nervous system involvement. Cribriform changes in the corpus callosum, basal ganglia, and white matter, diffuse high-intensity signal in the white matter, and cerebral atrophy have been described in patients with this disorder. This case report describes a child with Sanfilippo syndrome type A who exhibited fairly mild clinical findings but an unusual magnetic resonance imaging pattern that included multiple moderate-sized cysts (probably enlarged perivascular spaces) within the corpus callosum and an abnormal appearance of the clivus and cervical vertebrae. This case calls attention to the variety of appearances possible with magnetic resonance imaging in Sanfilippo syndrome type A.

Diagnosis and management of vaginal mullerian cyst in a virgin patient.

Benign cystic lesions of the vagina are uncommon and may become symptomatic. We describe two symptomatic anterior vaginal wall cysts in a virgin patient and the usefulness of imaging modalities. A 36-year-old virgin woman presented with a complaint of vaginal bulging and pelvic pressure. Pelvic examination revealed a cystic mass protruding from the vagina surrounded by the intact hymen. The initial abdominopelvic ultrasound showed a hypoechoic cystic mass measuring 42 x 20 mm in the vagina. She then had a pelvic magnetic resonance imaging (MRI) that revealed two anterior vaginal wall cysts with no communication with the urethra or bladder. The cysts were excised and histologic examination with mucicarmine revealed mucin-secreting tall columnar cells consistent with a diagnosis of mullerian cyst. While both ultrasonographic examination and MRI are helpful in localizing vaginal cysts, MRI is superior in showing multiple cystic lesions of the vagina and their communication with the surrounding structures.

Computerized tomography scout view for determining distal femoral resection angle in intramedullary instrumentation of total knee arthroplasty.

This study aims to investigate the results of distal femoral resection by determining the difference between mechanical and anatomical axes of femur using computerized tomography (CT) scout views in pre-operative planning of total knee arthroplasty. CT scout view of the lower extremities was taken before and after the operation in 16 patients undergoing total knee arthroplasty. Distal femoral resection was performed according to the previously determined ideal resection angle (IRA) using intramedullary instrumentation. At post-operative scanogram, femoral component deviation (FCD) was measured. The results were statistically analyzed. The average IRA was 6.95 (5-9) degrees. At post-operative measurements, the average FCD was 0.63 (0-3) degrees. CT scout films improve the accuracy in distal femoral resection and femoral component alignment.

Evaluation of acute trismus by MRI: a case report. Bilateral peritonsillar cellulitis.

We describe a rare case of a bilateral peritonsillar cellulitis (PTC). The clinical presentation of fever, trismus and odynophagia was consistent with PTC, more evident on the right side; but the presence of bilateral tonsillar swelling and midline uvula confounded the diagnosis. In spite of the throat examination was performed with a great difficulty due to trismus, the T2 weighted fat saturated STIR magnetic resonance imaging (MRI) guided us to make the diagnosis and to start the intravenous antibiotic treatment immediately.

Transient arterial enhancement in a hepatic peritumoral fat-spared area.

Early-enhancing areas that are perfusion abnormalities rather than tumor deposit are sometimes encountered on arterial dominant-phase images in multisection dynamic magnetic resonance imaging. Focal sparing in diffusely fatty liver is also a well recognized entity. However, both conditions occasionally create problems in the diagnosis of hepatic mass lesions. Familiarity with these abnormalities on ultrasonography and multisection dynamic magnetic resonance images is important to prevent misinterpretation of these pseudolesions as real masses. In addition, focal sparing can be the only clue for a space occupying lesion in the liver. We present here the ultrasonography and magnetic resonance imaging findings of a case with liver metastasis from pancreas cancer which caused a wedge-shaped fat-spared enhancing area on dynamic magnetic resonance imaging.

Relationship between tinnitus loudness level and internal jugular venous flow rate measured by coloured Doppler ultrasonography in patients with a high jugular bulb.

The aim of this study was to investigate the relationship between tinnitus loudness level (TLL) and internal jugular venous flow rate (IJVFR) in tinnitus patients with a unilateral high jugular bulb detected by temporal bone high-resolution computed tomography (HRCT). The study group consisted of 24 adult patients (13 male, 11 female) with a unilateral high jugular bulb. One ear suffered from tinnitus with a high jugular bulb was included into the study group. The ears without tinnitus and no high jugular bulb on temporal bone HRCT comprised the control group. All patients were evaluated with a history and physical and otolaryngologic examinations, and, using a questionnaire, TLLs were detected. The patency and flow rates in the internal jugular veins were measured by right and left internal jugular venous Doppler ultrasonography. The TLLs were "very quiet" in 1 (4.1%) patient, "intermediate loud" in 17 (70.9%) patients, and "very loud" in 6 (25.0%) patients. IJVFRs were not different in the study and control groups. In the study group, IJVFRs were not correlated with age. There was no relationship among TLLs and IJVFRs, dominance, dehiscence, and bony septum thickness between the high jugular bulb and the middle ear. TLLs were not affected by IJVFRs, dominance, dehiscence, and bony septum thickness in patients with a high jugular bulb. More detailed studies should be undertaken to determine the reason for the different TLLs in patients with a high jugular bulb.

Cerebral hemodynamics in ocular hypertension.

PURPOSE: To evaluate the cerebral blood flow velocity in patients with ocular hypertension. MATERIAL AND METHODS: Twenty-four ocular hypertensive patients and 24 age- and sex-matched healthy volunteers were recruited in a prospective comparative study. All subjects had normal findings on full-threshold visual field tests and clinically normal optic nerves. All patients with ocular hypertension had an intraocular pressure (IOP) of >21 mmHg on three separate occasions without treatment. Systolic and diastolic blood pressure by cuff, heart rate by palpation, IOP by Goldmann applanation tonometry, central corneal thickness by ultrasound pachymetry, blood flow velocities, and pulsatility index of the ipsilateral middle cerebral artery by transcranial color Doppler were measured. RESULTS: Systolic and diastolic blood pressures (P=0.40 and P=0.45, respectively), heart rate (P=0.30), and central corneal thickness (P=0.23) were similar in each group. Peak and end-diastolic blood flow velocities in the middle cerebral artery did not differ between ocular hypertensives and controls (P=0.37 and P=0.87, respectively). In addition, pulsatility index did not significantly differ between ocular hypertensives and controls (P=0.61). CONCLUSIONS: The results of this study suggest that ocular hypertension is not associated with reduction in blood flow velocity and elevation of resistance in the middle cerebral artery.

Doppler sonography of the normal lacrimal gland.

PURPOSE: We used Doppler sonography to determine the resistance index (RI) and pulsatility index (PI) of the normal lacrimal artery (LA) in both females and males. We also compared the values obtained at various periods of reproductive life. METHODS: The study was performed in 25 prepubertal girls, 28 females of reproductive age, and 27 postmenopausal women, 23 pregnant women, and 104 healthy males. Doppler sonography was used to determine the RI and PI of the LA. RESULTS: The mean PI for the entire patient population was 1.48 +/- 0.60 and the RI was 0.72 +/- 0.09. The RI and PI values of the LA did not differ between males and females. Similarly, the mean RI and PI values of the LA did not change significantly between the various reproductive phases. CONCLUSION: The PI and RI of the lacrimal gland are similar in both sexes. Moreover, they are not altered by changes in levels of sex steroids.

Giant abdominal wall abscess dissecting into thorax as a complication of ESWL.

Abscess as a complication of extracorporeal shock wave lithotripsy is a rare condition. We present the computed tomography findings of an abdominal wall abscess that occurred after extracorporeal shock wave lithotripsy for which prophylactic antibiotics had not been given. The abscess destroyed the posterior abdominal wall muscles and dissected into the thorax. The muscles were thickened and showed enhancement. A parenchymal defect in the right kidney adjacent to a caliceal stone, with strands extending from this defective region to the abscess, was observed, and was thought to be the result of parenchymal destruction caused by the shock waves. Other parts of the kidney and psoas muscle were normal. Microbiologic examination revealed Escherichia coli.

Contrast media induces hypoperfusion in kidneys with ureteral stone: Doppler US study.

We aimed to assess the hemodynamic effects of nonionic low-osmolarity contrast media (CM) on kidneys with ureteral stone (KUS). A total of 16 patients with KUS (group A) and 25 control patients (group B) were evaluated with Doppler ultrasound (US) bilaterally for main (MRA), interlobar (ILA) and arcuate renal arteries (ARA), before and 15 min after CM for IV pyelography. Peak systolic (PSV) and end diastolic velocities (EDV) and resistance index (RI) were measured. Data were analyzed by ANOVA and t-test. In group A, CM induced increase in PSV of MRA of contralateral kidney (p = 0.021) and decrease in PSV of ILA (p = 0.024), decrease in PSV and EDV and increase in RI of ARA of KUS (p = 0.010, 0.005, 0.027, respectively). CM induced hypoperfusion in KUS and compensatory changes in contralateral kidneys, similar to the effects of diuresis or mannitol. We conclude that the effect of CM on KUS is related to its osmolar load.