[Carotico-jugular fistula following a ballistic injury]

Carotico-jugular fistulae are known complications of gunshot injuries and stab wounds, but they can be iatrogenic. Untreated, these lesions may lead to heart failure, endocarditis, or cerebral embolization. We present the computerized tomography (CT)-angiographic view and its value in the treatment strategy in carotico-jugular fistula. A 35-year-old male was referred in the second hour of a ballistic injury to the right side of the neck. Physical examination revealed hematoma, exit hole and thrill on the right sternocleidomastoid muscle. Diagnosis was confirmed with Doppler ultrasound and CT angiography. Surgical interposition with 6 mm polytetrafluoroethylene for the carotid artery and with 12 mm Dacron for the internal jugular vein was performed. The fistulous tract was ligated. In the postoperative sixth month, Doppler ultrasound was normal and the patient was on antiaggregant therapy and healthy.

Strain elastography in the characterization of renal cell carcinoma and angiomyolipoma

INTRODUCTION

We evaluate the diagnostic performance of strain elastography to differentiate renal cell carcinoma (RCC) from angiomyolipoma (AML).

METHODS

Strain elastography was performed in 65 patients (mean age 55.5 years; range: 32-81) who had renal lesions (24 AMLs and 41 RCCs) prospectively. Lesions were classified according to lesion size and histological subtypes. The strain ratios of the RCCs and AMLs were evaluated by a radiologist. The area under the curve and the cut-off point were used to assess diagnostic performance. Sensitivity, specificity, and positive and negative predictive values were obtained.

RESULTS

In assessing the mean strain ratio, we divided the groups in 3 according to size: (1) <20-mm lesions; (2) 20- to 40-mm lesions; and (3) >40-mm lesions; the respective mean strain ratios were: 1.5 ± 0.5 (range: 0.06-5.92), 2.8 ± 0.4 (range: 0.17-9.92), 2.7 ± 0.3 (range: 0.08-6.15). When RCCs and AMLs were compared, there was a statistically significant difference in the strain ratio among the 3 groups divided per lesion size (p < 0.01). For the strain ratio, the mean ± standard deviation was 1.1 ± 0.1 for AMLs and 3.4 ± 0.3 for RCCs (p < 0.01). When lesion subtypes were compared, there was a statistically significant difference in the strain ratio between the AML and clear cell RCC (p < 0.01).

CONCLUSIONS

For assessing renal lesions, strain elastography and strain ratio values may be useful in differentiating RCCs from AMLs.

Potential role of interleukin-18 in patients with rheumatoid arthritis-associated carotid intima-media thickness but not insulin resistance

OBJECTIVE

Plasma interleukin-18 (IL-18) has been reported to be associated with homeostasis model assessment of insulin resistance (HOMA-IR). It also has been described as one of the factors that, in addition to insulin resistance, may also contribute to atherosclerosis. Parameters of systemic inflammation are also significantly associated with circulating IL-18. Our objective was to investigate whether IL-18 is associated with insulin resistance and atherosclerosis in patients with rheumatoid arthritis (RA) in which accelerated atherogenesis develops.

MATERIAL AND METHODS

Fifty-one female RA patients and 30 female controls were enrolled in the study; 31 of them were without disease-modifying antirheumatic drug (DMARD) treatment and had a relatively short disease duration. Disease activity was assessed by Disease Activity Score (DAS) 28 index. HOMA-IR method was used to detect insulin resistance. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), fasting plasma glucose (FPG), insulin, tumor necrosis factor alpha (TNF-α), and IL-18 levels were evaluated. Also, carotid intima-media thickness (cIMT) was measured.

RESULTS

There were no differences between patients and the control group according to age, sex, and body mass index. ESR, CRP, insulin, FPG, HOMA-IR, TNF-α, IL-18 levels, and cIMT measurements were significantly high in the patient group. HOMA-IR and cIMT measurements were similar and high in both the DMARD and non-DMARD patient groups. HOMA-IR correlated with TNF-α (r=0.308, p=0.028), but no correlation was found between IL-18 and HOMA-IR. However, IL-18 was correlated positively with cIMT (r= 0.318, p=0.028) and negatively with BMI (r=-0.360, p=0.01).

CONCLUSION

IL-18 is associated with atherosclerosis in RA patients. However, no significant relation was found with insulin resistance. IL-18 may be a marker for early evaluation of atherosclerosis in RA patients.

Endovenous laser ablation and foam sclerotherapy for varicose veins: does the presence of perforating vein insufficiency affect the treatment outcome?

BACKGROUND

Superficial venous insufficiency is a common problem associated with varicose veins. Endovenous laser ablation (EVLA) and concomitant ultrasound (US)-guided foam sclerotherapy are recent treatment methods alternative to surgery in the treatment of superficial venous insufficiency.

PURPOSE

To compare the effectiveness of EVLA and concomitant US-guided foam sclerotherapy prospectively in two different subgroups of the disease (isolated truncal vs. truncal with perforating vein insufficiency).

MATERIAL AND METHODS

The study was approved by the institutional review board. Fifty-five patients with symptomatic saphenous vein insufficiency and varicose veins were included in the study. Seventy-three EVLA and concomitant foam sclerotherapy were performed for 60 lower extremities. To determine the severity of the venous disease, Venous Clinical Severity Score (VCSS) and Visual Analogue Scale (VAS) were carried out before and 6 months after the treatment. Patients were followed up clinically and with Doppler ultrasonography for 6 months after the procedures.

RESULTS

At the sixth month of the follow-up; the total occlusion rate for the saphenous veins was 98.64% (72/73), and re-canalization rate was 1.36% (1/73). The total occlusion rate for the perforating veins was 75% (18/24), re-canalization rate was 25% (6/24). There was no notable major complication. VCSS and VAS scores were decreased significantly following the treatment (p < 0.05). The patients who had isolated saphenous vein insufficiency (Group I: 36/60) and those who had saphenous and perforating vein reflux (Group II: 24/60) were compared. VAS scores were more prominently decreased after the treatment in the isolated saphenous vein insufficiency group (p < 0.05). VCSS were also decreased more prominently in Group I when compared to Group II.

CONCLUSION

EVLA and concomitant US-guided foam sclerotherapy are effective, safe, and minimally invasive treatment options, yielding good cosmetic and clinical results in both isolated truncal and truncal with perforating vein insufficiency groups. However, clinical results and satisfaction of the patients were remarkably superior in cases with isolated truncal vein insufficiency compared to truncal and perforating vein insufficiency.

Hepatobiliary fascioliasis: a case with unusual radiological features

We report a case of hepatobiliary fascioliasis presenting with unusual radiological findings that have not been reported previously. Imaging studies revealed hepatic cystic pouches communicating with intrahepatic bile ducts. Snail-like, oval shaped and conglomerated echogenic particles with no acoustic shadowing, suggesting F. hepatica, were detected in these cystic pouches. In addition, secondary sclerosing cholangitis developed after fascioliasis.

Gallbladder function and dynamics of bile flow in asymptomatic gallstone disease

AIM: To investigate the effects of gallbladder stones on motor functions of the gallbladder and the dynamics of bile flow in asymptomatic gallstone disease.

METHODS: Quantitative hepatobiliary scintigraphy was performed to detect the parameters of gallbladder motor function [gallbladder ejection fraction (GBEF), gallbladder visualization time (GBVT), gallbladder time to peak activity (GBT_max), gallbladder half emptying time (GBT_1/2), and transit time of bile to duodenum (TTBD)] in 24 patients with asymptomatic cholelithiasis who were diagnosed incidentally during routine abdominal ultrasonographic examination and 20 healthy subjects with normal gallbladder.

RESULTS: Even though there was no significant difference in the clinical and laboratory parameters between the patient and control groups, all parameters of gallbladder function except TTBD were found to differ significantly between the two groups. GBEF in the patient group was decreased (P = 0.000) and GBVT, GBT_max, GBT_1/2 in the patient group were longer (P = 0.000, P = 0.015, P = 0.001, respectively).

CONCLUSION: Our results showed that even if there were not any clinical and laboratory findings, gallbladder filling and emptying could be impaired in patients with gallstone disease.

Hemodynamic response to intravitreal triamcinolone in eyes with macular edema

PURPOSE

To assess ocular hemodynamic response to intravitreal triamcinolone in patients with macular edema due to diabetes or retinal vein occlusion.

METHODS

Forty-three patients that were injected by intravitreal triamcinolone acetonide (0.1 cc 4 mg) for unilateral macular edema due to diabetes mellitus (n = 17) and occlusion of retinal vein (n = 26) underwent ocular hemodynamic evaluation by color Doppler imaging (CDI) before and one, two and three months after injection. Non-injected fellow eyes as well as 16 healthy volunteers were also evaluated.

RESULTS

In patients with diabetic macular edema, there was no hemodynamic difference between eyes to be injected and non-injected at baseline (P > 0.23). Compared to controls, a significant difference existed in the ophthalmic artery resistant index (P = 0.001) and end-diastolic velocity (P < 0.001) in diabetics. At one month, compared to fellow eyes, change in end diastolic velocity from baseline in treated eyes was significantly decreased in posterior ciliary arteries (0.68 +/- 0.34 cm/s [mean +/- SEM] vs. -1.04 +/- 0.81 cm/s, P = 0.012). Throughout the study period, no significant alteration from baseline in the resistant index of any artery was noted in treated diabetic eyes (P > 0.05). In eyes with retinal vein occlusion, baseline CDI evaluation demonstrated reduced posterior ciliary arteries systolic flow velocity compared to fellow and control eyes (13.24 +/- 1.04 cm/s, 16.37 +/- 0.76 cm/s and 14.33 +/- 1.41 cm/s, respectively, P = 0.007). Increased peak systolic velocity in the posterior ciliary arteries at one week (P = 0.02), one month (P = 0.005) and two months (P = 0.04), and increase in central retinal artery resistant index at one month was noted (P = 0.05).

CONCLUSION

Intravitreal triamcinolone temporarily changed central retinal artery blood flow and posterior ciliary arteries' peak systolic blood velocity in eyes with retinal vein occlusion whilst no response of blood flow to triamcinolone injection but only transiently altered end diastolic blood velocity in posterior ciliary arteries was observed in diabetic eyes.

Prenatal diagnosis of intracranial pial arteriovenous fistula and endovascular treatment during the neonatal period

We present a case with prenatal diagnosis of an intracranial high-flow pial arteriovenous fistula that was draining into the vein of Galen in the third trimester of pregnancy. The child was treated by transcatheter embolization with N-butyl 2-cyanoacrylate (NBCA) via the umbilical artery in the early neonatal period due to intractable cardiac failure. Hydrocephalus developed and a ventriculoperitoneal shunt was placed. At the time this report was prepared, the patient was 20 months old and without cardiac failure, but with a delay in neurological development. Prenatal diagnosis and endovascular treatment in the early neonatal period is important in preventing heart failure and resultant mortality due to such high-flow vascular malformations. To the best of our knowledge, the combination of prenatal diagnosis of an intracranial high-flow pial arteriovenous fistula draining into the vein of Galen and endovascular treatment in the early neonatal period is presented here for the first time.

Magnetic resonance imaging and diffusion-weighted imaging in methylmalonic acidemia

Methylmalonic acidemia (MMA) is an inborn disorder of amino acid metabolism, often presenting with neurological symptoms. We present the results of magnetic resonance imaging (MRI) and diffusion-weighted imaging (DWI) of the brain in a 16-month-old male patient with classic neurological and laboratory findings for MMA. MRI demonstrated the hyperintensity within globi pallidi both on T2-weighted image and DWI during the acute episode of metabolic acidosis.

An unusual type of severe barotrauma owing to automobile tire biting in a child

The authors report a rare case of a barotraumatic pneumothorax and pneumomediastinum associated with esophageal perforation and orbital emphysema. A 4-year-old boy presented with sudden respiratory distress after blowout of a defective tire that he bit. Computed tomography scan showed right pneumothorax and bilateral orbital emphysema. A linear rupture has been detected in the cervical esophagus in esophagoscopy. Stamm gastrostomy and tube thoracostomy were performed, and broad-spectrum antibiotics have been introduced. Oral feeding started 23 days after blowout of tire, and the patient was discharged 50 days after injury.

[Incidence of left renal vein anomalies in routine abdominal CT scans]

PURPOSE

To study the appearance and incidence of left renal vein anomalies in abdominal CT examinations.

MATERIALS AND METHODS

One thousand and three abdominal CT examinations were reviewed retrospectively for the presence of left renal vein anomalies. Nineteen CT scans were excluded from the study because of technical or patient-dependent factors. The course of the left renal vein was assessed on the CT slices to detect any anomalies.

RESULTS

Left renal vein anomaly was detected in 32 (3.2%) of 984 cases. Twenty-three (2.3%) of them were a retroaortic and 9 (0.9%) of them were a circumaortic left renal vein.

CONCLUSION

It is important to detect left renal vein anomalies before retroperitoneal surgery or interventional procedures. These anomalies can be identified in routine abdominal CT examinations with a careful inspection.

Detection of vesico-ureteric reflux in children by colour-flow Doppler ultrasonography

OBJECTIVES

To assess the findings of colour-flow Doppler ultrasonography (DUS) in the diagnosis of vesico-ureteric reflux (VUR), as an alternative to the primary diagnostic tool, voiding cysto-urethrography (VCUG).

PATIENTS AND METHODS

Thirty-five children (aged 2-15 years) were examined for VUR by DUS and standard VCUG. All patients underwent DUS and VCUG within 48 h but the findings of the latter were not reported to the ultrasonographer. The DUS was undertaken using a colour Doppler real-time system; a positive ultrasonogram was defined by visualizing Doppler signals from the bladder to the ureter during the course of bladder filling.

RESULTS

Of the 70 ureters assessed, 28 were refluxing on DUS and 29 on VCUG; there were two false-positive and three false-negative results. Comparing the two methods showed DUS to be 90% sensitive with a specificity of 93% for detecting VUR. Four patients underwent reimplantation during their treatment. DUS findings correlated well with standard VCUG in these patient as a method of follow-up.

CONCLUSION

DUS can be used as an alternative to standard VCUG for screening and following VUR. In addition, DUS avoids the danger of exposure to ionizing radiation and the unpleasant catheterization that many of these children fear.

Subjective pulsatile tinnitus associated with extensive pneumatization of temporal bone

Pulsatile tinnitus (PT) although an infrequent otologic symptom. PT can be objective (auscaltable) or subjective (non-auscultable). It has been suggested that subjective PT could occasionally be associated with vascular disorders such as arteriovenous malformation, traumatic or spontaneous carotico-cavernous fistula, intracranial aneurysms, vascular tumors of the temporal bone and cerebellopontine angle, fibromuscular dysplasia, cervical venous hums and high jugular bulb. To our literature knowledge, it has not been reported subjective PT due to extensive pneumatization of temporal bone around internal carotid artery (ICA). In this report, we present a case of subjective PT, which was caused by resonance due to extensive pneumatization of temporal bone particularly peripheral to the ICA.

Diagnostic ultrasound treatment increases the bone fracture-healing rate in an internally fixed rat femoral osteotomy model

OBJECTIVE

To investigate the healing effects of diagnostic ultrasound in a standardized rat femur fracture model.

METHODS

Thirty-two male rats aged 14 weeks were used, and each rat's right femur was osteotomized and stabilized under anesthesia. The rats were then divided into 4 groups. Five days after surgery, ultrasound was applied every fifth day with diagnostic sonographic equipment and a probe with a 7.5-MHz frequency and 11.8-mW/cm2 total output intensity for 10 minutes in each session. Ultrasound was applied 8 times in group A, 3 times in group B, and only once in group C. Ultrasound was not applied to sham-operated group D. Healing and callus formation of the rats' femur fractures were evaluated by radiography and dual-energy x-ray absorptiometry.

RESULTS

Dual-energy x-ray absorptiometric and radiographic results showed that the ultrasound therapy accelerated the fracture healing. Radiographically, groups A and B showed better fracture healing than groups C and D. Ultrasound exposure increased both the whole-bone mineral density and the density at the fracture region, increasing in parallel with the exposure period.

CONCLUSIONS

This study confirms the previously shown efficacy of low-intensity ultrasonic stimulation in acceleration of the normal fracture repair process even when performed with a diagnostic sonographic device.

Magnetic resonance imaging for stress incontinence: evaluation of patients before and after surgical correction

OBJECTIVE

The purpose of this study was to evaluate the accuracy of magnetic resonance imaging (MRI) in the pre and postoperative assessment of stress urinary incontinence.

METHODS

Fifteen female patients with clinical evidence of stress urinary incontinence were included in this prospective study. All the patients underwent MRI in the supine position both preoperatively and postoperatively. For imaging, we used a 1.0 T magnet, T2-weighted images were obtained in the midline sagittal plane with patients at rest. Images were evaluated for anatomical stress urinary incontinence alterations, such as the increased distance between the pubococcygeal line and the bladder base and the posterior urethro-vesical angle and the urethral inclination angle changes. Wilcoxon signed rank test allowed comparisons of pre and postoperative results.

RESULTS

Compared with postoperative measurements, the bladder base was lowered significantly by an average of 9.4+/-4.0 mm (P<0.01), posterior urethro-vesical angle was significantly increased by an average of 127.8+/-11.4 degrees (P<0.01), and the urethral inclination angle was significantly increased by an average of 54.9+/-10.1 degrees (P<0.01) preoperatively.

CONCLUSION

Our results suggest that MRI can play a major role in the preoperative and postoperative assessment of stress urinary incontinence. It can reliably detect anatomical urinary incontinence alterations. MRI should be considered in failed surgery, complex prolapse, and in differentiating genuine stress incontinence resulting from malposition of the bladder neck from stress incontinence due to intrinsic urethral damage.