Frequency of brain ventricular enlargement among patients with diabetes mellitus

AIMS

To determine the prevalence of dilated ventricles and concomitant high blood glucose measures.

METHODS

We retrieved blood glucose measures from the emergency department database and selected a subgroup of individuals having both the radiological marker Evans' index (EI) values and blood glucose measures.

RESULTS

Out of 1221 consecutive patients submitted to axial Computed Tomography scans, a blood glucose measure was detected in 841 individuals. 176 scans (21 %) showed an EI > 0.30. According to the blood glucose categorization, diabetic patients were 104 (12 %), 25 of them (24 %) were dilated (mean EI 0.33). The age difference between dilated and not-dilated ventricles is about ten years in not-diabetic participants, whereas it is five years in diabetic participants. The age difference between dilated and not-dilated ventricles is about 10 years in diabetic men, whereas it zero in diabetic women.

CONCLUSIONS

Pathological ventricular enlargement is more frequent in men and in the elderly. In diabetic patients (especially women), the cerebral ventricles enlarge faster than in non-diabetic individuals. Age, sex, and diabetes may interact in determining how cerebral ventricle size changes over time, especially in diabetic women, making routine brain imaging advisable in these patients after the age of 70 years.

Radiological measurements of lacrimal gland in thyroid eye disease

PURPOSE

Lacrimal gland enlargement is a common feature of thyroid eye disease (TED) and has been positively correlated with the clinical activity score. Although lacrimal gland volume is the preferred measure of lacrimal gland size, its calculation is not clinically translatable due to the expertise, time and advanced software required. The aim of our study is to determine whether the lacrimal gland volume in patients with TED undergoing magnetic resonance imaging (MRI) can be estimated using simpler lacrimal gland linear and area measurements.

METHODS

A retrospective review of 102 orbits (51 patients) with TED who underwent orbital MRI was conducted. The maximum length, width, and area of the lacrimal gland were measured in axial and coronal sections. Lacrimal gland volume was calculated by using a manual segmentation technique on all consecutive axial slices on commercially available software, OsiriX. All quantitative measurements were correlated with the lacrimal gland volume.

RESULTS

Mean age of participants was 59 ± 16 years, and 67% (n = 34) were females. With multivariate analyses, combined lacrimal gland axial and coronal areas strongly correlated with volume (r = 0.843, p < 0.01). Strong univariate predictors of volume included axial area (r = 0.704, p < 0.01) and coronal area (r = 0.722, p < 0.01), while moderate predictors included axial length (r = 0.523, p < 0.01), axial width (r = 0.521, p < 0.01), coronal length (r = 0.450, p < 0.01), and coronal width (r = 0.649, p < 0.01).

CONCLUSION

In patients with thyroid eye disease, lacrimal gland volume can be estimated using axial and coronal areas, which is simpler and more time efficient than calculating volumes.

Tumor enlargement in adrenal incidentaloma is related to glaucoma: a new prognostic feature?

PURPOSE

The uncertainty on the management of small adrenal incidentalomas (AIs) still represents a challenge in real clinical practice. Considering the lack of knowledge on risk factors implicated in tumour enlargement, the aim of this study was to identify risk factors for morphological changes during follow-up of adrenal incidentalomas (AIs).

METHODS

We retrospectively evaluated demographic, clinical, radiological and biochemical parameters of 153 AIs (2007-2021). Patients with histological diagnosis of metastases or pheochromocytoma were excluded. To detect risk factors for tumor enlargement, diseases associated with AIs were included if their prevalence was higher than 2%. Patients were divided into two groups (A: radiological stability; B: tumor enlargement defined as > 5 mm/year in the main diameter).

RESULTS

Group A: 89.5% and group B: 10.5%, mean follow-up 38.6 ± 6.9 months (range 6-240). Tumor enlargement when occurred was within 36 months of follow-up. In group B high body weight (p < 0.03), dehydroepiandrosterone sulfate (DHEAS) (p < 0.05) and direct renin concentration (DRC) (p < 0.04) were higher than group A, while aldosterone levels were lower; moreover, considering comorbidities, glaucoma and dysglycemia (p < 0.01 for both) had higher prevalence in group B. Glaucoma and dysglycemia were independent predictors of enlargement. Patients affected by glaucoma, atrial fibrillation, dysglycemia had a lower dimensional change-free survival than non-affected.

CONCLUSIONS

Glaucoma might be a novel risk factor for AI enlargement. If subtle undetectable cortisol hypersecretion has a role is a topic for further research.

Normative lacrimal gland dimensions by magnetic resonance imaging in an Australian cohort

PURPOSE

To report the normative dimensions of the lacrimal gland on fat-suppressed contrast-enhanced magnetic resonance imaging (MRI) in an Australian cohort.

METHODS

Retrospective review of patients who underwent 3 T orbital MRI is presented. Two hundred eleven orbits were used to conduct lacrimal gland measurements. Orbits were excluded if there was ipsilateral orbital or lacrimal gland disease, prior surgery, or poor image quality. The length and width of the lacrimal gland were measured in axial and coronal sections using the largest image.

RESULTS

The mean lacrimal gland axial length was 14.6 mm in the right orbit and 14.3 mm in the left orbit. The mean axial width was 4.9 mm in both orbits. Coronal lengths averaged 16.2 mm in the right orbit and 16.4 mm in the left orbit. The coronal width averaged 4.8 mm in both orbits. A significant negative correlation was found between age and the right axial length (r = -0.26, p < .01) and the left axial length (r = -0.26, p < .01) of the lacrimal gland. No statistically significant difference was found between genders or laterality.

CONCLUSION

This study presents the normal lacrimal gland dimensions on fat-suppressed contrast-enhanced MRI in an Australian cohort. An inverse relationship exists between age and the axial length of the lacrimal gland. These data may be used to help diagnose enlargement of the lacrimal gland.

Role of muscle biopsy in diagnosis of extraocular muscles enlargement

PURPOSE

To study the role of muscle biopsy in patients with enlarged extraocular muscles.

METHODS

A retrospective review of 31 patients who underwent biopsy for extraocular muscle enlargement. Characteristics, including signs, symptoms, imaging findings, and histopathological assessment were examined.

RESULTS

Chronic inflammatory disorders represented the most common cause of the muscle enlargement followed by malignancy/metastasis. Multiple muscle involvement was more consistent with benign diseases, whereas single muscle involvement was more consistent with malignant causes. Positive predictive value of muscle biopsy was 0.52 for determining a specific cause of the muscle enlargement.

CONCLUSIONS

Muscle biopsy is the standard for diagnosis in patients with extraocular muscle enlargement. This diagnostic test should be performed in every case of non-resolving muscle enlargement, with a specific diagnosis being made in over half of cases.

Ventricle shape analysis using modified WKS for atrophy detection

Brain ventricle is one of the biomarkers for detecting neurological disorders. Studying the shape of the ventricles will aid in the diagnosis process of atrophy and other CSF-related neurological disorders, as ventricles are filled with CSF. This paper introduces a spectral analysis algorithm based on wave kernel signature. This shape signature was used for studying the shape of segmented ventricles from the brain images. Based on the shape signature, the study groups were classified as normal subjects and atrophy subjects. The proposed algorithm is simple, effective, automated, and less time consuming. The proposed method performed better than the other methods heat kernel signature, scale invariant heat kernel signature, wave kernel signature, and spectral graph wavelet signature, which were used for validation purpose, by producing 94-95% classification accuracy by classifying normal and atrophy subjects correctly for CT, MR, and OASIS datasets.

Reversible severe ovarian enlargement in an infant with significant insulin resistance

The extent, severity, and radiological findings of ovarian growth in infants with genetic syndromes of insulin resistance have not been fully described. We report a rare case of reversible massive ovarian enlargement in a female infant with a congenital insulin resistance syndrome, likely Rabson-Mendenhall syndrome given the less clinically severe course. The patient presented with neonatal diabetes with hyperinsulinemia and hyperglycemia due to congenital insulin resistance. She developed increasing severe bilateral ovarian enlargement which peaked at 4 months of age, followed by gradual decrease in size of the ovaries following treatment with insulin-sensitizing drugs and improved hyperinsulinemia. The ovarian enlargement is postulated to be secondary to the trophic effects of insulin acting in a gonadotropin-independent mechanism. Hyperinsulinemia in congenital insulin resistance can also result in hypertrophy of other organs. Understanding the pathophysiology behind massive ovarian enlargement in the setting of congenital insulin resistance syndromes can help guide appropriate therapy.

Factors Predictive of Enlargement of Dissecting Aneurysms in the Vertebral Artery

OBJECTIVE

To elucidate the incidence rate of enlargement of vertebral artery dissecting aneurysms (VADAs) during the acute phase and factors associated with enlargement.

METHODS

Of 115 patients with unilateral intracranial vertebral artery dissection who did not experience subarachnoid hemorrhage, 64 with the pearl sign of vertebral artery dissection (VADA without stenosis) participated in the study. We performed initial magnetic resonance imaging to diagnose VADA and subsequent magnetic resonance imaging to evaluate VADA enlargement. The presence of a hyperintense intramural signal was confirmed using T1-weighted three-dimensional turbo spin-echo imaging. Enlargement of VADAs between the initial and subsequent examinations was evaluated via magnetic resonance angiography and defined as the end point. We studied the rate of VADA enlargement using Kaplan-Meier curve analysis. After independent variables were determined, the Cox proportional hazards model was applied in multivariable analysis to identify the factors significantly associated with VADA enlargement.

RESULTS

Of 64 patients (mean age, 55.7 ± 13.0 years; 44 men and 20 women), 15 exhibited VADA enlargement. Kaplan-Meier curve analysis indicated that 24.8% of VADA enlargements were detected 30 days after initial magnetic resonance imaging. The Cox proportional hazards model revealed that young age (hazard ratio 0.953, P = 0.043) and the presence of hyperintense intramural signal (hazard ratio 2.841, P = 0.033) were significantly associated with VADA enlargement.

CONCLUSIONS

VADAs enlarged by approximately 25% until day 30 after the initial examination. Younger age and the presence of hyperintense intramural signal were significantly associated with VADA enlargement.

Enlarged accessory spleen after splenectomy mimicking a pancreas tumor

INTRODUCTION

An accessory spleen (AS), a common condition, is usually located in the hilar region of the spleen. ASs are not often large; however, after splenectomy, the initially inactive AS may become reactive and hypertrophic. Therefore, an AS can be misdiagnosed as a neoplastic tumor and removed unnecessarily. An undiagnosed abdominal mass located in the spleen site in a patient who has had a splenectomy must be managed carefully. Computed tomography (CT) scanning and magnetic resonance imaging (MRI) may provide useful information for the diagnosis, preventing unnecessary surgery.

CASE PRESENTATION

Herein, we report the case of a 38-year-old female with an enlargement of AS after splenectomy that was misdiagnosed as a primary tumor of the pancreas and managed by a nonessential surgery.

CONCLUSION

An AS should be added to the differential diagnosis of a pancreatic tail tumor for patients with prior splenectomy in order to avoid nonessential surgery to ensure the patient's safety.

Coronoid hyperplasia: A review

Coronoid hyperplasia is one of the rare causes of progressive limitation of mouth opening due to impingement of the enlarged coronoid process of the mandible on the zygomatic bone. A review was performed on all cases reports and case series on coronoid hyperplasia. Gender, age at treatment, age of onset, types of hyperplasia (unilateral/bilateral), associated history, treatment, surgical approach, preoperative mouth opening, intraoperative mouth opening, mouth opening at follow up and follow up period were recorded and analyzed. A total of 82 articles which reported 115 cases were included. Coronoid hyperplasia was commonly reported at mean age of 22.64 years old with male preponderance. Most of the cases were diagnosed and treated between the age of 11-20 years old. This condition commonly involved bilateral coronoid process of mandible. The mean width of preoperative mouth opening was 16.5mm and was improved to a mean mouth opening of 36.3mm intraoperatively. Mean mouth opening was 34.8mm at an average follow up of 19 months. While the etiopathogenesis of coronoid hyperplasia is still not conclusive, treatment with either coronoidectomy or coronoidotomy produced good improvement in mouth opening.

Long term sequelae of amygdala enlargement in temporal lobe epilepsy

PURPOSE

Amygdala enlargement (AE) has been reported in drug resistant lesional and non-lesional temporal lobe epilepsy (TLE). Its contribution to development of intractability of epilepsy is at best uncertain. Our aim was to study the natural course of AE in a heterogenous group of TLE patients with follow-up imaging and clinical outcomes.

METHODS

A prospective observational study in patients with TLE with imaging features of AE recruited from epilepsy clinics between 1994 and 2018. Demographic data, details of epilepsy syndrome, outcomes and follow up neuroimaging were extracted.

RESULTS

Forty-two patients were recruited including 19 males (45 %). Mean age at onset of epilepsy was 30.6 years and mean duration of epilepsy was 19.9 years. On MRI, 33 patients had isolated unilateral AE and eleven had AE with hippocampal enlargement (HE). Twenty (48 %) underwent temporal resections with most common histopathology being amygdalar gliosis (40 %). Engel Class IA outcome at last follow up (mean, 10 years) was 60 %. Thirty-four patients had neuroimaging follow up of at least 1 year (mean, 5 years). AE resolved in 6, persisted in 25, evolved into bilateral HS in 1, bilateral mesial temporal atrophy in 1 and ipsilateral mesial temporal atrophy in 1. Resolution of AE was associated with better seizure free outcomes (p = 0.013).

CONCLUSIONS

TLE with AE is associated with favourable prognosis yet not benign. Over 50 % were drug resistant and surgical outcomes were similar to mTLE. Resolution of AE on follow up neuroimaging was associated with better seizure free outcomes.

Perioperative factors associated with aneurysm sac size changes after endovascular aneurysm repair

PURPOSE

To identify the perioperative factors associated with aneurysm size changes after endovascular aortic aneurysm repair (EVAR).

METHODS

Between August, 2008 and December, 2014, 187 patients underwent EVAR treatment in our institution. The subjects of this study were 135 of these patients without peripheral artery disease, who were followed up with computed tomography (CT) for 3 years. Significant aneurysm size change was defined as sac size change of more than 5 mm from the baseline.

RESULTS

Sac enlargement was identified in 25 patients (18.5%) and sac shrinkage was identified in 59 (43.7%) patients. The factors associated with sac enlargement were postoperative pulse wave velocity (OR: odds ratio 3.80, p = 0.047), prevalence of a type 2 endoleak 1 week after surgery (OR 4.26, p = 0.022), inner diameter (OR 1.10, p = 0.005), and distance from the lower renal artery to the terminal aorta (OR 1.05, p = 0.017). The factors associated with sac shrinkage were prevalence of a type 2 endoleak (OR 0.09, p < 0.001) and preoperative pulse wave velocity (OR 0.32, p = 0.022). The factors independently associated with type 2 endoleak were the use of an Excluder device (OR 3.99, p = 0.002) and the length of the aneurysm (OR 1.02, p = 0.027).

CONCLUSION

Inner diameter, treatment length, perioperative pulse wave velocity, and type 2 endoleak were associated with sac size changes after EVAR.

Bilateral cavernous carotid aneurysms treated by two-stage extracranial-intracranial bypass followed by parent artery occlusion: case report and literature review

Bilateral cavernous carotid aneurysms (CCAs) are often not amenable to neurosurgical clipping or endovascular coiling. Here, we report the case of a 50-year-old female who presented with a 1-year history of gradual severe headache. Preoperative angiograms revealed bilateral CCAs. Among these findings, the right giant CCA had been trapped after the external carotid artery-saphenous vein-middle cerebral artery (ECA-SV-MCA) bypass 8 years prior. Additionally, the left CCA was again trapped after the internal maxillary artery-radial artery-middle cerebral artery (IMA-RA-MCA) bypass, followed by parent artery occlusion (PAO), because of the enlargement of a 0.4-cm aneurysm to a 1.3-cm aneurysm during the 5th to 8th years following surgery. Postoperative radiologic findings proved that the aneurysms disappeared with good graft patency of the bilateral anastomoses and excellent filling of the bilateral MCA territories. This is the first case of bilateral CCAs treated with two stages of bilateral high-flow extracranial-intracranial (EC-IC) bypass, including an IMA-RA-MCA bypass.

Band gap in tubular pillar phononic crystal plate

In this paper, a phononic crystal (PC) plate with tubular pillars is presented and investigated. The band structures and mode displacement profiles are calculated by using finite element method. The result shows that a complete band gap opens when the ratio of the pillar height to the plate thickness is about 1.6. However, for classic cylinder pillar structures, a band gap opens when the ratio is equal or greater than 3. A tubular pillar design with a void room in it enhances acoustic multiple scattering and gives rise to the opening of the band gap. In order to verify it, a PC structure with double tubular pillars different in size (one within the other) is introduced and a more than 2times band gap enlargement is observed. Furthermore, the coupling between the resonant mode and the plate mode around the band gap is characterized, as well as the effect of the geometrical parameters on the band gap. The behavior of such structure could be utilized to design a pillar PC with stronger structural stability and to enlarge band gaps.

[Purkinje images in slit lamp videography : Video article]

Reflexes that accompany every examination with the slit lamp are usually regarded as annoying and therefore do not receive much attention. In the video available online, clinical information "hidden" in the Purkinje images is analyzed according to our concept of slit lamp videography. In the first part of the video, the four Purkinje images which are reflections on the eye's optical surfaces are introduced for the phakic eye. In the pseudophakic eye, however, the refracting surfaces of the intraocular lens (IOL) have excellent optical properties and therefore form Purkinje images 3 and 4 of high quality. Especially the third Purkinje image from the anterior IOL surface, which is usually hardly visible in the phakic eye can be detected deep in the vitreous, enlarged through the eye's own optics like a magnifying glass. Its area of reflection can be used to visualize changes of the anterior segment at high contrast. The third Purkinje image carries valuable information about the anterior curvature and, thus, about the power of the IOL. If the same IOL type is implanted in a patient, often a difference between right and left of 0.5 diopter in its power can be detected by the difference in size of the respective third Purkinje image. In a historical excursion to the "prenatal phase" of the slit lamp in Uppsala, we show that our most important instrument in clinical work was originally designed for catoptric investigations (of specular reflections). Accordingly A. Gullstrand called it an ophthalmometric Nernst lamp.

Adult symptomatic and growing arachnoid cyst successfully treated by ventriculocystostomy: a new insight on adult arachnoid cyst history

BACKGROUND

Adult arachnoid cysts are known to be stable and asymptomatic but their history remains undefined.

CASE DESCRIPTION

The authors report the case of an 81-year-old woman with progressive hemiplegia and aphasia. CT scan revealed a voluminous left frontotemporal arachnoid cyst with a major mass effect on the midline and contralateral blocked hydrocephalus. Endoscopic ventriculocystostomy was performed with a spectacular neurological improvement.

DISCUSSION AND CONCLUSIONS

Symptomatic adult arachnoid cysts are extremely rare. To our knowledge, no similar clinical case of a growing arachnoid cyst in elderly patients has yet been reported in the literature. The mechanisms of cyst enlargement and decompensation still remain undefined and debated. The possibility of adult arachnoid cyst growth has to be considered in clinical practice. Endoscopic ventriculocystostomy is as effective as in paediatric cases.

Familial gingival fibromatosis: A rare case report

Hereditary gingival fibromatosis is a rare condition that can occur as an isolated disease or as part of a syndrome or chromosomal abnormality. In severe cases, the gingival enlargement may cover the crowns of teeth and cause severe functional and aesthetic concerns. Here, we present a case of an 8-year-old girl with severe enlargement of gums in maxilla and mandible. Both deciduous and permanent teeth were not erupted in the oral cavity at all. Mutation in the Son-of-Sevenless (SOS-1) gene has been associated with the disease. The diagnosis was made based on clinical examination and family history. Surgical removal of the hyperplastic tissue was performed under general anesthesia.

Late unilateral breast enlargement after insertion of silicone gel implants: A histopathological study

Late unilateral breast enlargement after the insertion of silicone gel breast implants is a very rare phenomenon. The present study reports five women who presented with this finding over the past 20 years. Three of these patients presented with late unilateral hematomas, which developed nine, 12 and 14 years, respectively, after initial breast augmentation, in the absence of any known trauma. These patients presented for treatment one, four and 12 months, respectively, after their breast enlargements initially appeared. Two of these patients had developed chronic expanding hematomas. Extensive histopathological analyses of the capsules of all three patients provided explanations for the etiologies and progressions of the findings in these patients. In each of the three patients, the etiology of the hematoma was consistent with erosion of a capsular artery. Numerous large vessels were seen within the wall of the capsules. In each case, there was a class IV capsular contracture, which could have increased the friction of the intact implant against the capsule, and there was both old (hemosiderin deposits) and new bleeding into the pocket from the capsules. This supports the concept that numerous episodes of bleeding had occurred in each case. Histopathology also demonstrated the progression of the hematomas. After four weeks, only liquefied hematoma was present, while after four months, there were both liquefied hematoma and blood clotting. The hematoma on the surface of the capsule was becoming organized peripherally, but not centrally. After 12 months, the hematoma was becoming very well organized compared with the hematoma at four months. In one of the two remaining cases, late infection was the cause of the breast enlargement. Histopathology of this capsule showed that the involved capsule was six times as thick as the other side. It also showed edema and infiltration by scattered mononuclear cells, polymorphonuclear cells, and irregular crenated and degenerating nuclei. In the final patient, chronic inflammation appeared to be the cause of the breast enlargement. The histopathology of this capsule was unique. Its inner surface showed re-epithelialization and metaplasia of the ductal epithelium to form stratified squamous epithelium with early surface keratinization. These findings are consistent with synovial metaplasia. Several areas of the fibrous portion of the capsule showed patchy loss of cellular staining with loss of nuclei, indicative of necrosis. This produced a 'washed out' staining appearance. This tissue was paucivascular and fibrotic, and showed areas of fibrinoid necrosis, suggestive of mechanical abrasion and increased pressure.