Esin Gezmis

Diagnosis of early sacroiliitis in seronegative spondyloarthropathies by DWI and correlation of clinical and laboratory findings with ADC values

PURPOSE Sacroiliitis is one of the diagnostic criteria of seronegative SpA. The purpose of our study is to show the signal characteristics of the sacral and iliac surfaces by DWI which may contribute in early diagnosis of sacroiliitis and investigate the correlation between ADC values and clinical and laboratory parameters. MATERIALS AND METHODS 62 patients with inflammatory low back pain, with a history or suspect of seronegative SpA are enrolled into the study. 40 age and sex-matched subjects without SpA constituted the control group. After obtaining routine T1 and T2 weighted sequences, echo planar imaging at b values of 0, 400 and 800 was performed. ADC values on both surfaces of the both sacroiliac joints were measured in all subjects. The CRP and sedimentation results and the presence of arthritis and enthesitis were also correlated with the ADC values. RESULTS ADC values on both surfaces of the both sacroiliac joints were found 0.23 × 10(-3)mm(2)/sn in the control group. In the patient group, mean ADC value of 0.48 × 10(-3)mm(2)/sn was obtained (p<0.001), which was statistically significant, compatible with the increased diffusion due to medullary edema in early sacroiliitis. There was a slight correlation between CRP and ADC values; presumed to be showing the relation between the activity of the disease and the active inflammation on DWI. There was no correlation between arthritis and enthesitis and the ADC values (p>0.001). CONCLUSION DWI, by measuring ADC values, adds significant information in the early diagnosis of sacroiliitis and may help to evaluate the efficiency of the treatment.

Assessment of Subclinical Atherosclerosis by Carotid Intima-Media Thickness and Epicardial Adipose Tissue Thickness in Prediabetes.

Impaired fasting glucose (IFG) and impaired glucose intolerance (IGT) are predictors of cardiovascular disease (CVD). We tested the hypothesis that epicardial fat thickness (EFT) and carotid intima–media thickness (cIMT), as markers of early atherosclerosis, are increased in patients with prediabetes. We prospectively enrolled 246 patients (162 with prediabetes and 84 controls). Prediabetes was defined according to American Diabetes Association criteria, and patients were divided into 3 groups: group 1—IFG, group 2—IGT, and group 3—IFG + IGT. Both cIMT and EFT were significantly greater in patients with prediabetes compared with controls (0.81 ± 0.20 mm vs 0.68 ± 0.16 mm, P < .001 and 7.0 ± 2.0 mm vs 5.6 ± 1.6 mm, P < .001, respectively). This difference was mainly attributed to patients with IGT. Age, waist circumference, and 2-hour glucose independently predicted cIMT, while 2-hour glucose was the only independent predictor of EFT in multivariate analysis among other relevant parameters for cIMT and EFT. The cIMT and EFT (measured noninvasively) could be useful indicators of CVD risk in these patients. In order to prove this hypothesis, long-term prospective studies with greater patient numbers are required.

Assessment of epicardial adipose tissue and carotid/femoral intima media thickness in insulin resistance

BACKGROUND Metabolic syndrome is a combination of multiple cardiovascular (CV) risk factors including insulin resistance (IR). Carotid, femoral intima media thickness (IMT), and epicardial fat thickness (EFT) are considered as novel cardiometabolic risk factors. We aimed to test the hypothesis that carotid, femoral IMT, and EFT are increased in patients with IR. METHODS We enrolled consecutively and prospectively 113 patients with IR. Then we collected data from an age- and sex-matched control group of 112 individuals without IR. Homeostasis model assessment (HOMA) index value >2.5 was accepted as IR. Patients with diabetes mellitus, CV diseases, systolic heart failure, chronic liver or renal diseases were excluded. On B-mode duplex ultrasound the mean IMT at the far wall of both left and right common carotid/femoral arteries were measured manually. EFT was measured on the free wall of the right ventricle at end-diastole from the parasternal long-axis views by standard transthoracic 2D echocardiography. RESULTS Both carotid IMT and EFT were significantly higher in patients with IR compared to controls (0.80±0.21mm vs 0.60±0.21mm; p<0.001 and 7.34±1.96mm vs 5.22±1.75mm; p<0.001, respectively). However, there were no significant differences in femoral IMT between the groups (0.74±0.20 vs 0.69±0.17; p=0.062). In multivariate linear regression analysis age (β=0.223, p=0.010), 2-h blood glucose (β=0.198, p=0.021), and IR (β=0.369, p<0.001) were independent predictors of EFT. On the other hand age (β=0.363, p<0.001) and IR (β=0.321, p<0.001) were independent predictors of carotid IMT. CONCLUSIONS Patients with IR have increased carotid IMT and EFT, but not femoral IMT. This apparent incoherence may be due to the involvement of carotid arteries prior to femoral arteries in patients with IR.

Cortical membranectomy in chronic subdural hematoma: Report of two cases

Different surgical procedures have been used in the management of chronic subdural hematoma (CSDH). Nowadays treatment with burr hole is more preferable than craniotomy in most clinics. We present two cases of CSDH, which caused neurological deficits. In both cases cortical membranectomy was performed following craniotomy. After this procedure, significant improvement was observed in patients neurological deficits. We recommend that craniotomy and subtotal membranectomy may be a more adequate choice in such cases. This report underlined that craniotomy is still an acceptable, safe, efficient and even a better procedure in selected patients with CSDH.

A novel oral anticoagulant, dabigatran, in acute renal infarction.

Acute renal infarction (ARI), which is a rare cause of flank pain, results from interruption in the blood supply of renal tissue. The severity of its clinic depends on the width of the affected part of the kidney. It is often impossible to find the underlying cause (1, 2). Thromboembolic states related to cardiac diseases, such as atrial fibrillation, rheumatic mitral stenosis, endocarditis, and left ventricular wall aneurysms, are the major causes, whereas occlusion of the renal artery following endovascular aortic or renal intervention, renovascular diseases, malignant hypertension, paradoxical cardiac emboli associated with atrial septal defects, polyarteritis nodosa, and cocaine have also been reported as rare causes in the etiology (3-5). In the literature, the incidence of ARI lies within a range of 0.007%-1.4% (1-5). Herein, we present a patient with ARI and its treatment with a novel oral anticoagulant, dabigatran.

Assessment of epicardial fat and carotid intima media thickness in gestational hypertension

Gestational hypertension (GHT) is a common disorder of pregnancy characterized by new onset hypertension without the presence of detectable proteinuria after 20 weeks of gestation. Epicardial fat thickness (EFT) and carotid intima media thickness (CIMT) are suggested as new predictors of subclinical atherosclerosis. Although the relationship between these parameters and essential hypertension has been demonstrated, this association in patients with GHT is still unknown. We aimed to investigate CIMT and EFT in patients with GHT.

Temporal Lobe Parenchyma Herniation into the Transverse Sinus: MRI Findings in a Case

Brain parenchyma herniation into dural venous sinus which is a uncommon entity, can cause dural venous sinus filling and simulate sinus thrombosis and other pathologies. It is isointense to brain parenchyma on all sequences by magnetic resonance imaging, surrounded by a cerebrospinal fluid rim and is seen to be contiguous with brain tissue on images. We report a rare case with spontaneous occult herniation of temporal lobe tissue into the left transverse sinus that may associated with headache.

Piezogenic pedal papules with mitral valve prolapse

Piezogenic pedal papules (PPP) are herniations of subcutaneous adipose tissue into the dermis. PPP are skin-colored to yellowish papules and nodules on lateral surfaces of feet that typically become apparent when the patient stands flat on his/her feet. Some connective tissue diseases and syndromes have been reported in association with PPP. Mitral valve prolapse (MVP) is a myxomatous degeneration of the mitral valve, characterized by the displacement of an abnormally thickened mitral valve leaflet into the left atrium during systole. MVP may be isolated or part of a heritable connective tissue disorder. PPP, which is generally considered as an isolated lesion, might be also a predictor of some cardiac diseases associated with connective tissue abnormalities such as MVP. A detailed systemic investigation including cardiac examination should be done in patients with PPP. Since in the literature, there are no case reports of association of PPP with MVP, we report these cases.

Who is guilty of subclinical atherosclerosis in prediabetes? Chicken or Egg Causality Paradox Between Insulin Resistance and Epicardial Fat Reply

We thank Canpolat et al for their comments on our article entitled ‘‘Assessment of Subclinical Atherosclerosis by Carotid Intima-Media Thickness and Epicardial Adipose Tissue Thickness in Prediabetes.’’ In our study, patients with prediabetes were found to have higher levels of serum C-reactive protein (CRP), gammaglutamyltransferase (GGT), and uric acid. We suggested that elevated serum GGT and uric acid levels might be markers of subclinical atherosclerosis. Higher serum GGT levels in those patients might also be associated with greater rate of nonalcoholic fatty liver disease in prediabetes. However, transaminase levels of prediabetic patients were within normal limits and similar to controls. Unfortunately, we could not assess these patients by liver ultrasound to support this hypothesis. Multivariate linear regression analysis of our study was used to define independent predictors of carotid intima–media thickness (cIMT) and epicardial fat thickness (EFT). Among these variables including age, metabolic syndrome (MetS) criteria, and serum variables including biochemical, lipid as well as glycemic parameters, we found that age, waist circumference, and 2-hour glucose were independent predictors of cIMT. On the other hand, only 2-hour glucose was an independent predictor of EFT. Metabolic syndrome is a combination of multiple cardiovascular risk factors including visceral obesity, hypertension, prediabetes, and atherogenic dyslipidemia. Although there is still some debate about the nature of the MetS, insulin resistance (IR) is thought to be an important factor. Hyperinsulinemia is a surrogate measure of IR which is associated with several clinical conditions including diabetes mellitus, atherosclerosis, and cardiovascular diseases. We agree with Canpolat et al about IR and MetS components as a whole being associated with increased cIMT and EFT. This point will be more extensively assessed in a further study.

Is echocardiographic epicardial adipose tissue thickness measurement a reliable and reproducible method for risk stratification

With great interest, we read the article titled “Epicardial adipose tissue thickness is associated with myocardial infarction and impaired coronary perfusion” published by Tanindi et al. (1) in Anatol J Cardiol 2015; 15: 224-31. It is a good paper with well-conducted analysis. Tanındı et al. (1) investigated the association between epicardial adipose tissue thickness (EAT) and acute myocardial infarction (AMI) in their population. The measurement of EAT was performed manually at end-systole on the free wall of the right ventricle perpendicular to the aortic annulus in standard parasternal long-axis view. Tanındı et al. (1) found a positive correlation between EAT and AMI. They highlighted that the echocardiographic measurement of EAT is a useful method for risk stratification and for choosing patients who need more aggressive treatment in terms of risk reduction. At present, the echocardiographic measurement of EAT, which reflects cardiac and visceral adiposity, has become one of the leading topics in cardiovascular imaging studies. EAT is suggested as a new cardiometabolic risk factor. Correlations between increased EAT and insulin resistance, metabolic syndrome, hypertension as well as cardiovascular diseases have been studied (2-4). The echocardiographic measurement of EAT is a widely available, simple, safe, noninvasive, cheap, and rapid method; however, it should be questioned whether EAT is a reliable and reproducible method. If it is not a reliable and reproducible method, then inaccurate measurements may affect our clinical decision and research results. In addition, EAT that was measured from the free wall of the right ventricle by echocardiography does not reflect all subepicardial adipose tissue volume. Saura et al. (5) investigated the reproducibility of the echocardiographic measurement of EAT and compared the values with those obtained using multi-detector computed tomography (MDCT). Although the contrary was claimed, in a study by Saura et al. (5), they found a poor reproducibility of the echocardiographic measurements of EAT assessed by intraclass correlation coefficient. Moreover, measurements with echocardiography and MDCT showed low concordance. Saura et al. (5) found that echocardiography yielded larger values than those yielded by MDCT. In particular, there was a notable difference of up to 7 mm within two standard derivations of the mean values measured by these two different methods. The results of Saura et al. (5)’s study indicate that EAT measurements by echocardiography may lead to the misclassification of patients. Therefore, clinicians should be careful when this parameter is used as a diagnostic tool for risk stratification. Furthermore, there are some other controversial issues regarding EAT. There are no normality values of EAT, and the discussion on how to measure EAT by echocardiography is still ongoing. EAT may be deformed through the cardiac cycle, and to ensure the maximal stability of true EAT, it should be measured in end-diastole (5). Further comprehensive studies are required to investigate the reproducibility of EAT and to answer the other questions. Cihan Altın, Mustafa Yılmaz*, Esin Gezmiş** Departments of Cardiology and **Radiology, Faculty of Medicine, Başkent University, İzmir, Adana*-Turkey