A.Yigit Goktay

Lipoma of the pancreas: MRI findings

Lipomas of the pancreas are very rare. Focal fatty infiltration of the pancreas is an entity that should be differentiated from a pancreatic lipoma. In this report the MRI findings of an incidentally found pancreatic lipoma are presented and the role of MRI in the differentiation of pancreatic lipoma and focal fatty infiltration of the pancreas is discussed.

THE PREDICTION OF PAPAVERINE INDUCED PRIAPISM BY COLOR DOPPLER SONOGRAPHY

PURPOSE We identified color Doppler sonography findings that are useful for predicting priapism in patients after the intracavernous injection of diagnostic papaverine. MATERIALS AND METHODS We evaluated 72 men with erectile dysfunction by color Doppler sonography after the diagnostic injection of papaverine. Cavernous artery waveforms were recorded, and peak systolic and diastolic velocity of the recorded waveforms was measured. In cases of priapism color Doppler sonography findings were retrospectively evaluated to identify any finding that would predict priapism. RESULTS Priapism was observed in 8 of the 72 patients (11.1%). In 6 of 8 priapism cases there was no blood flow in the cavernous artery during or after adequate erection, including after minutes 5, 10 and 20 in 3, 1 and 2, respectively. This absence of encoding was not relieved even after all stimuli were removed. In 2 patients who later presented with complaints of priapism the Doppler study was completed normally and all parameters were acquired without any cessation of blood flow in the cavernous artery. The persistent disappearance of color and pulse encoding in the cavernous artery predicted priapism with 75% sensitivity, 100% specificity, a positive and negative predictive value of 100% and 96.9%, respectively, and 97% accuracy. CONCLUSIONS The persistence of absent blood flow in the cavernous artery even after the elimination of all stimuli during penile color Doppler ultrasound is a reliable predictor of priapism. The finding is accurate enough to initiate treatment for priapism to avoid further delay.

Splenic vascular malformations and portal hypertension in hereditary hemorrhagic telangiectasia: sonographic findings.

Hereditary hemorrhagic telangiectasia, or Osler‐Rendu‐Weber disease, is an autosomal dominant disorder in which a variety of vascular dysplasias occur throughout the organ systems. We report the gray‐scale and color Doppler sonographic findings in a case of hereditary hemorrhagic telangiectasia. Gray‐scale sonographic examination revealed massive splenomegaly, multiple dilated intrasplenic vascular structures (some with adjacent punctate calcifications), an aneurysmal dilatation of the splenic vein, dilated intrahepatic portal branches, and marked atrophy of the right hepatic lobe. Color Doppler sonography showed dilatation of the truncus coeliacus and high‐velocity flow in the splenic artery. There were significant aliasing in the splenic hilum and an abnormal, arterialized flow in intrasplenic branches of the splenic vein. The splenic vein was massively enlarged with increased flow velocity and contained an isolated aneurysmal dilatation in the hilum. There were multiple serpiginous retroperitoneal collateral vessels, and the left gastric vein was dilated with hepatofugal flow. The patient had portal hypertension that developed secondary to the increased portal flow.

Percutaneous Treatment of Congenital Splenic Cysts: Drainage and Sclerotherapy with Polidocanol

Congenital “true” splenic cysts are rare lesions. Therapeutic methods for the management of these lesions have been based on preserving splenic function due to the immunologic role of spleen. We report three different cases of congenital splenic cysts treated by percutaneous drainage and polidocanol sclerotherapy. This less invasive treatment appears to be safe and effective after 6 to 36 months of follow-up.

Color doppler sonography in the follow-up of giant glutealaneurysm embolization

False aneurysm of the gluteal artery is uncommon and may develop secondary to penetrating gluteal injury or pelvic trauma. The use of color Doppler sonography may allow the initial diagnosis of gluteal pseudoaneurysms and provide information about the success of the interventional radiological procedures. In this study, color Doppler sonographic examination demonstrated the failure of the endovascular treatment of a giant superior gluteal artery pseudoaneurysm. The second intervention of super-selective coil embolization provided optimal thrombosis and eliminated the need for open surgery.

Palliation of malignant esophageal strictures: initial results with self-expanding uncovered nitinol coil stents.

Abstract. The purpose of this study was to determine the efficacy of the uncovered coil stents in patients with malignant dysphagia. Coiled spring-shaped uncovered self-expanding metallic Esophacoil stents (Instent, Eden Prairie, Minnesota) were placed in 11 patients (9 men and 2 women; age range 38–77 years, mean age 60.5 years) with malignant esophageal strictures and dysphagia, under fluoroscopic guidance. Dysphagia was graded on a scale of 0 to 4 (0 = no dysphagia; 1 = dysphagia to normal solids; 2 = dysphagia to soft solids; 3 = dysphagia to solids and liquids; 4 = complete dysphagia, inability to swallow saliva). Two patients had received radiation therapy, 4 had had chemotherapy, and 5 had had a combination of both radiation and chemotherapy before stent palliation. Control clinical examinations and endoscopic or barium swallow studies were performed every 4 weeks until the patient died. The stents were well tolerated by all patients and were effective in 9 of 11 patients with malignant dysphagia. Complications of the procedure included incomplete opening of the stent in 1 case, migration in 1 case, transient pain in 8 cases, reflux in 3 cases and minor gastrointestinal bleeding in 2 cases. Stent migration in 1 case resulted in surgical intervention and incomplete opening of the stent allowed only partial improvement of dysphagia in 1 case. The quality of life significantly improved in all other patients. Mean survival time of the patients was 73 days (range 34–125 days) and no significant tumor ingrowth was detected during the follow-up period. Insertion of an Esophacoil has a good palliative effect on dysphagia in patients with malignant esophageal strictures with few complications. Although the stent is uncovered, tumor ingrowth and overgrowth were not observed in our study, possibly because of previous treatments.

Iliac artery aneurysm presenting with lower extremity deep vein thrombosis

A 63-year-old man presented to the Emergency Department with the complaints of pain and swelling of the right lower extremity. The history included intermittent pain and swelling of the right leg for about 1 year that had become prominent and intractable in the last day. At the time of admission the patient was conscious and cooperative. The vital signs were normal. Physical examination revealed diffuse edema of the entire right leg with a positive Homan’s sign. Peripheral arterial pulses of the right leg distal to the popliteal artery were faint on palpation. Respiratory system examination was unremarkable. The abdomen was not tender, bowel sounds were normal, guarding or rebound was not present. Abdominal palpation was suspicious for a pelvic mass. The patient was evaluated by color Doppler sonography examination that revealed thrombosis of the deep veins of the right lower extremity and also in the right common and external iliac veins. A mass 10 cm in diameter was noted in the pelvic cavity adjacent to the right common iliac vein. Color encoding demonstrated that the right common iliac artery was displaced anteriorly and the mass was contiguous to the artery. The mass was presumed to be a thrombosed iliac artery aneurysm. On computed tomography (CT) scan, the arteries were shown to have a tortuous course with thrombosis of the veins from the right iliac to the femoral vein (Figure 1). The mass that was detected by color Doppler sonography was shown to be an aneurysm of the right common iliac artery, originating from the portion just distal to the iliac artery bifurcation (Figures 1,2). The aneurysm developed from the posterior aspect of the common iliac artery, fusiformly grew distally with its partially thrombosed lumen, and became a huge space-occupying mass in the pelvic cavity (Figure 2A). The right iliac vein was laterally displaced by the aneurysm and the distal venous system was thrombosed by its mass effect (Figure 2B). The patient underwent an operation in which the aneurysm was extirpated, an ilio-femoral bypass graft was implanted, and femoral vein thrombectomy was performed. Deep venous thrombosis (DVT) results mainly from three factors: the slowing down or obstruction of the blood stream secondary to an injury to the veins, or due to the hypercoagulability states. External compression is one of the major causes of DVT, however, isolated iliac artery aneurysm is an uncommon mass that may cause lower extremity DVT. Apart from the compressive effect in the pelvic cavity, iliac artery aneurysms also have some important potential risks. The rupture of the aneurysm and development of an arteriovenous fistula are the major possible complications that are catastrophic clinical events (1,2). Inappropriate treatment of patients with venous obstruction from unrecognized arterial aneurysms has been reported to be associated with great mortality and morbidity (1). The elimination of hazardous risks may be provided by accurate diagnosis and timely aneurysm repair, as in the presented case.

Ectopic spleen and left-sided vena cava in Beckwith-Wiedemann syndrome.

Beckwith-Wiedemann syndrome (BWS) is a congenital overgrowth syndrome characterized by anterior abdominal wall defects, macroglossia, and gigantism. A variety of other abnormalities have been described, however association with ectopic spleen and left-sided vena cava has not been reported previously. We report ectopic spleen, left-sided vena cava and the other abdominal imaging findings of an adult BWS case who came up to date without any follow-up from the early childhood.

Esophageal duplication cyst coexisting with Bochdalek's hernia and polysplenia

Abstract. Esophageal duplication cyst, Bochdaleks hernia and polysplenia are uncommon congenital anomalies which have not been reported to be associated with each other. We present the radiological aspects of an unusual coexistence of these three congenital anomalies in a 4-month-old girl.

Missile injury of the pelvis.

A 12-year-old male presented to the Emergency Department with an accidental missile injury in the right lower quadrant. At the time of his admission, the boy was conscious, cooperating, and was not in any acute distress. On physical examination, vital signs were stable and cardiovascular and respiratory examinations were normal. A penetrating wound was found in the right lower quadrant of the abdomen, just above the inguinal canal. A similar but smaller hole was noticed on the left backside of the patient where the left gluteus met the posterior thigh. The abdominal hole represented the inlet and the gluteal-thigh hole was the outlet of the bullet that gave the impression of an oblique superficial injury. The hematologic profile was within normal limits except for an elevated white cell count of 20,600; a biochemistry panel was unremarkable. Urine analysis demonstrated marked hematuria. Abdominal x-ray obtained in erect posture showed a crescent shaped metallic opacity superimposed on the symphysis pubis (Figure 1), and this was thought to represent a fragment of the bullet. The patient was then evaluated by abdominal computed tomography (CT) scan (Figure 2). On the CT scan, the bullet fragment was found to be inside of the urinary bladder. The change in the position of the fragment when compared to the abdominal X-ray showed that it was freely moving in the bladder. On the right anterior margin of the bladder, a hematoma of the wall was noticed with air bubbles indicating the inlet of the bullet into the bladder. In the midline of the posterior wall of the bladder, a similar hematoma was noticed. The left perirectal fat and gluteal fat tissue planes were found to be inhomogenous, demonstrating the course of the broken bullet. The detection