Frank Voyvodic

Endosonographic imaging of anal sphincter injury: does the size of the tear correlate with the degree of dysfunction?

AbstractPURPOSE: This study was designed to test the hypothesis that the extent of anal sphincter muscle injury as graded at endosonography correlates with the degree of functional impairment. METHODS: Three hundred and thirty adults presenting for evaluation of fecal incontinence were recruited. Ultrasound was performed with a 7.5-MHz radial rotating axial endoprobe in the left lateral position. Anal sphincter muscle tears were graded on the basis of the degree of circumferential involvement (< or >25 percent) and by an assessment of the superoinferior longitudinal extent of an external anal sphincter tear. Muscles that demonstrated multiple tears, poor visualization, or fragmentation were classed as fragmented. Sphincter injuries were correlated with basal and squeeze pressures at manometry, pudendal nerve terminal latencies, and the severity of symptoms using the Parks-Browning clinical score. RESULTS: Patients with an intact external anal sphincter had a higher squeeze pressure (mean, 162.6 cm H2O) than those with a partial- (mean, 125.7 cm H2O) or full-length tear (mean, 124.9 cm H2O; P < 0.0001). There was no significant difference in squeeze pressure between those with partial- vs. full-length external anal sphincter tears nor between circumference tears < or >25 percent. Basal pressure was significantly lower in those with a full-length external anal sphincter tear (47.8 cm H2O) vs. an intact external anal sphincter (65.7 cm H2O; P < 0.001). The basal pressure in those with an intact internal anal sphincter was not significantly different from those with clearly defined internal anal sphincter tears, and the degree of circumferential involvement was also not important in this regard. However, those with a fragmented internal anal sphincter had a significantly lower basal pressure than other subgroups of internal anal sphincter injuries (P < 0.001). There was no association between external or internal anal sphincter status and the mean pudendal nerve terminal motor latency, suggesting the patient groups were neurologically similar. There was no significant association between external or internal anal sphincter status and the severity of reported symptoms. CONCLUSION: Correlations between the presence or absence of muscle tears and reduced manometric function have been identified. Further grading of tears was of less importance. No relationship between muscle injuries and the severity of clinical symptoms could be elicited.

Anterior sacral meningocele as a pelvic complication of Marfan syndrome.

Anterior sacral meningocele (ASM) is well recognized in Marfan syndrome as a consequence of dural ectasia. Two cases presenting as non‐gynaecological pelvic masses are described highlighting the clinical difficulty in diagnosis and the classical radiological findings. The classification of ASM and associated anomalies of the sacrum are reviewed.

Anal sphincter tears in patients with rectal prolapse and faecal incontinence.

Objective  Faecal incontinence often persists after surgery for rectal prolapse. Multiple mechanisms have been proposed as responsible, however, anal sphincter integrity has only been studied in a handful of cases. This study assesses the incidence of ultrasound detected anal sphincter tears in patients with rectal prolapse and faecal incontinence.

Percutaneous retrieval of a partially expanded iliac artery stent: Case report

A partially expanded, intraluminal, balloon-expandable Palmaz vascular stent was retrieved percutaneously in a 48-year-old woman after attempted placement across a common iliac artery stenosis. A pinhole in the balloon prevented expansion, and the stent could not be stabilized to allow balloon exchange. The stent was snared by a 5Fr 4 mm balloon catheter replaced coaxially through the stent and then withdrawn into a 14Fr Amplatz sheath which had been percutaneously placed in the external iliac artery. Open surgical removal of the stent was thus avoided.

An unusual cause of hemifacial spasm

Hemifacial spasm (HFS) is a movement disorder characterized by involuntary paroxysmal chronic contractions of the facial musculature. The usual cause is vascular compression of the seventh cranial nerve, at its exit zone from the brain stem. We report a case of left hemifacial spasm, in a 66-year-old woman, in which the neuroradiological investigation with magnetic resonance imaging showed a hypervascular soft tissue mass arising from the left skull base, in the jugular foramen. This lesion was thought highly likely to be a glomus jugulare tumour. While the usual occurrence of tumour compression causing HFS has been previously recognized, the association of glomus jugulare tumours presenting with HFS has not. The importance of this association is discussed. Copyright 1999 Harcourt Publishers Ltd.

Transient uterine contractions as a potential pathology mimic on premenopausal pelvic MRI and the role of routine repeat T2 sagittal images to improve observer confidence.

Pelvic MRI has an increasingly important role in the evaluation of non‐malignant uterine pathology including uterine leiomyomas, adenomyosis and endometriosis. Normal physiological myometrial junctional zone transient contractions can also be identified on MRI and have the potential to act as pathology mimics. This study aims to evaluate both the incidence of visible physiological contractions in premenopausal female pelvic MRI and also to support the routine acquisition of a repeat T2 sagittal sequence to differentiate transient physiological contractions from true underlying pathology and therefore improve observer confidence.

Intravenous lobular capillary haemangioma (pyogenic granuloma): A case report and a review of imaging findings as reported in the literature

INTRODUCTION Intravenous lobular capillary haemangioma (IVLCH) is a rare benign lesion with minimal published reports containing a description of its appearance at medical imaging. We present the ultrasound and MRI images of a histologically proven IVLCH and provide the first review of the imaging findings reported in the literature. METHODS The imaging findings of a case of IVLCH are presented. A PubMed search of English language articles was performed from 1966 to October 2016, and all relevant papers were reviewed. Imaging findings from those papers are summarised. RESULTS Key features on ultrasound are of a well-defined, usually hypoechoic, mass which is highly vascular. The host vein is usually apparent. MRI imaging usually shows T1 signal isointense to muscle and variable T2 signal, either isointense or of high signal relative to the vein. The lesions enhance with gadolinium. CONCLUSION Intravenous lobular capillary haemangioma has distinctive ultrasound but less consistent MRI features although radiological diagnosis should usually be possible. Review of reported cases shows that a previously described gender bias is incorrect.

Image-Guided Interventions

Image-guided procedures are increasingly utilised in oncology patients in diagnosis and management, with both curative and palliative intent, and are often performed in interventional radiology. Interventional radiologists, given their background in diagnostic imaging, can provide useful input to the multidisciplinary team caring for oncology patients with regard to technical feasibility of diagnostic and therapeutic interventions and their likely outcomes. This chapter aims to outline available interface between interventional radiology and the rest of the multidisciplinary team in caring for palliative patients, focusing on common conditions and how imaging can be used in assessment.