Syringe needle located deep in the brain: image-guided removal

BACKGROUND

Removal of a thin but long foreign body lodged in the deep brain tissue may need special technique to remove it without causing major injury. We report a special technique for the safe, elective removal of such objects.

CASE DESCRIPTION

A 5-year-old boy presented following mild head trauma; he was asymptomatic and physical examination revealed an intact scalp and no neurological deficit. The incidental presence of a 3.4 cm-long syringe needle in the right frontal region was noted on the skull radiographs. Cranial computed tomography (CT) scan showed the deeper end of the needle in the right caudate head and the superficial end at a depth of 3.5 cm from the cortical surface. Burr hole surgery was performed under general anesthesia employing a Fisher stereotactic frame and continuous biplanar guidance from the image intensifiers. The superficial end of the needle was clasped with an endoscopy biopsy forceps, allowing removal of the needle via the least traumatic route. The child had an uneventful recovery. Follow-up magnetic resonance imaging at 6 months did not reveal any abnormality.

CONCLUSIONS

The two-dimensional biplanar image-guided stereotactic technique allowed safe removal of a long foreign body from a deep brain location with minimal trauma to the brain.

[Radiological evidence of lung involvement in metal fume fever]

We report the case of a 32-year-old welder who developed a flu-like syndrome a few hours after founding zinc. The patient experienced fever, headache, muscle pain and dyspnea that resolved spontaneously with a few hours. The diagnosis of metal fume fever was retained. The chest x-ray evidenced bilateral diffuse infiltrative pulmonary lesions, rarely described in this syndrome. Metal fume fever is a likely diagnosis in exposed patients who develop fever with diffuse lung involvement.

[Pulmonary lymphangioleiomyomatosis in a menopaused woman]

We report an unusual case of pulmonary lymphangioleiomyomatosis in a menopaused woman who had been taking estrogen hormone replacement therapy for several years. The characteristic feature of this uncommon disease is a proliferation of non-tumoral abnormal smooth muscle cells within the alveolar walls, and around the bronchi, lymph nodes and blood vessels. About twenty cases of pulmonary lymphangioleiomyomatosis have been described in menopaused women, who generally were taking estrogen hormone replacement therapy. This subpopulation does not appear to present any particular clinical, functional or radiographic features.

Ocular manifestations of hindbrain-related syringomyelia and outcome following craniovertebral decompression

PURPOSE

To analyse and evaluate associated ocular symptoms and signs in hindbrain-related syringomyelia and their response to treatment.

METHODS

From a database of 275 patients treated in a single institution for hindbrain hernia and syringomyelia, 39 patients (14%) had ocular symptoms and signs. Only 31 patients were included in this study; the remainder were excluded due to inadequate follow-up information. All patients had confirmed evidence of hindbrain-related syringomyelia with MRI scan or CT myelogram. Treatment included craniovertebral decompression or ventriculo-peritoneal shunting. The mean follow-up was 23 months.

RESULTS

In addition to the well-recognised sign of downbeat nystagmus, classically associated with foramen magnum abnormalities, a number of other ophthalmic features were identified. Symptoms included diplopia, oscillopsia, tunnel vision and difficulty in lateral gaze. Signs included nystagmus (downbeat, horizontal, rotatory, and combinations), strabismus, disc pallor, anisocoria, ptosis and field defect. Patients were categorised into two groups depending on whether the ocular features were manifest at first presentation (group 1, n = 14) or developed later in the course of the disease (group 2, n = 17). The delay in diagnosis from first presentation was 5 and 6 years respectively. All patients underwent surgery. Craniovertebral decompression was performed in 13 patients in group 1 and in 15 patients in group 2. Ventriculo-peritoneal shunt was inserted in 1 patient in group 1 and in 3 patients in group 2, for the associated hydrocephalus. Following surgery, 100% of patients in group 1 and 82% of patients in group 2 had complete or partial resolution of their ocular symptoms and signs.

CONCLUSIONS

The presence of unexplained ophthalmic features such as nystagmus or oscillopsia should alert one to the potential diagnosis of hindbrain-related syringomyelia. Delay in diagnosis is often associated with poorer outcome. Surgical treatment can offer excellent results for these patients.

Congenital absence of a cervical pedicle: report of two cases and review of the literature

OBJECTIVE AND IMPORTANCE

The congenital absence of a cervical pedicle is a rare clinical entity. Patients with this anomaly tend to present with cervical pain or after a traumatic incident. Initial evaluations with conventional radiography frequently lead to misinterpretation and misguided intervention. We report two cases of absent cervical pedicles and describe the presentation, diagnosis, and treatment of these patients. Moreover, we review the literature on this clinical entity.

CLINICAL PRESENTATION

The first patient was a 4-year-old boy who presented with neck pain after falling off a trampoline. His neurological examination did not reveal any focal abnormalities, but radiographs were thought to be consistent with a right, C4-C5, unilateral, jumped facet. The second patient was a 27-year-old woman who presented with severe neck, back, and left upper extremity pain and paresthesias after an alleged incident of spousal abuse. Her neurological examination results were remarkable for left upper extremity weakness and hemibody sensory changes. Conventional radiographs were thought to reveal a left, C3-C4, unilateral, locked facet.

INTERVENTION

For both patients, reduction attempts were made with Gardner-Wells tongs and traction. After failure to achieve adequate reduction, evaluations using two-dimensional computed tomography confirmed congenitally absent cervical pedicles. Both patients were ultimately treated conservatively and experienced resolution of their presenting symptoms.

CONCLUSION

The congenital absence of a cervical pedicle is a rare entity that is frequently misdiagnosed. Diagnoses can be accurately confirmed with two-dimensional computed tomography. Conservative treatment resulted in successful management of this clinical entity.

Emergency tracheostomy following life-threatening hemorrhage in the floor of the mouth during immediate implant placement in the mandibular canine region

BACKGROUND

The edentulous interforaminal mandibular area is frequently the preferred area for implant placement.

METHODS

A case of emergency tracheostomy following life-threatening hemorrhage in the floor of the mouth during immediate implant placement in the mandibular canine region is described. The probable cause was bleeding from the sublingual artery or a branch of that artery following implant perforation of the lingual cortex.

RESULTS

Healing was uneventful and the patient was released from the hospital after 11 days. Three years later, CT showed a well-osseointegrated implant with a severe buccolingual inclination.

CONCLUSIONS

It is stressed that short implants (14 mm or less) should be used in the mandibular canine region and that effective treatment of this complication is essential.

Bilateral fronto-orbito-zygomatic craniotomy--a combined extended frontal and orbitozygomatic approach

In extensive skull base lesions involving the spheno-ethmoido-clival region and extending into both the cavernous sinuses and infratemporal regions, a combination of approaches is usually required, either in the same operation or at a second stage. The bilateral fronto-orbito-zygomatic craniotomy described in this report is a combination of an extended frontal approach and fronto-orbito-zygomatic craniotomy. This gives a wide exposure of the spheno-ethmoido-clival regions of both the cavernous sinuses and both the infratemporal regions. The exposure is thus greatly improved with minimal frontal lobe retraction. The single bone piece can be speedily replaced obviating the need for a complicated reconstruction technique and gives a superior cosmetic result. The operative technique is described in detail.

Chronic systemic (hepatosplenic) candidiasis in a patient with granulocytic sarcoma

Chronic systemic (hepatosplenic) candidiasis (CSC) is a syndrome of invasive candidiasis characterized by fever without localizing signs or symptoms. It occurs predominantly in patients with acute leukemia, after prolonged severe neutropenia. We report a young woman who underwent extensive chemotherapy for granulocytic sarcoma of the ovary; CSC then developed in this patient. She was successfully treated with fluconazole and liposomal amphotericin B. Clinical presentation, diagnostic problems, and the current successful treatment with fluconazole and liposomal amphotericin B are discussed.

Impact in the emergency department of unenhanced CT on diagnostic confidence and therapeutic efficacy in patients with suspected renal colic: a prospective survey. 2000 ARRS President's Award. American Roentgen Ray Society

OBJECTIVE

Our objective was to evaluate the impact of unenhanced CT on clinician diagnostic confidence and therapeutic efficacy in emergency department patients with clinically suspected renal colic.

SUBJECTS AND METHODS

Questionnaires were completed on 93 patients who were referred to the radiology department with clinically suspected renal colic. We prospectively surveyed the clinician's diagnostic confidence and treatment plan before and after unenhanced abdominal and pelvic CT.

RESULTS

Fifty-six patients (60%) had positive findings for calculi, 20 patients (22%) had normal findings, and alternative diagnoses were found in 17 patients (18%). The clinician's diagnostic certainty of stones before CT was variable with the largest frequencies at 41-60% (n = 30) and 71-90% (n = 35). The diagnostic certainty of stones after CT showed movement toward either less than or equal to 10% (n = 25) or greater than or equal to 91% (n = 51). The mean change in diagnostic confidence was 34%. Fifty-seven patients (61%) had a change in treatment plan. Specifically, the need for urology consultation as the initial treatment plan was reduced from 24 patients to one patient. Plans for admissions suggested before CT (n = 11) were nearly cut in half (n = 6) after imaging. Lastly, seven patients who would have initially been discharged were admitted to the hospital after imaging.

CONCLUSION

CT significantly increased emergency department clinician diagnostic confidence and altered initial treatment decisions in patients with suspected renal colic. Most often, CT confirmed a ureteral stone and allowed appropriate discharge or urologic intervention. In a smaller subset of patients, CT established a significant alternative diagnosis that allowed the prompt initiation of appropriate treatment.

Predictive value of preoperative tests in discriminating bilateral adrenal hyperplasia from an aldosterone-producing adrenal adenoma

In primary hyperaldosteronism, discriminating bilateral adrenal hyperplasia (BAH) from an aldosterone-producing adenoma (APA) is important because adrenalectomy, which is usually curative in APA, is seldom effective in BAH. We analyzed the results from our most recent 7-yr series to evaluate the predictive value of preoperative noninvasive tests compared with adrenal vein sampling (AVS). Forty-eight patients with hypertensive hyperaldosteronism underwent bedside testing, computed tomography (CT) imaging, and AVS. Those in whom the results of AVS indicated APA underwent adrenalectomy. Twelve (30%) and 14 (34%) of 41 patients with APA had paradoxical falls with ambulation in plasma aldosterone concentration (PAC) and 18-hydroxycorticosterone (18-OH-B), respectively. Twenty-nine (70%) and 26 (65%) APA patients had a rise in PAC and 18-OH-B, respectively, as did all 8 BAH patients. Significant identifiers of BAH were supine PAC values less than 15 ng/dL (P: = 0.04), an increase greater than 60% (P: = 0.02) in PAC with ambulation, and supine 18-OH-B values less than 60 ng/dL (P: = 0.04). CT imaging alone was not predictive for BAH or APA. In our population, patients with a positive bedside test result (e.g. a fall in PAC and/or 18-OH-B) and a unilateral adrenal nodule on CT (10 of 41 patients) could have proceeded directly to adrenalectomy for APA. However, a positive bedside test result with a negative CT or a negative bedside test result regardless of CT findings required AVS to confirm the diagnosis and site of disease.

Local intraarterial fibrinolytic therapy for embolic stroke associated with vascular anomalies--two case reports

Two cases of embolic stroke associated with vascular anomalies were treated by intraarterial fibrinolytic therapy. A 78-year-old male had embolic stroke associated with fenestration of the middle cerebral artery (MCA). The embolus lodged in the terminal portion of the right internal carotid artery (ICA) and in the M2 portion of the right MCA. The fenestration was not detected before local fibrinolytic therapy, but was identified by postinterventional angiography. An 82-year-old female had a left-sided persistent primitive trigeminal artery (PPTA), and the embolus lodged in the terminal portion of the left ICA. Left internal carotid angiography also showed rich collateral circulation via the abundant leptomeningeal anastomosis. The PPTA involved the left ICA, so the anomalous anatomy had to be considered in performing local thrombolysis. However, the rich collateral circulation allowed recanalization of the occluded ICA without inducing bleeding. Dissolution of persistently adherent emboli must be performed with great care because of the possibility of such rare vascular anomalies.

[Surgical treatment of injuries of the thoracolumbar transition. 2: Operation and roentgenologic findings]

The authors report on a prospective multicenter study with regard to the operative treatment of acute fractures and dislocations of the thoracolumbar spine (T10-L2). The study should analyze the operative methods currently used and determine the results in a large representative collective. This investigation was realized by the working group "spine" of the German Trauma Society. Between September 1994 and December 1996, 682 patients treated in 18 different traumatology centers in Germany and Austria were included. Part 2 describes the details of the operative methods and measured data in standard radiographs and CT scans of the spine. Of the patients, 448 (65.7%) were treated with posterior, 197 (28.9%) with combined posterior-anterior, and 37 (5.4%) with anterior surgery alone. In 72% of the posterior operations, the instrumentation was combined with transpedicular bone grafting. The combined procedures were performed as one-stage operations in 38.1%. A significantly longer average operative time (4:14 h) was noted in combined cases compared to the posterior (P < 0.001) or anterior (P < 0.05) procedures. The average blood loss was comparable in both posterior and anterior groups. During combined surgery the blood loss was significantly higher (P < 0.001; P < 0.05). The longest intraoperative fluoroscopy time (average 4:08 min) was noticed in posterior surgery with a significant difference compared to the anterior group. In almost every case a "Fixateur interne" (eight different types of internal fixators) was used for posterior stabilization. For anterior instrumentation, fixed angle implants (plate or rod systems) were mainly preferred (n = 22) compared to non-fixed angle plate systems (n = 12). A decompression of the spinal canal (indirect by reduction or direct by surgical means) was performed in 70.8% of the neurologically intact patients (Frankel/ASIA E) and in 82.6% of those with neurologic deficit (Frankel/ASIA grade A-D). An intraoperative myelography was added in 22% of all patients. The authors found a significant correlation between the amount of canal compromise in preoperative CT scans and the neurologic deficit in Frankel/ASIA grades. The wedge angle and sagittal index measured on lateral radiographs improved from -17.0 degrees and 0.63 (preoperative) to -6.3 degrees and 0.86 (postoperative). A significantly (P < 0.01) stronger deformity was noted preoperatively in the combined group compared to the posterior one. The segmental kyphosis angle improved by 11.3 degrees (8.8 degrees with inclusion of the two adjacent intervertebral disc spaces). A significantly better operative correction of the kyphotic deformity was found in the combined group. In 101 (14.8%) patients, intra- or postoperative complications were noticed, 41 (6.0%) required reoperation. There was no significant difference between the three treatment groups. Of the 2264 pedicle screws, 139 (6.1%) were found to be misplaced. This number included all screws, which were judged to be not placed in an optimal direction or location. In seven (1.0%) patients the false placement of screws was judged as a complication, four (0.6%) of them required revision. The multicenter study determines the actual incidence of thoracolumbar fractures and dislocations with associated injuries and describes the current standard of operative treatment. The efforts and prospects of different surgical methods could be demonstrated considering certain related risks. The follow-up of the population is still in progress and the late results remain for future publication.

Recurrent myelinoclastic diffuse sclerosis: a case report of a child with Schilder's variant of multiple sclerosis

Myelinoclastic diffuse sclerosis (MDS, Schilder's disease) is a rare CNS demyelinating disorder affecting mainly children and usually presenting as an intracranial mass lesion. We report the first case of recurrent intracranial MDS where the third episode of demyelination involved the cervical spinal cord. This may represent a subset of the disease, which should be considered as Schilder's variant (childhood form) of multiple sclerosis.

CT-guided cutting needle biopsy of lung lesions--safety and efficacy of an out-patient service

AIM

To determine the safety and efficacy of CT-guided cutting needle biopsy of lung lesions as an out-patient procedure.

MATERIALS AND METHODS

A total of 185 consecutive biopsies were performed under CT guidance on 183 patients between January 1991 and December 1998 using 20-gauge (n= 33), 18-gauge (n= 151) or 14-gauge (n= 1) core biopsy needles. A chest radiograph was taken after observation in the Radiology department for 1 h and asymptomatic patients were discharged.

RESULTS

The histology was malignant in 150 biopsies (81. 1%) and benign in 23 (12.4%) with 12 false-negative results (6.5%); there were no false-positive results. The sensitivity was 92.6%; specificity 100%; negative predictive value 65.7%; and overall accuracy 93.5%. Pneumothoraces occurred in 48 patients (25.9%); one required aspiration only and four required insertion of an intercostal drain. One patient developed a pneumothorax after discharge. Small haemoptyses occurred in 13 patients without pneumothorax (7.0%), one of whom was admitted. In-patient treatment was required in 10 patients (5.4%).

CONCLUSION

Computed tomography-guided cutting needle biopsy of pulmonary lesions is a safe technique with a diagnostic accuracy and complication rate comparable to reported figures for fine needle aspiration biopsy. It can be safely performed on an out-patient basis.

Embolization of cerebral arteriovenous malformations with n-butyl-2-cyanoacrylate

PURPOSE

To determine the safety and effectiveness of arteriovenous malformation (AVM) embolization using liquid adhesives in a series of 103 patients with cerebral AVMs who underwent embolization with n-butyl-2-cyanoacrylate (NBCA).

METHODS

All embolization procedures were performed using NBCA and a lipiodol mixture delivered by a flow-directed and/or guide-wire directed microcatheter.

RESULTS

Using the Spetzler-Martin grading system, there were two cases of grade I AVM, 23 of grade II AVM, 31 of grade III AVM, 37 of grade IV AVM, and 10 of grade V AVM. Eleven patients underwent embolization only; these patients either had evidence of morphologic cure on follow-up angiogram, or showed evidence of a stable condition at 2-years follow-up. Seven patients were not treated owing to technical problems or a positive functional test. All other patients underwent preoperative embolization; 75%-99% obliteration was noted in 39 of these patients, 50%-74% obliteration in 33, and less than 50% obliteration in 13. Embolization-related complications occurred in nine patients, and two patients died as a result of the procedure. Severe neurologic complications occurred in two patients and five patients developed mild or transient neurologic deficit.

CONCLUSIONS

Endovascular treatment of brain AVMs with an NBCA mixture has a lower complication rate than shown in previous studies using other materials. The percentage of obliteration of the nidus is increased because NBCA penetrates AVMs better than polyvinyl alcohol particles. NBCA can be used at a lower concentration than other acrylates, and therefore causes almost no catheter gluing. The embolic mass formed by NBCA is more biocompatable than that formed by other acrylates.

Short regimen of praziquantel in the treatment of single brain enhancing lesions

Twenty-six patients with single enhancing brain lesion (SEL) were openly assigned to receive single-day praziquantel therapy (n=14), or not (n=12). From 14 treated patients, complete resolution was found in 11, partial resolution in two, and the remaining case was later diagnosed as an arteriovenous malformation. Side effects presented in only one patient and remitted in the same day with symptomatic treatment. Conversely, the lesions persisted unchanged in six of 12 patients in the non-treatment group. Untreated patients with persisting lesions were prescribed praziquantel treatment. After this, SELs disappeared in three cases, other diagnoses (brain tuberculoma and arteriovenous malformation) were made in two, and one was not evaluated. When analyzed in regard to the baseline serology, resolution of lesions on computed tomography was found in 13 (complete=12, partial=1) of 14 seropositive patients, whereas it only happened in six (complete=5, partial=1) of 12 seronegative patients. Serological screening defines a subset of SEL patients with good prognosis. If antiparasitic therapy is to be used in patients with SEL, and we cannot find a strong argument against it, single-day praziquantel is the regimen of choice based on duration, costs, and minimal side effects.

Nodal staging of lymphoma with whole-body PET: comparison of

Accurate staging is elementary for optimal management of malignant lymphoma. Advanced cases may be curable with multidrug chemotherapy combined with radiotherapy, whereas limited disease can sometimes be cured by local radiotherapy only. Recently, FDG imaging with whole-body PET (WB PET) has been introduced as an accurate method for staging lymphoma. We evaluated the usefulness of L-[methyl-11C]methionine (MET) in comparison with FDG as a tracer for nodal staging of lymphoma with WB PET.

METHODS

Nineteen patients with untreated, histologically proven malignant lymphoma underwent WB PET imaging with MET and FDG within 1 wk before treatment. Fourteen patients had non-Hodgkin's lymphoma (NHL), and 5 had Hodgkin's disease (HD). Two of these 19 patients were excluded from the final analysis because of hyperglycemia. WB PET images using FDG and MET were visually compared by 3 independent interpreters, and the PET findings were correlated with the data on the basis of conventional staging studies.

RESULTS

Fifty-five of 178 lymph node regions were classified as diseased both by FDG PET and by CT, and 54 of 178 were classified as diseased both by MET PET and by CT. In addition, 11 lymph node regions that CT showed to be normal avidly accumulated FDG. Ten of these lymph node regions also had clear uptake of MET. Another 4 and 5 lymph node regions were enlarged at CT but were judged to be normal by FDG and MET PET, respectively. In nodal staging, both FDG PET and MET PET would have upstaged the disease in 3 patients. MET PET would also have downstaged the disease in 1 patient.

CONCLUSION

FDG and MET seem to be comparable in the detection of lymphoma by WB PET. However, visual interpretation of the images tends to be hampered more by physiologic accumulations of MET than by normal accumulations of FDG, and MET may be preferable to FDG in hyperglycemic patients undergoing staging studies with PET.

Fractures of the talus: experience of two level 1 trauma centers

Fifty-eight patients with 60 talar fractures were retrospectively reviewed. There were 39 men and 19 women. The age average was 32 (range, 14-74). Eighty six percent of the patients had multiple injuries. The most common mechanism of injury was a motor vehicle accident. Twenty-seven (45%) of the fractures were neck, 22 (36.7%) process, and 11 (18.3%) body. Forty-eight fractures had operative treatment and 12 had non-operative management. The average follow-up period was 30 months (range, 24-65). Thirty-two fractures (53.3%) developed subtalar arthritis. Two patients had subsequent subtalar fusion. Fifteen fractures (25%) developed ankle arthritis. None of these patients required ankle fusion. Fractures of the body of the talus were associated with the highest incidence of degenerative joint disease of both the subtalar and ankle joints. Ten fractures (16.6%) developed avascular necrosis (AVN), only one of which had subsequent slight collapse. Avascular necrosis occurred mostly after Hawkins Type 3 and 2 fractures of the talar neck. Three rating scores were used in this series to assess the outcome: the American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score, Maryland Foot Score, and Hawkins Evaluation Criteria. The outcome was different with every rating system. However, the outcome with AOFAS Ankle-Hindfoot Score and Hawkins Evaluation Criteria were almost equivalent. Assessment with the three rating scores showed that the process fractures had the best results followed by the neck and then the body fractures.

Does complete aneurysm exclusion ensure long-term success after endovascular repair?

PURPOSE

To examine whether complete aneurysm exclusion is a reliable marker for successful long-term endovascular abdominal aortic aneurysm (AAA) repair.

METHODS

The medical records, computed tomographic (CT) scans, and duplex examinations of all the patients who underwent endovascular AAA repair at a single institution and had at least 12 months of follow-up were reviewed. Sixty-seven patients (58 men; mean age 74 years, range 57-87) were identified. Complete aneurysm exclusion was defined by the absence of an endoleak at any time before an adverse event. The primary endpoint included all major adverse events that occurred during the postoperative period, including aneurysm expansion, acute symptoms referable to the AAA, late secondary procedures, ruptures, and deaths from ruptures and all other causes.

RESULTS

There were 44 adverse events (8 expanding aneurysms, 4 acute symptoms, 17 secondary procedures, and 15 deaths from other causes) in 28 (42%) patients. Among 36 (54%) patients who had initial complete aneurysm exclusion (no endoleak), 12 (33%) experienced adverse events, compared with 16 (52%) events in 31 patients who had endoleak (chi2 = 1.59, p = 0.21).

CONCLUSIONS

There was no statistically significant difference in adverse events based on the presence or absence of endoleak. Complete aneurysm exclusion as defined by absence of an endoleak does not indicate an event-free postoperative course. A better marker of clinical success of endovascular AAA repair is needed.

Schwannoma of the larynx: case report

Neurogenous tumours of the larynx are extremely uncommon. We present a rare case of schwannoma of the larynx. Clinical findings are presented together with computed tomography (CT) and magnetic resonance images. The tumour was located in the right aryepiglottic fold of the larynx. CT showed a well defined and hypodense mass extending from the right aryepiglottic fold to the right vocal cord. The patient underwent an excision of the mass through a lateral thyrotomy and the tumour was completely removed. The diagnosis and treatment of this tumour are discussed.

Giant cell tumour of the hamate. Case report

We report the case of a 31-year-old woman who had had the distal end of the ulna resected for a giant cell tumour five years before presenting with a further one in the hamate. The medullary cavity of the hamate was curetted and cancellous bone grafted from the distal radius. Her symptoms resolved, and 26 months postoperatively the cortex of the hamate was fully restored.

Bronchiolitis obliterans in children: clinical profile and diagnosis

OBJECTIVE

The aim of the study was to determine the clinical profile, aetiology and radiological categories in children diagnosed with bronchiolitis obliterans (BO).

METHODOLOGY

We undertook a review of the medical records and radiological studies of 14 children with BO.

RESULTS

Unresolving cough and wheeze after a short respiratory illness was the commonest presentation. A viral pneumonitis was identified as the initial respiratory event prior to the development of BO in six children and Mycoplasma pneumoniae was the cause in another three children. Chest X-ray findings could be divided into four distinct patterns that were hyperinflation (n=5), mixed pattern of atelectasis, hyperlucency and bronchial thickening (n=4), unilateral small hyperlucent lung (n=3) and unilateral collapse of one lung (n=2). High resolution computed tomogram (HRCT) chest showing areas of hyperaeration and mosaic ground glass patterns with bronchial thickening were commonly found in patients whose chest X-ray showed bilateral changes. Patients with bilateral lung changes were more likely to have failure to thrive and persistent respiratory symptoms on follow up.

CONCLUSION

A diagnosis of BO can be made from typical clinical features combined with an understanding of the different chest X-ray categories and HRCT of the chest. A viral aetiology was the commonest cause for BO in our series.

An imaging evaluation of angiodysplasia syndromes

Current imaging techniques such as magnetic resonance, magnetic resonance angiography, computer tomography, ultrasound, plain x-rays, and lymphangioscintigraphy have enhanced the ability to define blood and lymph vascular malformations in more precise pathophysiologic terms. Not only can these imaging modalities distinguish arterial anomalies from lymphatic and venous angiodysplasia, but they also readily differentiate edema in the epifascial as opposed to the subfascial peripheral compartments. Moreover, visceral lymphangiectasia (e.g., chylous and non-chylous reflux), bone and muscle overgrowth, agenesis, and fat deposits can also be delineated. Clinical examples are provided including an algorithm for approaching these conditions.

Advanced hepatocellular carcinoma with distant metastases, successfully treated by a combination therapy of alpha-interferon and oral tegafur/uracil

We report a case of advanced hepatocellular carcinoma (HCC), successfully treated by a combination therapy of alpha-interferon (IFN-alpha) and tegafur/uracil (UFT). A 44-year-old Japanese man who underwent a partial hepatectomy for HCC developed tumor recurrence in the liver 10 months after surgery. Transcatheter arterial chemoembolization (TAE) was performed twice within 7 months, but was ineffective. Later, multiple metastatic lesions appeared in the liver, lung and spine. Following the third TAE, a combination therapy of IFN-alpha (10 x 10(6) units, i.m., t.i.w.) and UFT (300 mg, p.o.d.) was started. The treatment resulted in a fall in serum PIVKA-II (protein induced by vitamin K antagonism) levels from 906 mAU to normal levels and a complete resolution of all lung nodules within 6 months. At the latest follow up 24 months after the initiation of combination treatment, the patient was working full-time and showed no evidence of tumor relapse. A combination therapy of IFN-alpha and UFT may be promising for the treatment of advanced HCC.

Evaluation of the effect of high-energy proton irradiation treatment on meningiomas by means of 11C-L-methionine PET

A remnant meningioma of WHO grade I that is located at the base of the skull and is treated with radiotherapy has to be followed up for at least 5-10 years to evaluate the treatment effect and detect recurrence. The tumour has to grow considerably to show detectable volume increase on computed tomography (CT) or magnetic resonance imaging (MRI). Owing to the location at the base of the skull, a small increase in tumour volume may be hazardous. It is thus important to find a method to evaluate treatment effects earlier and potentially detect those tumours that have a tendency to grow. Nineteen patients with intracranial meningiomas were given irradiation with the 180-MeV proton beam at the Svedberg Laboratory, Uppsala, Sweden. The fractionation schedule used was in general a total dose of 24 Gy in four consecutive daily 6-Gy fractions. Serial 11C-Lmethionine PET examinations were used to evaluate the effect of stereotactic proton beam treatment. The radioactivity uptake in the tumour was evaluated as the ratio to the uptake in normal brain tissue. The follow-up period thus far is 36 months. In 15 of the 19 patients, 11C-L-methionine uptake was reduced 36 months after irradiation compared with the pre-treatment uptake of the tracer. In the total patient group the average reduction was 19.4%. Our results reveal that proton beam irradiation of meningiomas had an inhibitory effect on the methionine uptake in the meningiomas, although tumour size remained unchanged. The combination of unchanged tumour morphology and a reduction in methionine uptake after irradiation suggests that 11C-L-methionine PET might enable earlier evaluation of the treatment effect than is possible with CT or MRI.

Congenital lobar emphysema

Congenital lobar emphysema is a cause of respiratory distress during infancy that may present a diagnostic problem. Recognition of this entity is rewarding, because excisional therapy is fairly specific and the results are satisfactory. We present two infants aged 7 weeks and 2 days with congenital lobar emphysema who were diagnosed and treated in our institution for the past two years. Published work is reviewed; diagnostic and treatment issues are discussed.

[Pyogenic liver abscess as a complication of Crohn's disease]

Pyogenic liver abscess in patients with Crohn's disease is not common, but the mortality has been reported to be high if diagnosis and treatment is delayed. Intra-abdominal abscesses, fistulous disease, and steroid therapy have all been reported to be important predisposing factors in the pathogenesis of this entity. We present a patient with Crohn's disease in whom multiple abscesses were encountered in the right lobe of the liver. The diagnosis of liver abscess was established by abdominal computed tomography and the patient was treated by percutaneous catheter drainage. Awareness of this rare complication is important because diagnosis is difficult to make and a high index of suspicion is required. Once suspected, aggressive diagnostic workup and treatment is indicated. Most patients with liver abscess can be successfully managed by percutaneous catheter drainage combined with antibiotic therapy if it is diagnosed before extensive necrosis has occurred.

Epidermoid cyst of the cavernous sinus: clinical features, pathogenesis and treatment

Epidermoid cyst may rarely arise within the lateral wall of the cavernous sinus (CS) and produce clinical symptoms mimicking the Tolosa-Hunt syndrome. Pathogenically, it is suggested that some of the subpopulation of cells arising from the neural crest which give rise to skin, may remain entrapped in the meninges around the nerves in the lateral wall in an uncompleted stage of maturation and may develop epidermoid cysts. A case is presented of a 68-year-old man with a 4-week history previously diagnosed as Tolosa-Hunt syndrome. MRI is the investigation of choice. Surgical resection can result in excellent recovery of preoperative deficits of cranial nerves (CN) III through VI.

Memory rehabilitation of an amnesic patient following limbic encephalitis and a role of family members: a case report

We describe problems in daily living that arose in a 46-year-old man with severe amnesia following limbic encephalitis. Amnesic symptoms changed from stage I (difficulty in memory retention) to stage II (loss of continuity of memory) and finally to stage III (paramnesia and confused sequence of events), significantly affecting his ability to function. Questionnaire response assessment, directly observed behavior, neuropsychological testing, and especially interviewing permitted qualitative assessment of clinical changes, promoted patient insight into the memory disturbance, and enhanced motivation to use a memory notebook. Additionally, the family gained a better understanding of the disorder, made appropriate environmental modifications, and provided other necessary assistance. Episodic memory improved, and the memory notebook served as an effective compensatory tool. However, disturbance in prospective memory did not improve, and was not compensated adequately by use of the notebook. Anxiety and significant impairment of everyday functioning resulted. Long-term supportive intervention at home was necessary. The patient's wife in particular needed to make environmental adjustments and aid him in use of the notebook.

Clinical profile and multimodality approach in the management of juvenile nasopharyngeal angiofibroma

Our experience with 19 cases of juvenile nasopharyngeal angiofibroma (JNA) over a period of 10 years is discussed. All cases are managed with combined modalities which include pre-operative hormonal therapy, radiotherapy and/or surgical resection via transpalatal approach. All patients became asymptomatic with these treatment modalities. The use of combined modalities of treatment is advocated so as to achieve decreased intraoperative blood loss and cure, a reality.

Alcohol-sensitive hereditary essential myoclonus with dystonia: a study of 6 Brazilian patients

We present the clinical profile of a group of patients with myoclonus and dystonia sensitive to alcohol and address these cases in the context of essential myoclonus. Six patients from 4 families were selected: 4 men and 2 women with myoclonus affecting predominantly the arms. Active movements of these segments elicited the dystonic and myoclonic movements. A marked improvement with alcohol intake was seen. Laboratory findings including EEG, SSEP, and cranial CT and MRI were normal. Surface EMG recording showed bursts with duration of 30-112 ms in 3 patients. One patient showed a triphasic recording pattern (agonist-antagonist-agonist) of ballistic type. Our findings suggest that the myoclonus-dystonia disorder is present in Brazilian patients.

Transient global amnesia or subarachnoid haemorrhage? Clinical and laboratory findings in a particular type of acute global amnesia

Acute global amnesia may be due to several causes, such as transient global amnesia (TGA), acute drug-related confusional state, toxic substances, metabolic abnormalities, infective diseases, cerebral tumours, cerebrovascular accidents, subarachnoid haemorrhage and epilepsy. In particular both TGA and subarachnoid haemorrhage may be precipitated by sexual activity; by contrast the two diseases are quite different in prognosis and treatment. Ten subjects were admitted in the period 1997-99 to our emergency department for acute global amnesia related to sexual activity. They represented 18% of total acute global amnesias observed in the same period. All patients were males, aged between 41 and 64 years. TGA was found in nine cases, while one patient had subarachnoid haemorrhage, due to rupture of an aneurysm of the right middle cerebral artery. The patient with subarachnoid haemorrhage showed neurologic defects (second-degree nystagmus and retropulsion), while no major neurologic abnormalities were found in TGA. Likewise computerized tomography (CT) scan was positive only in the case of subarachnoid haemorrhage. Patients and relatives in most cases left out sexual activity as a trigger factor. This experience indicates that acute global amnesia related to sexual activity is mostly due to TGA. Major neurologic signs are suggestive of subarachnoid haemorrhage and an immediate CT scan is recommended. Targeted questions are needed to identify the cause of the event.

Perfusion abnormalities of kidney parenchyma: microvascular imaging with contrast-enhanced color and power Doppler ultrasonography--preliminary results

The purpose of this study was to evaluate the feasibility of microvascular imaging using contrast-enhanced color and power Doppler sonography. Ten patients with a focal lesion of the kidney were examined. Three patients were investigated with the polymeric butylcyanacrylate-based contrast agent SHU 563A, and the remaining patients were investigated with the galactose-based agent Levovist. It was possible to observe the microvascularization with Levovist during the blood pool phase of the agent over a period of 1 to 3 s at 1 min and 2 min after injection. With SHU 563A, microvascular imaging was possible 0.50 s after injection and lasted for 10.35 min. No intratumoral signals were seen in cysts (n = 6) and the investigated abscess. Weak intratumoral polychromatic effects were observed in both renal cell carcinomas in this series. Metastasis could be differentiated from healthy parenchyma due to lack of the polychromatic effect. SHU 563A is appropriate for performing microvascular imaging. The Levovist-induced polychromatic effects are smaller, of shorter duration, and observable only during the blood pool phase; thus, the expected diagnostic benefit is limited.

The human tail associated with intraspinal lipoma: case report

A case of a tail in a 9-month-old baby is reported. Computed tomography and magnetic resonance imaging clearly demonstrated the presence of spina bifida and lipoma continuous from the tail to the spinal canal. A few medical-historical aspects are discussed. The human tail may be related to spinal dysraphism and requires detailed neuroimaging investigation and microsurgery.

[The examinations for diffuse lung diseases]

Diffuse lung diseases show an abnormal shadow that is widely scattered on the bilateral lung fields in the chest X ray view and includes many respiratory diseases such as the infectious or the non-infectious disease; neoplasms. Among these, idiopathic pulmonary fibrosis(IPF) has been studied extensively because of its high frequency and difficulty of treatment. IPF is defined by the respiratory functions, the radiological findings, which depend on HRCT, and the histopathological evaluation by surgical lung biopsy. In particular, the histopathological appearance of usual interstitial pneumonia(UIP) is essential for the diagnosis of IPF. Most serum examinations such as angiotensin-converting enzyme, anti-nuclear antibodies are applied to rule out other diffuse lung diseases. SP-D or KL-6, which is the marker of the type II epithelial cells, is thought to be very useful for revealing the disease activity, but since it is not increased in the early stages of IPF, it is not applied in the diagnosis of IPF. The definitive serum examinations for the diagnosis or determinations of the therapeutic effect or prognosis of IPF have not been established. Easier, more useful and critical examinations including genetic diagnosis are required to manage patients with IPF.

[Strategy for early diagnosis of lung involvement in systemic scleroderma]

Systemic sclerosis (SSc) is an autoimmune disorder characterized by accumulation of collagen in affected organs, mainly the skin and the lungs, associated with abnormalities of the arterioles and capillaries. There are two types of pulmonary involvement, which influence long term prognosis: infiltration of the lungs and/or pulmonary artery hypertension. Full investigations into possible lung involvement must be performed systematically when SSc is diagnosed and during follow-up. The double pathophysiology sometimes makes diagnosis difficult but it must be made as early as possible in order to decide on the optimal treatment. The aim of this study was to evaluate the usual explorations and to propose biological markers to identify patients requiring more detailed lung investigations, in order to establish a diagnostic approach to treatment and follow-up patients with SSc.

Growth rate of small lung cancers detected on mass CT screening

CT has recently been used in mass screening for lung cancer. Small cancers have been identified but the growth characteristics of these lesions are not fully understood. We identified 82 primary cancers in our 3-year mass CT screening programme, of which 61 were examined in the present study. The volume doubling time (VDT) was calculated based on the exponential model using successive annual CT images or follow-up CT images. All cases were also examined in the hospital by high resolution CT (HRCT). Lesions were divided into three types based on HRCT characteristics: type G (n = 19), ground glass opacity (GGO); type GS (n = 19), focal GGO with a solid central component; and type S (n = 23), solid nodule. 18 (95%) lesions of type G, 18 (95%) of type GS and 7 (30%) of type S were invisible on conventional chest radiographs. The mean size of the tumour was 10 mm, 11 mm and 16 mm for type G, type GS and type S, respectively. Most tumours (80%) were adenocarcinomas; 78% of these were GGO (type G and GS). Mean VDT values were 813 days, 457 days and 149 days for type G, type GS and type S, respectively; these are significantly different from each other (p < 0.05). Our results show that annual mass screening CT for 3 successive years resulted in the identification of a large number of slowly growing adenocarcinomas that were not visible on chest radiographs.

Approach to decortication of simple cysts and polycystic kidneys

Laparoscopic excision and marsupialization of symptomatic of recurrent simple renal cysts is an alternative to open or percutaneous surgery. Such surgery may also be useful for pain relief in patients with autosomal dominant polycystic kidney disease (ADPKD). An occlusion balloon catheter is placed in the renal pelvis at the start of the procedure. Cysts are punctured, and the outer wall of the larger cysts is excised with care not to incise the renal parenchyma. In patients with ADPKD, it is important to mobilize the kidney completely, particularly the upper pole, to treat every visible cyst. A laparoscopic ultrasound probe is used to guide the unroofing of any large cysts within 5 to 10 mm of the renal surface. At the end of the procedure, the integrity of the collecting system is confirmed. Strict criteria must be used in selecting patients with simple cysts for laparoscopic marsupialization to minimize the incidence of unsuspected malignancy, and the cyst wall should be examined by frozen and permanent section. Long-term follow-up is needed to evaluate the effect of laparoscopic decompression in ADPKD.

[Alternative diagnoses among suspected herpes simplex encephalitis patients with negative polymerase chain reaction]

The aim of this study was to analyze the diagnosis found in a series of patients in which the diagnosis of Herpes simplex encephalitis (HSE) was ruled out by a negative polymerase chain reaction (PCR) result for HSV DNA in cerebrospinal fluid (CSF) samples. Forty three out of 61 HSE suspected patients had negative PCR. An alternative diagnosis was established in 41.9% of these patients. These patients were diagnosed as having viral (2 cases-11.1%) and non viral (5 cases-27.2%) CNS infections, vascular (4 cases-22.2%) and demyelinating diseases (3 cases-16.7%), metabolic disturbances (3 cases-16.7%), and CNS tumor (1 case-5.6%). The non specific clinical presentation of this disease and the availability of an efficient treatment for HSE explain why several patients with other diseases were initially treated with acyclovir. The early use of PCR in CSF was considered essential for the evaluation of the acute encephalitis cases in this study.

Tophaceous gout of the lumbar spine in a renal transplant patient: a case report and literature review

Tophaceous gout of the spine is rare. We report the case of a 27-year-old male, renal transplant recipient, who presented with an acute onset of lower back pain. Radiological, biochemical and histo-pathological findings confirmed a diagnosis of tophaceous gout of the lumbar spine. We present the case history with the radiological findings and discuss the literature.

Chronic rhinosinusitis: allergy and sinus computed tomography relationships

The management of chronic or recurrent rhinosinusitis problems is multifaceted and should include consideration of contributory and potentially correctable medical and anatomic factors. To date, the relationship between allergy and rhinosinusitis has not been clearly defined. The purpose of this study is to improve understanding of the relative roles of perennial and seasonal allergens in the cause of chronic rhinosinusitis. A retrospective review of 200 consecutive patients was carried out on patients who had chronic rhinosinusitis refractory to medical therapy and who subsequently underwent functional endoscopic sinus surgery. All of these patients had allergy testing for common perennial and seasonal inhalant allergens before surgery. Each patient had sinus CT imaging before undergoing the surgery. The CT scans of each patient were staged according to a validated, standardized grading system by investigators blinded to allergic profile. Allergy testing indicated that 84% of all patients tested positive for allergies. Moreover, 60% of all patients had significant allergic sensitivity; 52% of all patients had multiple allergen sensitivities. Furthermore, there was a predominance of perennial allergens, especially house dust mite over seasonal allergens. The vast majority of our patients undergoing functional endoscopic sinus surgery had concomitant allergy. This study highlights the potential contribution of perennial allergies to the development of rhinosinusitis. Given this direction, future studies may reveal that in the care of patients with perennial allergic rhinitis, early intervention with identification of the offending allergen(s), and subsequent treatment through avoidance, pharmacotherapy, and/or immunotherapy may help in the prevention of recurrent and chronic rhinosinusitis.

Craniofacial resection for paranasal sinus cancers

BACKGROUND

Combined anterior craniofacial resection (CFR) has been in use for more than 25 years. The advent of the free revascularized tissue transfer flap in l980 permitted safe resection of tumors that had spread beyond the confines of the paranasal sinuses with immediate reconstruction of the sino-orbital cranial defect. The purpose of this study was to examine the outcomes and morbidity of a management policy of primary CFR and postoperative radiotherapy for paranasal sinus cancers infiltrating the skull base over a 21-year period.

METHODS

Seventy-three patients with paranasal sinus cancers were treated at the Prince of Wales Hospital between l975 and l996. All were newly diagnosed with the exception of one patient who had received radiotherapy elsewhere 5 years earlier. Only 22% were early lesions and 31% were advanced (more than six sites involved). There were 59 men and 14 women. The mean age was 57 years. All but two patients had a performance status of either 0 or 1. Orbital exenteration was performed in 31 patients. Since l980, all major defects were reconstructed with free tissue transfer flaps.

RESULTS

The 5-year cancer-specific survival (CSS) for the 73 patients was 69%, which was unchanged at 10 years. Twenty two patients died from or with their index cancer. An additional 11 patients died from unrelated causes. The actuarial overall survival (OS) at 5 and 10 years was 61% and 48%, respectively. The 5-year recurrence-free rate was 59%. The CSS for the three dominant pathologic conditions were adenocarcinoma 70%, squamous cancer 51%, and olfactory neuroblastoma 84%. The difference was not significant; however, there was a significant difference in OS, with olfactory neuroblastoma having the best prognosis. Orbital involvement, radiologic evidence of skull base erosion, and involvement of the infratemporal fossa were not poor prognostic indicators. Patients with a performance status of 0 had improved OS. There was no operative mortality.

CONCLUSIONS

An aggressive policy of combined CFR and postoperative radiotherapy with free-flap reconstruction for large defects gave survival results that were comparable to less-advanced lesions and superior to many other treatment alternatives. There was a high exenteration rate (42%). Squamous cancers were associated with the greatest morbidity and poorest OS.