Multicystic encephalomalacia and gastrointestinal injury following single fetal death in first trimester and subsequent fetofetal transfusion syndrome in a monochorionic triplet pregnancy: a case report.

BACKGROUND: Monochorionic multifetal pregnancies are at increased risk of adverse perinatal outcome because of placental vascular anastomoses. We present a case of multicystic encephalomalacia and gastrointestinal injury in two surviving fetuses following single fetal death in first trimester and subsequent fetofetal transfusion syndrome in a monochorionic triplet pregnancy. CASE PRESENTATION: A 31-year-old nulliparous woman had a spontaneous monochorionic triamniotic triplet pregnancy. Three live fetuses with single placenta were seen at 8-week ultrasound scan. One fetus demised at 11 weeks and 3 days of gestation. Dilated echogenic bowel and ascites were found in one surviving fetus at 23 weeks of gestation. At 28 weeks of gestation, the pregnancy was complicated by fetofetal transfusion syndrome in which discordant amniotic fluid volumes were found. Two days later, emergency Caesarean section was performed because of worsening of fetal Doppler and biophysical profile. One baby was found to have jejunal atresia requiring surgery at 4 days old. He had periventricular leukomalacia and intracranial haemorrhage, but subsequent normal neurological development. Another baby had gastric perforation requiring surgery at 2 days old. He was confirmed to have multicystic encephalomalacia by cranial ultrasound and magnetic resonance imaging. He suffered from developmental delay, epilepsy and cerebral palsy. CONCLUSION: This case alerts the obstetricians the possible hypoxic-ischemic injury to the survivors of monochorionic triplet pregnancy after the co-triplet death in the first trimester and fetofetal transfusion syndrome. Antenatal assessment and postnatal follow-up are important for these high-risk multiple pregnancies.

Can pre-operative axial CT imaging predict syndesmosis instability in patients sustaining ankle fractures? Seven years' experience in a tertiary trauma center.

OBJECTIVE: The purpose of this study is to explore the diagnostic accuracy of CT measurements in predicting syndesmosis instability of injured ankle, with correlation to operative findings. METHODS: From July 2006 to June 2013, 123 patients presented to a single tertiary hospital who received pre-operative CT for ankle fractures were retrospectively reviewed. All patients underwent open reduction and internal fixation for fractures and intra-operative syndesmosis integrity tests. The morphology of incisura fibularis was categorized as deep or shallow. The tibiofibular distance (TFD) between the medial border of the fibula and the nearest point of the lateral border of tibia were measured at anterior (aTFD), middle (mTFD), posterior (pTFD), and maximal (maxTFD) portions across the syndesmosis on axial CT images at 10 mm proximal to the tibial plafond. Statistical analysis was performed with independent samples t test and ROC curve analysis. Intraobserver reproducibility and inter-observers agreement were also evaluated. RESULTS: Of the 123 patients, 39 (31.7%) were operatively diagnosed with syndesmosis instability. No significant difference of incisura fibularis morphology (deep or shallow) and TFDs was demonstrated respective to genders. The axial CT measurements were significantly higher in ankles diagnosed with syndesmosis instability than the group without (maxTFD means 7.2 ± 2.96 mm vs. 4.6 ± 1.4 mm, aTFD mean 4.9 ± 3.7 mm vs. 1.8 ± 1.4 mm, mTFD mean 5.3 ± 2.4 mm vs. 3.2 ± 1.6 mm, pTFD mean 5.3 ± 1.8 mm vs. 4.1 ± 1.3 mm, p < 0.05). Their respective cutoff values with best sensitivity and specificity were calculated; the aTFD (AUC 0.798) and maxTFD (AUC 0.794) achieved the highest diagnostic accuracy. The optimal cutoff levels were aTFD = mm (sensitivity, 56.4%; specificity, 91.7%) and maxTFD = 5.65 mm (sensitivity, 74.4%; specificity, 79.8%). The inter-observer agreement was good for all aTFD, mTFD, pTFD, and maxTFD measurements (ICC 0.959, 0.799, 0.783, and 0.865). The ICC for intraobserver agreement was also very good, ranging from 0.826 to 0.923. CONCLUSIONS: Axial CT measurements of tibiofibular distance were useful predictors for syndesmosis instability in fractured ankles. The aTFD and maxTFD are the most powerful parameters to predict positive operative instability.

Diagnostic accuracy of mediastinal width measurement on posteroanterior and anteroposterior chest radiographs in the depiction of acute nontraumatic thoracic aortic dissection.

We aimed to explore the diagnostic accuracy of various mediastinal measurements in determining acute nontraumatic thoracic aortic dissection with respect to posteroanterior (PA) and anteroposterior (AP) chest radiographs, which had received little attention so far. We retrospectively reviewed 100 patients (50 PA and 50 AP chest radiographs) with confirmed acute thoracic aortic dissection and 120 patients (60 PA and 60 AP chest radiographs) with confirmed normal aorta. Those who had prior history of trauma or aortic disease were excluded. The maximal mediastinal width (MW) and maximal left mediastinal width (LMW) were measured by two independent radiologists and the mediastinal width ratio (MWR) was calculated. Statistical analysis was then performed with independent sample t test. PA projection was significantly more accurate than AP projection, achieving higher sensitivity and specificity. LMW and MW were the most powerful parameters on PA and AP chest radiographs, respectively. The optimal cutoff levels were LMW = 4.95 cm (sensitivity, 90 %; specificity, 90 %) and MW = 7.45 cm (sensitivity, 90 %; specificity, 88.3 %) for PA projection and LMW = 5.45 cm (sensitivity, 76 %; specificity, 65 %) and MW = 8.65 cm (sensitivity, 72 %; specificity, 80 %) for AP projection. MWR was found less useful and less reliable. The use of LMW alone in PA film would allow more accurate prediction of aortic dissection. PA chest radiograph has a higher diagnostic accuracy when compared with AP chest radiograph, with negative PA chest radiograph showing less probability for aortic dissection. Lower threshold for proceeding to computed tomography aortogram is recommended however, especially in the elderly and patients with widened mediastinum on AP chest radiograph.

One of a kind-chordoid glioma in the fourth ventricle: a case report and literature review.

Chordoid glioma (CG) is a rare brain tumor that is known for its characteristic location in the third ventricle. A wide spectrum of radiological presentations has been described, with few common features among them. Its radiological diagnosis is mainly suggested by location. However, several cases of CG with atypical locations have been described, illustrating that CG is not limited to the third ventricle, and should be considered in the list of radiological differential diagnosis for intraventricular masses. We present here a case of CG that was found in the fourth ventricle.

Long-term outcome of endovascular reconstruction with the Pipeline embolization device in the management of unruptured dissecting aneurysms of the intracranial vertebral artery.

OBJECT: Use of a flow-diverting device has shown promising short-term results in the management of vertebral artery (VA) dissecting aneurysms, but there is still uncertainty regarding its long-term efficacy and safety. The authors report their initial experience with respect to the potential utility and long-term clinical outcomes of using a flow-diverting device in the treatment of unruptured dissecting VA aneurysms. METHODS: The authors conducted a retrospective review of all cases of unruptured intracranial VA dissecting aneurysms treated at their institution (Tuen Mun Hospital) with a flow-diverting device. They describe the clinical presentations and angiographic features of the cases and report the clinical outcome (with modified Rankin Scale [mRS] scores) at most recent follow-up, as well as results of the latest angiographic assessment, with particular focus on in-stent patency and side-branch occlusion. RESULTS: A total of 4 aneurysms were successfully obliterated by using flow-diverting devices alone. Two devices were deployed in a telescoping fashion in each of 2 aneurysms, whereas only 1 device was inserted in each of the other 2 aneurysms. No periprocedural complication was encountered. No patient showed any angiographic evidence of recurrence, in-stent thrombosis, or side-branch occlusion in angiographic reassessment at a mean of 22 months after treatment (range 18-24 months). As of the most recent clinical follow-up (mean 30 months after treatment, range 24-37 months), all patients had favorable outcomes (mRS Score 0). CONCLUSIONS: Reconstruction using a flow-diverting device is an attractive alternative in definitive treatment of dissecting VA aneurysms, demonstrating favorable long-term clinical and angiographic outcomes and the ability to maintain parent artery and side-branch patency. It is particularly useful in cases with eloquent side-branch or dominant VA involvement.

Diagnostic power of various computed tomography signs in diagnosing acute appendicitis.

OBJECTIVE: To review the diagnostic power of various computed tomography (CT) signs in acute appendicitis, in particular those initially classified as inconclusive. MATERIALS AND METHODS: Retrospective review of 100 CT abdomen and pelvis studies with assessment of maximal luminal diameter, wall thickness and cross-sectional diameter of the appendix, periappendiceal inflammatory changes, and presence of appendicolith. RESULTS: All CT signs show statistically significant occurrences in acute appendicitis. Their respective cut-off values with best sensitivity and specificity were calculated. Those from the inconclusive cases were also reviewed. CONCLUSION: Maximal cross-sectional diameter of the appendix is the most powerful parameter. Rest of the CT signs is supportive, especially in cases with inconclusive results.