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1.
BMJ Case Rep ; 14(8)2021 Aug 25.
Artigo em Inglês | MEDLINE | ID: mdl-34433532

RESUMO

Plain CT is routinely ordered following blunt trauma of the cervical spine, and performs well in the exclusion of significant bony injuries. MRI is reserved for cases of suspected neural or posterior ligamentous compromise, and when other imaging modalities are contraindicated. There are patients however, with unremarkable radiology, and without suggestive clinical features, who are later found to have significant discoligamentous instability. In this report, we present two such cases. In both instances, worsening neurological symptoms prompted follow-up imaging, that demonstrated interval development of sub-axial cervical spondylolisthesis, requiring surgery and instrumentation. We identify and discuss radiological features that may be associated with occult discoligamentous injury, and highlight them as avenues for future research. These may prove useful in stratifying at-risk patients for further imaging in the acute setting.


Assuntos
Traumatismos da Coluna Vertebral , Ferimentos não Penetrantes , Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/lesões , Humanos , Imageamento por Ressonância Magnética , Traumatismos da Coluna Vertebral/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Ferimentos não Penetrantes/complicações , Ferimentos não Penetrantes/diagnóstico por imagem
2.
BMJ Case Rep ; 14(8)2021 Aug 24.
Artigo em Inglês | MEDLINE | ID: mdl-34429290

RESUMO

Penetrating trauma due to nail gun is an uncommon yet important clinical entity. There are numerous case reports describing these injuries, yet few describe those resulting in cerebrovascular injury. Laceration of cerebral blood vessels may result in significant intracranial haemorrhage and cerebral ischaemia, with catastrophic consequences. In the present study, we report a female patient who was shot in the face with a nail gun in a domestic assault. The nail entered her right cavernous sinus and lacerated her right internal carotid artery causing a pseudoaneurysm and a caroticocavernous fistula. This report details the approach to, and pitfalls of, managing a cerebrovascular injury due to penetrating intracranial nail. Catheter cerebral angiography is essential in the diagnosis and treatment of these injuries. Best treatment and outcomes require clinicians with expertise in endovascular and surgical repair strategies.


Assuntos
Falso Aneurisma , Fístula Carotidocavernosa , Traumatismos Craniocerebrais , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/etiologia , Falso Aneurisma/cirurgia , Artéria Carótida Interna/diagnóstico por imagem , Artéria Carótida Interna/cirurgia , Fístula Carotidocavernosa/diagnóstico por imagem , Fístula Carotidocavernosa/etiologia , Fístula Carotidocavernosa/cirurgia , Angiografia Cerebral , Feminino , Humanos
3.
J Clin Neurosci ; 85: 49-56, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33581789

RESUMO

Management of patients with thoracolumbar burst fractures who do not have a neurologic injury has historically been controversial. Whilst management with an orthosis has gained popularity over surgical management, more recent evidence has suggested that even an orthosis may be unnecessary. A systematic review of the literature comparing orthosis with no orthosis in the management of thoracolumbar burst fractures in patients without neurological deficit was conducted. A risk of bias assessment was performed according to the Cochrane Collaboration Back Review Group. The quality of evidence was assessed according to the GRADE system. Two trials met the eligibility criteria. The functional outcomes, radiologic measures of kyphosis, pain scores, and quality of life scores were equivalent between the orthosis and the no orthosis groups. The level of evidence ranged from very low to moderate for the outcomes evaluated. The rate of complications and the rate of failure of treatment requiring surgery was low. Evidence from two small randomised controlled trials suggests that there are equivalent outcomes between treatment with and without an orthosis. Larger trials are needed to assess the treatment effect with greater confidence.


Assuntos
Braquetes , Vértebras Lombares/lesões , Fraturas da Coluna Vertebral/terapia , Vértebras Torácicas/lesões , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Resultado do Tratamento
4.
J Clin Neurosci ; 81: 442-446, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33222960

RESUMO

The prognostic significance of preoperative MRI findings in patients undergoing discectomy is incompletely understood. Identifying the radiological predictors of revision surgery on pre-operative MRI can guide management decisions and potentially prevent multiple surgeries. We included 181 patients who underwent primary lumbar discectomy between 2010 and 2014. All patients were contacted via a short telephone interview to determine if they had revision surgery within 5 years of their index surgery. Preoperative MRI of the lumbosacral spine was evaluated for various radiological factors including type of disc herniation, anatomical location of herniation, direction of herniation, degree of disc degeneration, end plate changes and presence of listhesis. Other potential confounders including age, gender, smoking status and index level of surgery were also recorded. Multivariate model of all radiological predictors and confounders were developed and a step-wise approach was used to remove insignificant variables in order to develop final significant multivariate model. P value of <0.05 was considered statistically significant. Patients with retrolisthesis were found to be 2.7 times more likely than the patients without listhesis to require revision surgery (p = 0.019). Patients with foraminal disc herniation were 3.45 times more likely than the patients with paramedian disc herniation to require revision surgery (p = 0.026). Other MRI predictors failed to achieve statistical significance. Based on the data presented patients with retrolisthesis and/or foraminal disc herniation should be counselled on the relatively higher risk of revision surgery when proceeding with discectomy, or alternative options should be considered.


Assuntos
Discotomia , Deslocamento do Disco Intervertebral/diagnóstico por imagem , Deslocamento do Disco Intervertebral/patologia , Deslocamento do Disco Intervertebral/cirurgia , Reoperação , Adulto , Feminino , Humanos , Degeneração do Disco Intervertebral/diagnóstico por imagem , Degeneração do Disco Intervertebral/cirurgia , Vértebras Lombares/cirurgia , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade
5.
J Neurosurg Spine ; : 1-11, 2020 Nov 27.
Artigo em Inglês | MEDLINE | ID: mdl-33254135

RESUMO

OBJECTIVE: Lumbar discectomy for the management of lumbar radiculopathy is a commonly performed procedure with generally excellent patient outcomes. However, recurrent lumbar disc herniation (rLDH) remains one of the most common complications of the procedure, often necessitating repeat surgery. rLDH is known to be influenced by a variety of factors, and in this systematic review the authors aimed to explore the radiological predictors of recurrence. METHODS: A systematic review and meta-analysis was conducted to identify studies analyzing radiological predictors of recurrent herniation, both ipsilateral and contralateral. A search was conducted on Medline and EMBASE. Both retrospective and prospective comparative studies were included, measuring radiological parameters of lumbar discectomy patients. All factors were considered irrespective of imaging modality, and a meta-analysis of the data was performed in which 5 or more studies were identified analyzing the same parameter. RESULTS: In total, 1626 reported studies were screened, with 23 being included in this review, of which 13 were appropriate for meta-analysis. Three factors, namely disc height index, Modic changes, and sagittal range of motion, were determined to be significantly correlated with an increased rate of rLDH. Some variables were considered in only 1 or 2 different studies, and the authors have included a narrative review of these novel findings. CONCLUSIONS: The findings of associations between the radiological parameters and rLDH implicates the role of instability in the development of recurrence. Understanding the physiological factors associated with instability is important, because although early degenerative disc changes may predispose patients to herniation recurrence, more advanced degeneration likely reduces segmental motion and concurrently risk of recurrence.

6.
Am J Case Rep ; 21: e921795, 2020 Mar 28.
Artigo em Inglês | MEDLINE | ID: mdl-32221270

RESUMO

BACKGROUND SMART (Stroke-like Migraine Attacks after Radiation Therapy) syndrome is an uncommon delayed complication of cerebral radiotherapy. Less than 50 cases have been reported in the literature since it was first described in 1995. On average, presentation is about 20 years after radiotherapy, and patients commonly present with headaches, complex seizures, and stroke-like symptoms. The exact pathophysiology of the disease remains poorly understood, but one theory suggests radiation-induced vascular dysfunction. CASE REPORT We present one such case of a 28-year-old man who presented to our Emergency Department with a gradually progressive severe headache and right-sided weakness developing over a few hours. MRI played a central role in the diagnosis of SMART syndrome, with serial studies demonstrating and supporting the theory of vascular dysfunction. The condition is usually self-limiting, and most patients achieve complete recovery of symptoms, as did ours. Its optimal management remains unclear. CONCLUSIONS Better understanding of the imaging findings in SMART syndrome may help differentiate it from tumor recurrence, cerebral infections, or vasculitis. Because the diagnosis of this condition portends a significantly better prognosis and substantially alters patient expectation and management, it is important that clinicians are aware of the usual delayed presentation, symptomology, and imaging findings.


Assuntos
Neoplasias Encefálicas/radioterapia , Transtornos de Enxaqueca/diagnóstico por imagem , Transtornos de Enxaqueca/etiologia , Lesões por Radiação/complicações , Adulto , Diagnóstico Diferencial , Glucocorticoides/uso terapêutico , Humanos , Masculino , Metilprednisolona/uso terapêutico , Transtornos de Enxaqueca/tratamento farmacológico , Convulsões , Síndrome
7.
J Clin Neurosci ; 74: 256-257, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31126846
8.
BMJ Case Rep ; 12(11)2019 Nov 28.
Artigo em Inglês | MEDLINE | ID: mdl-31780615

RESUMO

Syncopal events are a concerning presentation and timely evaluation is warranted. Common aetiologies include cardiac and neurological pathology such as arrhythmias, vertebrobasilar arterial disease and vasovagal syncope. We describe the case of a 65-year-old man who presented to our emergency department with symptoms of vertigo and syncope. He was investigated extensively for both cardiac and neurological causes of his symptoms which returned negative results. An outpatient CT scan demonstrated the presence of Os odontoideum and dynamic instability of the atlantoaxial junction, with presumed dynamic obstruction of the vertebral arterial system. This was successfully managed with a posterior atlantoaxial lateral mass fusion with resolution of syncopal symptoms.


Assuntos
Articulação Atlantoaxial , Vértebra Cervical Áxis , Instabilidade Articular/complicações , Síncope/etiologia , Idoso , Humanos , Masculino
9.
World Neurosurg ; 128: 114-121, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31028982

RESUMO

BACKGROUND: Lumbar radicular pain is one of the most commonly encountered clinical syndromes; however, its underlying mechanistic basis, and its relation to the natural history of the disease, are poorly understood. METHODS: We revieved the available literature to explore the pathophysiology and natural history of lumbar radicular pain. RESULTS: Experimental observations have spawned distinctive, but not mutually exclusive, pathophysiologic descriptions of radicular pain. These mechanisms include mechanical compression and inflammatory processes. In most cases, a complex interplay between these mechanisms is required to sustain the pain. However, when the dorsal root ganglion is mechanically deformed, sustained discharges causing pain can be evoked, leading to pain based on a purely mechanical basis. However, in other instances, previous sensitization of the nerve root by inflammatory processes is required. CONCLUSION: An understanding of these processes and the natural history of the syndrome is important to developing therapeutic strategies.


Assuntos
Vértebras Lombares , Ciática/fisiopatologia , Sensibilização do Sistema Nervoso Central/fisiologia , Progressão da Doença , Gânglios Espinais/fisiopatologia , Humanos , Inflamação/fisiopatologia , Deslocamento do Disco Intervertebral/complicações , Ciática/etiologia
10.
World Neurosurg ; 110: 403-406, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29203309

RESUMO

BACKGROUND: Spontaneous acute arterial subdural hematoma (SDH) is a rare entity caused by hemorrhage from a cortical perisylvian artery without a known precipitant. CASE DESCRIPTION: A 53-year-old man presented with a 2-day history of acute-onset headache and dysphasia. He had a generalized seizure on arrival to hospital and no history of trauma. A computed tomography demonstrated an acute left-sided SDH. A computed tomography angiogram and a digital subtraction angiogram demonstrated active contrast extravasation into the SDH. A craniotomy was performed to evacuate the hematoma; the bleeding perisylvian artery was visualized and coagulated. CONCLUSIONS: We report a rare case of acute SDH and present a review of the literature. The etiology, investigation, and management of this rare neurosurgical emergency are discussed.


Assuntos
Doenças Arteriais Cerebrais/diagnóstico por imagem , Hematoma Subdural Agudo/diagnóstico por imagem , Angiografia Cerebral , Doenças Arteriais Cerebrais/cirurgia , Diagnóstico Diferencial , Hematoma Subdural Agudo/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada por Raios X
12.
J Spine Surg ; 3(1): 102-107, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-28435928

RESUMO

Extra-skeletal Ewing sarcoma in pregnancy is rare. There is thus limited scientific evidence to guide clinicians in its complicated management, particularly within the context of early gestation. We therefore share our successful outcome in a 32-year-old pregnant patient, following a unique management strategy of complete aggressive surgical resection prior to neo-adjuvant therapy. The case involved a 2-month history of right-sided back and gluteal pain, with associated paraesthesia. Lumbosacral magnetic resonance imaging (MRI) revealed an approximate 40×50 mm indeterminate mass in the lower right paraspinal musculature. The mass extended into the first right sacral foramen and the central canal; and also impinged on the S2 exiting nerve. After considering the patients' rapid deterioration, pregnant status and other clinical factors, it was elected to proceed with complete surgical resection prior to any other therapeutic modality. Following surgery, the patient experienced immediate resolution of her pain and by 6 weeks was able to cease the use of all analgesics. At 32-weeks' gestation she underwent an uncomplicated vaginal delivery. At 9 months follow up, she remains disease free and has experienced complete resolution of her back pain and radiculopathy.

14.
Mol Cancer Res ; 14(12): 1217-1228, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27671336

RESUMO

Laterally spreading tumors (LST) are colorectal adenomas that develop into extremely large lesions with predominantly slow progression to cancer, depending on lesion subtype. Comparing and contrasting the molecular profiles of LSTs and colorectal cancers offers an opportunity to delineate key molecular alterations that drive malignant transformation in the colorectum. In a discovery cohort of 11 LSTs and paired normal mucosa, we performed a comprehensive and unbiased screen of the genome, epigenome, and transcriptome followed by bioinformatics integration of these data and validation in an additional 84 large, benign colorectal lesions. Mutation rates in LSTs were comparable with microsatellite-stable colorectal cancers (2.4 vs. 2.6 mutations per megabase); however, copy number alterations were infrequent (averaging only 1.5 per LST). Frequent genetic, epigenetic, and transcriptional alterations were identified in genes not previously implicated in colorectal neoplasia (ANO5, MED12L, EPB41L4A, RGMB, SLITRK1, SLITRK5, NRXN1, ANK2). Alterations to pathways commonly mutated in colorectal cancers, namely, the p53, PI3K, and TGFß pathways, were rare. Instead, LST-altered genes converged on axonal guidance, Wnt, and actin cytoskeleton signaling. These integrated omics data identify molecular features associated with noncancerous LSTs and highlight that mutation load, which is relatively high in LSTs, is a poor predictor of invasive potential. IMPLICATIONS: The novel genetic, epigenetic, and transcriptional changes associated with LST development reveal important insights into why some adenomas do not progress to cancer. The finding that LSTs exhibit a mutational load similar to colorectal carcinomas has implications for the validity of molecular biomarkers for assessing cancer risk. Mol Cancer Res; 14(12); 1217-28. ©2016 AACR.


Assuntos
Adenoma/genética , Neoplasias Colorretais/genética , Redes Reguladoras de Genes , Genômica/métodos , Biologia Computacional/métodos , Metilação de DNA , Epigênese Genética , Feminino , Dosagem de Genes , Perfilação da Expressão Gênica/métodos , Regulação Neoplásica da Expressão Gênica , Estudo de Associação Genômica Ampla/métodos , Humanos , Mutação , Análise de Sequência de RNA/métodos
15.
ANZ J Surg ; 86(12): 1002-1006, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26923903

RESUMO

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) provides support to patients with severe but reversible cardiac or pulmonary failure. Vascular complications of ECMO are well recognized. METHODS: We performed a retrospective review of 70 patients (mean age 48 years; 15-85) who received peripheral veno-arterial ECMO from 2004 to 2010 in a single centre. For statistical analysis, chi-squared test and multivariate binary logistic regression analysis were used to assess for association between response variables (i.e. limb ischaemia, ECMO site bleeding and deep vein thrombosis (DVT)) and possible predictive variables. RESULTS: There were 14 (20%) cases of acute limb ischaemia with no statistically significant relationship between acute limb ischaemia and independent variables. Thirty-three patients received distal limb cannulas (47%). There was no statistically significant association between limb ischaemia and presence of distal limb cannula (P = 0.8). Multivariate binary logistic regression analysis identified insertion by cutdown as a predictor of lower probability of insertion site bleeding (n = 12, odds ratio 0.24, P = 0.04). Seven cases of DVT were identified; multivariate binary logistic regression analysis identified insertion by cutdown (odds ratio 0.08, P = 0.03) and days of ECMO less than five (odds ratio 0.08, P = 0.04) as predictive factors for reduced rates of DVT. CONCLUSION: Ischaemic complications of ECMO are common and occur despite the presence of a distal limb-perfusing cannula; however in our study the distal limb cannula was a limb-salvaging intervention in six patients. Prolonged time on ECMO is a risk factor for DVT, and a high index of suspicion must be maintained. Percutaneous insertion was associated with higher rates of bleeding and DVT.


Assuntos
Cânula , Oxigenação por Membrana Extracorpórea/instrumentação , Isquemia/prevenção & controle , Perna (Membro)/irrigação sanguínea , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Desenho de Equipamento , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
16.
J Clin Neurosci ; 23: 44-50, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26282154

RESUMO

This systematic review was performed to evaluate the various operative management strategies for recurrent lumbar disc herniation (RLDH), including the efficacy of instrumented spinal fusion (ISF) at repeat discectomy, and whether the operative approach for repeat discectomy, minimally invasive (MID) or conventional open discectomy (CD), affected the outcomes. RLDH is one of the most common complications of lumbar discectomies. Whilst repeat discectomy is the standard procedure performed, the routine addition of ISF has been advocated to improve outcomes and prevent reherniation. A comprehensive search of the MEDLINE, EMBASE, CINAHL and Cochrane databases was performed. The measured outcomes included the rate of satisfactory clinical outcome, improvement in leg and back pain, Japanese Orthopaedic Association (JOA) recovery score, and complication rates. In total, 37 studies met our inclusion criteria, with 1483 patients. The rate of satisfactory outcomes was found to be statistically similar between the patients undergoing a discectomy with or without fusion (77.8% with ISF versus 79.5% without ISF; p=0.665). Back pain and JOA scores showed greater improvements in the patients undergoing discectomy and fusion, compared to discectomy alone. The rate of satisfactory outcomes was marginally higher in the patients undergoing MID compared to CD (MID 81.2% versus CD 77.5%; p=0.248). However, the leg pain improvement was similar. The postoperative back pain improvement was greater in the MID group (52.5% MID versus 36.3% CD), but with lower complication rates, specifically durotomies (MID 5.2% versus CD 15.3%; p<0.001). There is no evidence to recommend the routine addition of ISF in the management of RLDH. The data suggest that MID has lower complication rates than CD in the setting of RLDH, yet unequivocal evidence is lacking.


Assuntos
Discotomia/métodos , Deslocamento do Disco Intervertebral/cirurgia , Complicações Pós-Operatórias/epidemiologia , Fusão Vertebral/métodos , Adulto , Idoso , Dor nas Costas/cirurgia , Discotomia/efeitos adversos , Feminino , Humanos , Vértebras Lombares/cirurgia , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Recidiva , Fusão Vertebral/efeitos adversos , Resultado do Tratamento
17.
Eur J Gastroenterol Hepatol ; 25(3): 319-26, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-23354161

RESUMO

OBJECTIVES: Laterally spreading tumours (LSTs) are a heterogeneous group of adenomas that are emerging as important precursors of colorectal cancer and in which the risk for cancer is related to their endoscopically definable morphology. It is currently unclear whether different molecular alterations determine their morphologies. We aimed to assess this relationship in LSTs using strict morphological classifications. METHODS: We characterized 135 sessile adenomatous lesions (≥ 20 mm) according to histopathology and the Paris classification. We investigated key molecular changes commonly found in colorectal neoplasms, namely mutation of KRAS, BRAF, APC and CTNNB1 and microsatellite instability, and determined their relationship with morphology. RESULTS: The Paris classification revealed a heterogeneous cohort comprising Is/IIa+Is (41.5%), IIa/IIb (53.3%) and IIc/IIa+IIc (5.2%) lesions. Histopathological analysis showed that 19 (14.1%) of these were sessile serrated adenomas. Here, we defined a group of 58 lesions that showed either Paris IIa or IIb morphology with no serrated histopathology. These 'classical LSTs' showed the following molecular characteristics: microsatellite instability 0/56 (0%), APC mutation 29/30 (96.7%), CTNNB1 mutation 2/55 (3.6%), KRAS mutation 24/55 (43.6%) and BRAF mutation 2/55 (3.6%). Separation of lesions according to surface morphology showed that KRAS mutations occurred much more frequently in granular (56.4%, 22/39) than in nongranular LSTs (12.5%, 1/16, P=0.004). CONCLUSION: The microsatellite instable pathway is not important in the development of LSTs, which are instead likely to develop along a divergent chromosomal instability pathway. We demonstrate the biological significance of endoscopic findings by showing that the morphological characteristics of LSTs are underpinned by distinctive molecular profiles.


Assuntos
Adenoma/genética , Adenoma/patologia , Biomarcadores Tumorais/genética , Neoplasias do Colo/genética , Neoplasias do Colo/patologia , Colonoscopia , Adenoma/cirurgia , Idoso , Distribuição de Qui-Quadrado , Neoplasias do Colo/cirurgia , Feminino , Genes APC , Predisposição Genética para Doença , Humanos , Masculino , Instabilidade de Microssatélites , Pessoa de Meia-Idade , Mutação , Invasividade Neoplásica , New South Wales , Fenótipo , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Proteínas Proto-Oncogênicas/genética , Proteínas Proto-Oncogênicas B-raf/genética , Proteínas Proto-Oncogênicas p21(ras) , beta Catenina/genética , Proteínas ras/genética
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