SMART Syndrome: Case Report and Review of the Literature.

Stroke-like migraine attacks after radiation therapy (SMART) syndrome is a rare condition characterized by stroke-like deficits, seizures, and headache that can occur years after radiation therapy (RT) to the brain. RT is a cornerstone in the treatment of primary brain tumours and is indicated in more than 90% of patients. It is therefore essential to be aware of this entity to prevent misdiagnosis leading to inappropriate treatment. In this article, typical imaging findings of this condition are presented through a case report and review of the literature.

Different Faces of Rathke's Cleft Cyst.

Rathke's cleft cysts (RCC) are rare benign cystic lesions that might present with different imaging features, potentially posing a problem in the radiological diagnosis of cystic sellar lesions. The purpose of this pictorial review is to present an overview of the radioclinical features of RCC through four clinical cases with different radiologic findings confirmed by pathology, as well as reviewing the common differential diagnosis to be considered. The subjects are women, aged 11 to 73 who underwent recent transsphenoidal surgical resection with a postoperative follow-up period of a few months to three years.

Effects of transcutaneous electrical nerve stimulation on rats with post-operative ileus.

BACKGROUND: Post-operative ileus (POI) is a type of bowel dismotility causing accumulation of gas and fluid. Transcutaneous electrical nerve stimulation (TENS) has been frequently used for medical applications such as pain treatment and nervous stimulation. In this experimental animal model of POI, our aim is to investigate the effects of TENS on POI, and to demonstrate histopathological changes in rat intestine after TENS application. METHODS: The present study is an experimental animal model of POI. Sixteen Wistar-Albino male rats in two groups were used and laparotomy was performed. After colorectum and small intestine were manipulated, activated charcoal and Nile red were ad-ministered by oral gavage. Electrodes were placed to the abdomen skin of the rats and TENS method was used. Rats in two groups were sacrificed on 24 h. The esophagus, stomach, and all intestines of the rats were resected and a direct X-ray and computerized tomography scan, and 'J' images were taken, and the progression of active coals was measured radiologically. Histopathological and microscopic evaluation was performed. RESULTS: The median of activated charcoal measure was 429 mm (178-594) in TENS group, 203 mm (149-313) in the control group, respectively, and these were statistically significant (p=0.004963). There was a significant difference between the two groups in terms of histopathological necrosis (p=0.041). In addition, the amount of Nil Red (550 nm) in the GI track is increased after 8 h of gavage with sequential applications of TENS. CONCLUSION: This study demonstrated the protective and therapeutic efficacy of TENS in POI in a rat model by radiologically and histopathologically. In clinical practice, TENS may be examined on POI. Further studies are warranted to validate and generalize our findings, and to assess the impact of TENS for post-operative pain also.

Advanced Magnetic Resonance Imaging Findings of Multinodular and Vacuolating Neuronal Tumor.

AIM: To present the magnetic resonance imaging (MRI) findings of a multinodular and vacuolating neuronal tumor (MVNT). MATERIAL AND METHODS: The authors identified four patients with MVNT in the hospital between January 2015 and October 2019. Both the clinical and radiological data of the patients were collected for analysis. RESULTS: Three patients complained of non-specific headaches. One patient had vertigo and imbalance. MRI sequences, including spectroscopy, perfusion, and DWI sequences, were retrospectively evaluated. The lesions were located in the subcortical and periventricular white matter of the parietal and temporal lobes, showed confluency, and comprised nodular pattern. The lesions appeared isointense to the cerebral cortex on T1 weighted imaging and hyperintense on T2 weighted and FLAIR sequences. None of the lesions showed diffusion restriction or contrast enhancement. Three of the lesions demonstrated a slight increase in choline peak and a slight decrease in N-acetyl aspartate peak. One lesion showed a noticeable increase in the Cho peak and a decrease in the NAA peak. CONCLUSION: Radiological features of MVNT are specific. Recognizing the MRI findings would help avoid unnecessary interventions in these patients, who are usually asymptomatic.

The Correlation of Intraabdominal Pressure With Renal Resistive Index.

BACKGROUND: To evaluate the correlation between intraabdominal pressure (IAP) measured via the bladder and renal resistive index (RRI) measured by Doppler ultrasonography (USG). METHODS: Eighty consecutive surgical patients were included into this study. Before Doppler USG evaluation, IAP was measured by a Foley catheter via the bladder. The left and right RRI, the diameters of the inferior vena cava and portal vein were measured by colored Doppler USG. Spearman correlation analysis was used to evaluate the correlation between different measurements. Intraabdominal hypertension (IAH) was defined as of IAP ≥ 12 mmHg. Significantly different variables from the univariate analysis between patients with and without IAH were entered into backward stepwise binary logistic regression analysis of IAH as the dependent variable. P values < 0.05 were accepted as statistically significant. RESULTS: In total, 80 patients were included into study. In 27 patients (34%) IAP was normal and in 53 patients (66%) IAH was diagnosed. The Spearman correlation analysis of IAP and the ultrasonographic measurements revealed a strong correlation between RRI and IAP (P < 0.001). Patients with IAH were more likely to be diabetic and had abdominal incisional hernia compared with patients with normal IAP (P < 0.05). The results of the multivariate logistic regression analysis revealed right RRI as the only independent predictor of IAH (B: 57.04, S. E.: 13.7, P < 0.001). CONCLUSIONS: There is a strong correlation between IAP and RRI. RRI can be an alternative, noninvasive technique for the diagnosis and follow-up of IAH after further evaluations in different patient groups.

Correlation of pelvic fractures and associated injuries: An analysis of 471 pelvic trauma patients.

BACKGROUND: In most respects, the vast majority of pelvic injuries is not of a life-threatening status, but co-presence of other injuries needs to be diagnosed. This study aims to evaluate associated pelvic and extra-pelvic visceral organ injuries of the patients with closed pelvic fractures. METHODS: This retrospective study was conducted with 471 adult patients who had been admitted to our Emergency Service with the diagnosis of pelvic fractures. Type of fractures, accompanying visceral organ injuries, the demographic data, type of operation, mortality rates were recorded and analysed statistically. RESULTS: The rate of operations carried out by the general surgery clinic or other surgical clinics in each type of fracture according to AO classification did not differ (p=0.118). In patients with A2, A3 and B1 types of fractures, the operation rate of general surgery clinic did not show a significant difference. However, most of the patients who had extrapelvic surgery were in the mild severity pelvic trauma, such as AO A2 and A3. A total of 31 patients were ex-patients, 17 of whom had AO-A2 type of fractures. The findings showed that there was a significant difference between abdominal ultrasonography outcome that was normal and non-orthopedic surgery types (p<0.001). There was no significant difference between the types of surgery performed and Abdominal CT outcome, which was normal (p=0.215). CONCLUSION: In the management of patients with pelvic fractures irrespective of its type or grade, the findings suggests that greater attention should be paid to not to overlook the associated injuries. Early blood and imaging tests are encouraged after the patient's hemodynamic status is stabilized.

CT-guided tractography is a safe and complementary diagnostic tool in the management of penetrating abdominal trauma.

BACKGROUND/OBJECTIVE: Despite extensive published research, the surgical approach to penetrating abdominal trauma patients is still under debate. Computed tomography-guided tractography (CTT) is an imaging modality in which water soluble iodinated contrast medium is administered into the site of the injury in the CT unit. The aim of this study was to determine the diagnostic accuracy of the CTT. METHODS: A retrospective evaluation was made of patients admitted to the Emergency Department with penetrating abdominal trauma and who underwent CTT. Contrast enhanced abdominal CT and CTT reports, surgical findings and clinical results were examined. RESULTS: Evaluation was made of a total of 101 patients comprising 89 males (88.1%) and 12 females (11.9%). CTT was determined to have 92.8% sensitivity, 93.6% specificity, 97% positive predictive value, and 85.5% negative predictive value. In 27 patients (26.7%) where the CTT indicated passage through the peritoneum, no parenchymal organ injury was present. Only one patient (2.9%) without peritoneal penetration on CTT had organ injury at exploration. No procedure-related morbidities developed. CONCLUSION: CTT is a safe imaging modality for the evaluation of hemodynamically stable patients. Compared to other imaging modalities, there is clearer demonstration of whether or not the peritoneum is intact. However penetration on CTT does not exactly correlate with organ injury.

Spontaneous perforation of pyometra: A rare cause of acute abdomen and sepsis.

Pyometra, the accumulation of purulent material in the uterine cavity, is a rare gynecological condition whose etiology is impaired drainage of the uterine cavity. It is uncommon in premenopausal age and occurs mainly in older and postmenopausal women. Clinical signs of pyometra are vaginal discharge, postmenopausal bleeding, and lower abdominal pain. An 87-year-old woman was admitted to our emergency department with abdominal pain, fever, and vomiting. The results of physical examination revealed rebound tenderness and muscular rigidity in the lower abdomen. Ultrasonography demonstrated free fluid in the abdomen, and percutaneous aspiration revealed that this fluid was purulent. A computed tomography scan showed a large amount of free fluid in the abdominal cavity and a uterine myoma. The patient underwent emergency laparotomy due to acute abdomen. During the laparotomy, a 2×1 cm perforation was seen at the fundus of the uterus. The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy. A culture of the pus grew Escherichia coli. Histopathological examination revealed degenerative uterine myoma with no evidence of malignancy. Pathological results indicated myometrial suppurative inflammation along with neutrophilia and necrosis. Pyometra is a rare event; however, it must be considered when investigating acute abdomen etiology. Because pyometra involves abscess formation, drainage and evacuation of the uterine cavity while leaving a drain in the cavity and dilating the cervical canal is the main treatment protocol. In cases of perforation, hysterectomy is the treatment choice; however, with concomitant diseases in older patients, immediate surgery is related to important morbidity and mortality risks.

Shear Wave Sonoelastography Findings of Testicles in Chronic Kidney Disease Patients Who Undergo Hemodialysis.

OBJECTIVE: Chronic kidney disease (CKD) is known to cause significant deterioration in the function of the testicles and sexual dysfunction in male patients who undergo hemodialysis. The aim of this study was to show the changes in the testicles that occur as a result of hypogonadism secondary to CKD and to analyze the elasticity of the parenchyma by shear wave sonoelastography. MATERIALS AND METHODS: In our study we included 28 male patients who undergo dialysis three times per week and 25 healthy volunteers. Firstly, B-mode ultrasonographic evaluation was performed in both testicles for structural analysis and to detect the presence of focal lesions. Afterward, the stiffness of the parenchyma was measured in kilopascals by shear wave sonoelastography. RESULTS: The CKD group had lower right, left, and mean testicular volumes (p<0.001). The CKD group also displayed greater right, left, and mean testicular parenchymal stiffness (p<0.001). CONCLUSION: CKD patients who undergo hemodialysis demonstrated significant changes in testicular size and stiffness in comparison to healthy volunteers.

Carpal tunnel syndrome: elastosonographic strain ratio and cross-sectional area evaluation for the diagnosis and disease severity.

AIM: To evaluate the role of gray scale ultrasonography (US) and real time elastosonography (RTE) in carpal tunnel syndrome (CTS). MATERIALS AND METHODS: Both wrists of 18 healthy volunteers (n=36) formed the control group (Group 1) and 19 symptomatic outpatients of the neurology clinic constituted the patient group. According to nerve conduction study results, cases with mild CTS (n=15) formed Group 2; cases with moderate to severe CTS (n=20) formed Group 3. Cross sectional area (CSA) and strain ratio (SR) were measured at carpal tunnel inlet (CTI) and 4 cm proximal to the distal end of the radius (P). CSA and SR change score (CSACTI-CSAP; SRCTI-SRP), CSA and SR ratio score (CSACTI / CSAP; SRCTI / SRP) were calculated. RESULTS: The median nerve was significantly stiffer in Group 2 compared to Group 1; also in Group 3 compared to Group 1 (p=0.000). For CSACTI, the difference was significant between Group 1 and Group 3 (p=0.000), also between Group 2 and Group 3 (p=0.001). For CSA change scores the difference was only significant between Group 1 and Group 3 (p=0.015). In the diagnosis of CTS the best cut-off value for CSACTI was 10.8 (p=0.001), 2.3 for SRCTI (p=0.000), 4.9 for the CSA change score (p=0.005), 0.05 for the SR change score (p=0.000), 1.3 for the the CSA ratio score (p=0.015) and 1.1 for the SR ratio score (p=0.000). CONCLUSION: SR measurements do not exclude patients even with mild CTS but cannot categorize disease severity. CSA measurements on the other hand can categorize disease severity. Therefore, the combined use of US and RTE is suggested.

Endovascular treatment for acute traumatic thoracic aortic transection.

BACKGROUND: This study aimed to present our experience in patients with acute traumatic thoracic aortic transection treated by endovascular stent-graft. METHODS: From October 2011 to October 2014, eleven patients were brought to our hospitals after suffering motor vehicle accident or fall from height. Computed tomography revealed acute traumatic transection of the thoracic aorta at the aortic isthmus just distal to the left subclavian artery in nine patients, at the middle or distal thoracic aorta in two, and both aortic isthmus and middle thoracic aorta in one. Endovascular technique was preferred as the treatment modality. All patients, except one, were treated within twelve hours of diagnosis. RESULTS: Deployment of stent-grafts was successful in all cases. The stent-grafts were oversized between 10% and 20%. The origin of left subclavian artery was covered with stent-graft in six patients to achieve adequate proximal landing zone. In two of them, carotico-subclavian bypass and periscope graft placement were applied to maintain subclavian artery blood flow. There were no procedure related deaths, paraplegia or ischemic complications. A patient with cardiac arrest, on whom cardiopulmonary resuscitation and transient aortic balloon occlusion within the aorta were applied in the angiography suit died at the postoperative twelve hours. Mean hospital stay after procedures was 14.8 days (range, 4-60 days). Mean follow-up time of ten patients was 16.6 months (range, 1-36 months). CONCLUSION: Our study supports that thoracic endovascular aortic stenting for acute transection is promising in terms of short- and mid-term results similar to other studies in the literature.

Diagnosis of acute pancreatitis by diffusion-weighted magnetic resonance imaging.

Diffusion-weighted magnetic resonance imaging has emerged as a successful technique in the early diagnosis of acute pancreatitis. An 82-year-old male patient suspected of acute pancreatitis refused to undergo intravenous contrast-enhanced abdominal computed tomography due to a history of previous allergic reactions to contrast medium. He was imaged with diffusion-weighted magnetic resonance imaging without the use of oral or intravenous contrast material. Diffuse hyperintensity in the pancreas with a relevant apparent diffusion coefficient map showing diffuse hypointensity was demonstrated. The findings were interpreted as restricted diffusion and were diagnostic for acute pancreatitis. Diffusion-weighted magnetic resonance imaging, an imaging modality that does not involve ionizing radiation and does not require the use of contrast material, can successfully demonstrate the manifestations of acute pancreatitis.

[Angiographic evaluation of branching pattern and anatomy of the aortic arch]. / Arkus aorta anatomisinin ve dallanma paternindeki varyasyonlarin anjiyografik olarak degerlendirilmesi.

OBJECTIVE: The study aimed to investigate anatomical variations in branching pattern and anatomy of the aortic arch, and the prevalence of each type. METHODS: Between September 2011 and November 2013, angiographic studies of 270 patients (144 male, 126 female) were analyzed retrospectively for variations in branching pattern and anatomy of the aortic arch. Patient mean age was 59.8 years (range, 13-88). Branching variations were found and divided into subtypes. Patients were also classified according to arch anatomy. Incidence of variations and types of aortic arch were statistically analysed. RESULTS: Analysis of the 270 patients revealed six types of branching pattern. Type I, classical pattern arch with three branches (TB, LCC, LS), was observed in 198 cases (73.3%). Type II (bovine arch), the most commonly observed variation, in which LCC originates from TB, was observed in 58 cases (21.5%). Type III, in which the left vertebral artery arises from the arch, was seen in seven cases (2.6%). Type IV, a combination of types II and III, was observed in three cases (1.1%). Type V, common origin of common carotids, LS and aberrant RS, was found in three cases (1.1%). Type VI (avian type), arch with only two branches, was observed in one case (0.4%). When patients were classified according to aortic arch anatomy, Type 1, Type 2 and Type 3 were observed in 195, 40 and 35 patients respectively. CONCLUSION: Knowledge of the variations and anatomy of the aortic arch is essential during interventional procedures and neck-thorax surgery.

Cystic schwannoma of the axillary region: imaging findings of a rare disease. Case report.

Schwannomas are well capsulated, benign, and slowly growing tumors which originate from Schwann cells of peripheral nerve sheath. The incidence of schwannomanas in the axillary region is not common. This rarity causes misdiagnosis at the radiological evaluation. In this case we present the imaging and histopathological findings of a cystic schwannoma located in the axillary fossa of a 47-year-old female patient mimicking complex cyst, lymphadenopathy or hydatid cyst in radiological evaluation. Although lymphadenopathy, lymphatic malformation, lipoma, cyst, hidradenitis suppurativa or dermatofibroma are the most frequent lesions to be considered, peripheral nerve sheath should also be kept in mind in the differential diagnosis of axillary masses.

Can arteriovenous malformation prevent the diagnosis of brain death?

We present a case of a 14-year-old boy with spontaneous intracranial hemorrhage that was referred to us to confirm the diagnosis of brain death with cerebral angiography. In the left carotid angiogram, there was no arterial flow above the craniovertebral junction. But in the right carotid angiogram, there was arterial flow up to the level of posterior communicating artery. Right posterior cerebral artery was filled with contrast medium via patent posterior communicating artery and later, an opacifying arteriovenous malformation (AVM) was detected which was also seen in the vertebral angiogram. Although the angiographic findings of the patient did not confirm the angiographic criteria for the diagnosis of brain death, it could not be also excluded because the only cerebral flow was the filling of the AVM and no other cerebral perfusion was detected.

The role of elastosonography, gray-scale and colour flow Doppler sonography in prediction of malignancy in thyroid nodules.

BACKGROUND: Ultrasound is as a noninvasive method commonly used in the work-up of thyroid nodules. This study aimed to evaluate the usefulness of sonographic and elastosonographic parameters in the discrimination of malignancy. PATIENTS AND METHODS: 150 thyroid nodules were evaluated by gray-scale, Doppler and elastosonography. The cytological analysis revealed that 141 nodules were benign and 9 were malignant. RESULTS: Orientation of the nodule was the only sonographic parameter associated with malignancy (p = 0.003). In the strain ratio analysis the best cut-off point was 1.935 to discriminate malignancy (p = 0.000), with 100% sensitivity, 76% specificity, 100% negative predictive value, 78.5% positive predictive value and 78% accuracy rate. There was a statistically significant correlation between the elasticity score and malignancy (p = 0.001). Most of the benign nodules had score 2 and 3, none of them displayed score 5. On the other hand, none of the malignant nodules had score 1 and 2, most of them displaying score 5. CONCLUSIONS: A change in the diagnostic algorithm of the thyroid nodules should be considered integrating the elastosonographic analysis.

Value of prostate gland volume measurement by transrectal US in prediction of the severity of lower urinary tract symptoms.

AIM: The aim of our study was to analyze the value of prostate gland volume measurement by transrectal ultrasonography (TRUS) in prediction of lower urinary tract symptoms (LUTS). MATERIAL AND METHODS: One hundred and one patients undergoing TRUS guided core needle prostate biopsy for the investigation of prostate cancer were prospectively evaluated. All patients had filled in the international prostate symptom score (IPSS) scala, tested for PSA and prostate volume measurement was done by TRUS prior to biopsy. According to their biopsy results, patients were divided into two groups: negative and positive for malignancy. RESULTS: There was a significant but low correlation of 0.37 between IPSS and prostate volume measurement by TRUS (p=0.001). Serum free prostate specific antigen (fPSA), total PSA (tPSA), ratio of fPSA to tPSA and PSA density did not show a statistically significant correlation with IPSS (p>0.05). No statistically significant difference in IPSS between the benign and malignant groups (p=0.681) was found. In the benign group, mean IPSS was 14.59 +/- 8.73, range: 0-35 while in the malignant group, mean IPSS was 15.33 +/- 9.22, range: 3-28. CONCLUSIONS: Prostate volume measurement by TRUS is a poor predictor for the determination of the severity of LUTS and IPSS should be primarily considered for the determination of the severity of LUTS. On the other hand according to this study conducted with patients who were at their first set of prostate biopsy, IPSS cannot be used as a predictor of malignancy. PSA values are not related to IPSS.

The role of elastosonography in the differentiation of parotid gland lesions: report of three cases and review of the literature.

BACKGROUND: The parotid gland is the mostly affected site among major salivary gland tumors in up to 85% of cases. Preoperative knowledge of the tumour nature is crucial since it influences the surgical procedure and patient's morbidity, especially the risk of facial nerve palsy. Ultrasonography is commonly used as the first line imaging modality for the salivary gland lesions. A pitfall is that the histologic pleomorphism often reflects an imaging pleomorphism. CASE REPORT: HEREIN WE AIMED TO PRESENT THE ROLE OF ELASTOSONOGRAPHY IN THREE PAROTID LESIONS: a case of benign pleomorphic adenoma, a Wharthin's tumour and a malignant parotid tumour. CONCLUSIONS: Our findings show that malignant parotid lesion was the stiffest lesion according to elastosonography. Wharthin's tumour demonstrated soft elastosonographic features. The pleomorphic adenoma was also interpreted as stiff by elastosonography suggesting that the elastosonographic features of pleomorphic adenoma may resemble those of malignant lesions limiting the utility of the technique.

Superselective arterial embolization of pseudoaneurysm and arteriovenous fistula caused by transurethral resection of the prostate.

BACKGROUND: Pelvic vascular lesions such as pseudoaneurysms and arteriovenous fistulas associated with the internal pudendal artery are uncommon. The most common cause is traumas including those of iatrogenic origin. Surgical treatment is complicated due to location of the lesions and endovascular approach is usually the first choice among the treatment options. CASE REPORT: A 79-year-old patient was admitted with massive hematuria following transurethral resection of prostate for benign prostatic hyperplasia. Doppler US and angiography revealed a pseudoaneurysm and arteriovenous fistula originating from the right internal pudendal artery. It was successfully treated with coil embolization. CONCLUSIONS: Arteriovenous fistulas and pseudoaneurysms concerning internal pudendal artery may occur as complications of prostate operations. Minimally invasive endovascular methods provide safe and efficient treatment and today should be considered as the first line of choice.