Gavin Sugrue

Unsuspected Cardiovascular Involvement in Relapsing Polychondritis A Case of Aortitis With Critical Coronary Artery Stenosis Secondary to Relapsing Polychondritis

A 51-year-old man presented with a prodrome of arthralgia, intermittent oral ulceration, and raised inflammatory markers. He was extensively investigated; however, no firm diagnosis could be established, and he remained under regular surveillance by rheumatology and infectious disease services. After 12 months, he presented with painful ear swelling. Clinical examination revealed a swollen tender ear (Figure 1) and a soft diastolic heart murmur. Serum inflammatory markers were raised, with a c-reactive protein (CRP) of 28 mg/L and an erythrocyte sedimentation rate (ESR) of 25 mm/h. Figure 1. Tender, erythematous left ear. Biopsy of affected cartilage showed characteristic features of auricular chondritis (Figure 2). Echocardiogram (Movie I in the Data Supplement) revealed mild aortic incompetence, a left ventricular ejection fraction of 60%, aortic root dilatation, and an incidental patent foramen ovale (Movie II in the Data Supplement). Computed tomography (CT) of the thorax demonstrated no tracheal abnormality; however, aortic root dilatation of 4.6 cm was noted (Figure 3). A fasting positron emission tomography-CT (PET-CT) showed increased F-18 fluorodeoxyglucose accumulation in the ascending aorta (Figure 4), and a diagnosis of relapsing polychondritis with secondary aortitis with structural aortic dilatation was made. Figure 2. Left ear biopsy identified cartilage with perichondrial inflammatory granulation tissue. Figure 3. Coronal computed tomography of thorax with contrast demonstrating aortic root dilatation of 4.6 cm at the level of the sinuses with mural …

Hemiplegic migraine: neuroimaging findings during a hemiplegic migraine attack.

CASE A 19-year-old male presented with sudden onset right-sided weakness and slurred speech following a severe headache. His past medical history was relevant for a similar episode 3 years previously; however, he did not seek medical advice at this time. He denied any recent drug or alcohol use, or any recent head injury. He had no family history of migraine. Routine biochemical, hematological, and lumbar puncture test results were normal. On clinical exam, he had a dense right hemiparesis, inattention, and aphasia. An urgent noncontrast computerized tomography (CT) brain (Fig. 1) on admission demonstrated subtle asymmetrical sulcal effacement in the left cerebral hemisphere suggestive of cerebral edema. There was no intracranial hemorrhage and no evidence of an ischemic event. There was no enhancing lesion or abnormal enhancement following the administration of contrast. In light of these findings on CT, he underwent a magnetic resonance imaging (MRI) of the brain. T2-FLuid Attenuated Inversion Recovery (FLAIR)weighted images (Fig. 2) showed increased cortical hyperintensity and cortical swelling of the left cerebral hemisphere consistent with unilateral cerebral edema and were consistent with the clinical findings of right-sided weakness. Diffusion-weighted MR images (Fig. 3) show no abnormal signal intensity. Post-contrast T1-weighted MR (Fig. 4) imaging demonstrated no abnormal enhancement. On day 2 of admission, he subsequently developed seizures, which spontaneously settled. The remained of his hospital admission was uncomplicated, and his neurological deficit had begun to

Computed Tomography Evaluation of Small Bowel Ischemia

Early and accurate diagnosis of mesenteric ischemia remains challenging due to the broad spectrum of clinical symptoms and radiological findings. Prompt diagnosis reduces and may allow for interventional radiology treatment opportunities. Computed tomography (CT) is now the first-line imaging tool for investigation of suspected acute or chronic mesenteric ischemia. However, CT has limitations and may over- or undercall mesenteric ischemia. The optimal CT protocol includes a biphasic or triphasic CT with judicious use of “neutral” oral contrast agents. An understanding of the spectrum of CT findings encountered in mesenteric ischemia is pivotal to an early diagnosis. Failure of timely CT and implementation of the optimal CT protocols may result in the patient’s death. Key radiological features vary significantly according to the etiology and severity of mesenteric ischemia. Detailed assessment of the mesenteric vessels, bowel wall thickness, mucosal enhancement patterns, and mesenteric abnormalities are required.

Combined intramedullary and intradural extramedullary spinal metastases in malignant melanoma

A patient in their 30s presented with a 3-day history of lower back pain, lower limb weakness and new onset of urinary incontinence. The patient had a history of metastatic melanoma, including to brain, for which they had previously been treated with adjuvant chemotherapy and radiotherapy. Clinical exam revealed a palpable bladder at the umbilicus and reduced power in the lower limbs bilaterally. An MRI whole spine with gadolinium contrast agent revealed multiple enhancing lesions at the T5/6, T9 and T12–L3 levels, pronounced spinal cord oedema and a markedly distended bladder (figures 1 and 2). The location of these lesions within the spinal canal …

A rare testicular vein anatomical variant contributes to right-sided varicocoele formation and leads to the diagnosis of renal cell carcinoma

A man in his 60s presented for a testicular ultrasound due to asymptomatic scrotal swelling. Ultrasound showed a right-sided varicocoele (figure 1). A varicocoele is an abnormal dilatation of the pampiniform venous plexus in the scrotum. A renal ultrasound demonstrated a heterogeneous mass arising from the right kidney (figure 2). Histology subsequently revealed a renal cell carcinoma. CT identified duplication of the right testicular vein (figure 3). The first emptied into the inferior venacava (IVC) as expected. The second had a tortuous course arcing over the upper pole of the right kidney and emptying into the right renal vein (figure 4). Tumour extension …

Author’s Response to: Letter to Editor

To the editor, Thank you to Conroy et al. for their interesting letter. This certainly provides further evidence supporting the safety and efficacy of pneumatic compression devices (PCD) for achieving haemostasis in patients undergoing haemodialysis fistula intervention. Their series included 116 device deployments in an unstated mixture of arteriovenous fistulas and grafts, and so, it would also appear to support its use after accessing dialysis grafts and with sheath sizes up to 7 Fr. It is interesting that both case series examining this use of achieving haemostasis used the same PCD, namely the Safeguard Radial Compression Device (Merit Medical Systems Inc. Utah, USA). This is a 26-cm-long self-adhesive band that is designed for achieving patent haemostasis after radial artery catheterisation. We believe it is important to point out that not all radial artery PCDs are the same. For example, other PCDs incorporate nonadhesive wrist bands that are required to fit completely around the wrist (similar to a watch) and may have a larger surface area. Where a wrist band may be expected to work at a radiocephalic Cimino-Brescia-type fistula, if the band is not large enough to fit around the elbow it will not be possible to use it on a brachiocephalic or brachiobasilictype fistula or indeed many arteriovenous grafts. Also PCDs with a larger surface area may make it more difficult to achieve haemostasis at two adjacent fistula/graft catheterisation access sites. One of the advantages of using a PCD is the ability to accurately control the amount of compression at the access site. This allows optimal compression without occlusion. The concept of patent haemostasis is now well established with transradial artery access, and indeed, there is evidence that a decrease in radial artery occlusion after radial artery catheterisation can result from prophylactic ipsilateral ulnar artery compression [1]. Although a dialysis fistula has a significantly larger lumen than the radial artery, it would be interesting to study whether similar benefits in radiocephalic fistula patency rate could be achieved with concomitant ulnar artery compression. Regardless, further studies are warranted looking at the use of various types of PCDs for haemostasis and ideally manufacturers would design PCDs specifically for use after dialysis access intervention. In the interim, we continue to use the PCD described in our study and we would advise our colleagues to join us with a technique that is simple, speedy, safe and sutureless.

Modern imaging techniques in intra-abdominal hypertension and abdominal compartment syndrome: a bench to bedside overview

Intra-abdominal hypertension (IAH) is common in critically ill patients. Diagnosis is based on measurement of intraabdominal pressure, most commonly via the bladder. Modern imaging techniques with plain radiographs, computed tomography and magnetic resonance can help establish the diagnosis and also guide treatment. In 2013 the Abdominal Compartment Society (WSACS) published updated consensus definitions and recommendations for management of IAH and abdominal compartment syndrome (ACS). This review will give a concise overview of the important role radiographic imaging plays within these management guidelines.