Gökhan Pekindil

Phlebectasia of left anterior jugular vein

We present a rare case of unilateral phlebectasia of the anterior jugular vein in a 56-year-old male patient whose complaint is a neck swelling that appears during talking. Although in this age group the most common cause of such a mass in the anterior aspect of the neck increasing in size during any type of straining or Valsalva manoeuvre is a laryngocele, phlebectasia of the anterior jugular vein should be considered in the differential diagnosis. Doppler ultrasound and computed tomography are the most useful and non-invasive methods to use for the investigation. Treatment should be conservative.

Technetium-99m sestamibi limb scintigraphy in post-traumatic reflex sympathetic dystrophy: preliminary results.

Abstract. Reflex sympathetic dystrophy (RSD) has widely variable clinical manifestations. Its pathogenesis remains partially unexplained. RSD is commonly divided into three stages; these stages are not always clearly separable, but staging remains important for correct treatment. Since the disease involves soft tissue alterations as well as bone changes, we decided to investigate whether technetium-99m sestamibi limb imaging can be used to evaluate the soft tissue appearance. Fifteen patients (seven females and eight males; age range 12–68 years) with clinically significant post-fracture RSD were evaluated with both three-phase bone scan (TPBS) and 99mTc-sestamibi limb scintigraphy. Although, in general, patients with similar duration of disease, clinical stage and TPBS activity tended to have similar patterns of sestamibi uptake, discordant uptake patterns were observed in some patients with clinical stage 1. Thus, of 12 patients with stage I disease, eight had increased 99mTc-sestamibi activity in the distal part of the affected limb, while three had normal activity and one had decreased activity. All three patients with stage II disease showed normal 99mTc-sestamibi uptake. Although most of the patients with increased 99mTc-sestamibi uptake had increased activity on all three phases of the bone scan, there were discordant results between the scan patterns in other patients. On the basis of these findings, we suggest that 99mTc-sestamibi imaging may contribute to the differentiation between clinical stages and may permit evaluation of the disease course and selection of appropriate therapy. 99mTc-sestamibi imaging is not, however, a primary diagnostic procedure for RSD.

99mTc-sestamibi muscle scintigraphy to assess the response to neuromuscular electrical stimulation of normal quadriceps femoris muscle.

ObjectivesNeuromuscular electrical stimulation (NMES) is widely used for improving muscle strength by simultaneous contraction in the prevention of muscle atrophy. Although there exist many clinical methods for evaluating the therapeutic response of muscles,99mTc-sestamibi which is a skeletal muscle perfusion and metabolism agent has not previously been used for this purpose. The aim of our work was to ascertain whether99mTc-sestamibi muscle scintigraphy is useful in the monitoring of therapeutic response to NMES in healthy women.MethodsThe study included 16 women aged between 21 and 45, with a mean age of 32.7±6.4. Both quadriceps femoris muscles (QFM) of each patient were studied. After randomization to remove the effect of the dominant side, one QFM of each patient was subjected to the NMES procedure for a period of 20 days. NMES was performed with an alternating biphasic rectangular current, from a computed electrical stimulator daily for 23 minutes. After measurement of skinfold thickness over the thigh, pre- and post-NMES girth measurements were assessed in centimeters. Sixty minutes after injections of 555 MBq99mTc-sestamibi, static images of the thigh were obtained for 5 minutes. The thigh-to-knee uptake ratio was calculated by semiquantitative analysis and normalized to body surface area (NUR=normalized uptake ratio).ResultsThe difference between the pre and post NMES NUR values was significant (1.76±0.31 versus 2.25±0.38, p=0.0000). The percentage (%) increase in NUR values also well correlated with the % increase in thigh girth measurements (r=0.89, p=0.0000).ConclusionThese results indicated that99mTc-sestamibi muscle scintigraphy as a new tool may be useful in evaluating therapeutic response to NMES.

Bilateral synchronous granulomatous orchitis: gray-scale and colour Doppler sonographic findings.

A 60-year-old man presented with impotence ultrasonography demonstrated bilateral irregular hypoechoic infiltration of testes and normal epididymis. Colour Doppler sonography showed only peripheral but no intralesional flow. Since the lesion was presumed as malignancy bilateral high inguinal orchiectomy was performed and bilateral idiopathic granulomatous orchitis was diagnosed. It was concluded that granulomatous orchitis should be considered in the differential diagnosis of diffuse testicular hypoechoic involvement which showed only peripheral low-resistance flow on colour Doppler sonography, in the proper clinical setting. Although this may be a helpful sign in the differential diagnosis of diffuse testicular infiltrations, high inguinal exploration remains mandatory.

Evaluation of hepatic venous pulsatility and portal venous velocity with Doppler ultrasonography during the puerperium.

OBJECTIVE The aim of this study is to evaluate pregnancy-induced changes of hepatic venous pulsatility and portal venous velocity in the puerperium and to determine if these changes disappeared by the end of the puerperium. METHODS AND MATERIAL Healthy normal volunteers (90) were examined on the 2nd and 7th days of puerperium and between the 6th and 8th weeks postpartum. Doppler waveform patterns were obtained in the middle hepatic vein and main portal vein. The hepatic venous pulsatility was named as normal, damped or flat. RESULTS On the 2nd day postpartum, the hepatic vein pulsatility was shown as normal in 8 (26%), damped in 11 (37%) and flat in 11 (37%) cases. On the 7th day postpartum, 15 (50%) cases had normal, 9 (30%) cases had dampened, and 6 (20%) cases had still flat pattern. The majority of the cases (60%) displayed normal hepatic venous pulsatility in the 6th and 8th weeks of puerperium, whereas 23% had still dampened and 17% had flat patterns. There was a trend toward normal pulsatility with increasing puerperal age. The mean portal venous velocity was still higher than the non-pregnant levels and did not showed significant alterations during puerperium. CONCLUSION This study emphasised that, since pregnancy-induced alterations in hepatic venous pulsatility and portal venous velocity had not completely returned to normal in most cases until the end of the puerperium, these physiological changes should be considered whenever hepatic and portal systems are interpreted with Doppler sonography during the puerperal period.

Utility of99mTc dextran scintigraphy in diabetic patients with suspected osteomyelitis of the foot

Purpose: Osteomyelitis of the foot is a frequent complication of diabetes mellitus and its diagnosis is often difficult. The goal of this study was to demonstrate the utility of99mTc dextran scintigraphy in suspected diabetic foot infections.Materials and Methods: Twenty-six patients (20 males, 6 females, age range 18–80 years) with diabetes mellitus who had a total of 36 foot ulcers or necrosis were studied. All the patients underwent both three phase bone scan and99mTc dextran scintigraphy. Final diagnosis was based upon either pathologic examination or clinical follow-up at least four months.Results: On bone scan increased uptake was seen in 55 sites, and among these there were 11 lesions of proven osteomyelitis. There were 11 true-positive, 0 false negative, 0 true negative and 44 false positive results for bone scan. The sensitivity, specificity and accuracy of bone scan were 100%, 0% and 20%, respectively. With regard to99mTc dextran scan, nine lesions produced true-positive results with two lesions indicating false negatives resulting in a sensitivity of 82%. Thirty-six true negative and eight false positive results produced a specificity of 82%, and an accuracy 82% from99mTc dextran studies was obtained. Eight false-positive results were possibly due to neuroarthropathy, pressure points and deep penetrating ulcers. A patient with one false-negative result had angiopathy while other had neither neuropathy nor angiopathy.Conclusions: According to these results,99mTc dextran scintigraphy seems to be a sensitive and specific diagnostic method, and because of its advantages over other radiopharmaceuticals (shorter preparation time, highly stabilityin vivo/in vitro, early diagnostic imaging and low cost), it may be a radiopharmaceutical of choice for diagnosing in diabetic foot infections.

Magnetic resonance imaging in follow-up of treated clubfoot during childhood

In this study, we evaluated the short-term results of surgically treated clubfoot with magnetic resonance imaging (MRI). T1- and T2-weighted MRI images with 4-mm slices in the standard anatomic sagittal, transverse, and coronal planes were obtained in seven cases of clubfoot aged 4--11 years (mean 5.6 years old). The mean follow-up period was 3.6 years (ranged between 2 and 6 years). Sagittal talocalcaneal angle, talar head and neck axis internal rotation, calcaneal axis internal rotation, transverse talar neck and head/calcaneus angle and posterior calcaneus external rotation were measured. Three cases with dorsal talonavicular subluxation and a case of calcaneocuboid luxation were demonstrated by MRI. It was concluded that MRI may help to understand results of surgically-treated clubfoot by revealing hindfoot articular relationships and many complications.

Doppler Sonographic Assessment of Posttraumatic Reflex Sympathetic Dystrophy

Objective. To reveal the arterial Doppler sonographic findings in cases of posttraumatic reflex sympathetic dystrophy. Methods. Eleven patients had hand reflex sympathetic dystrophy, and 9 had foot reflex sympathetic dystrophy. The duration of symptoms ranged from 1 to 28 weeks, and the history of fracture ranged from 6 to 48 weeks. Bilateral brachial or popliteal arteries proximal to injuries were evaluated by Doppler sonography with a 7.5‐MHz linear transducer. All patients also had triphasic bone scintigraphy and extremity thermography. Results. Two patients had monophasic waveforms and 4 had low‐pulsatility triphasic waveforms on the affected limbs when compared with the asymptomatic limbs. All opposite asymptomatic limbs had normal triphasic waveforms in these 6 cases. Spectral analysis revealed a loss or decrease of a normal reversed flow component with a reduced pulsatility index on the affected limb. Fourteen other patients had symmetric triphasic waveforms. We observed that the patients who had stage 1 reflex sympathetic dystrophy and warm limbs with durations of symptoms of more than 2 weeks had positive Doppler sonographic findings, whereas all patients with stage 2 reflex sympathetic dystrophy and all with normal skin temperature, regardless of stage, had normal waveforms. Conclusions. Doppler sonography revealed loss of normal triphasic arterial waveforms in some of the cases of stage 1 disease, whereas many cases of stage 1 disease and all cases of stage 2 disease had normal findings. Therefore, we think that Doppler sonography cannot be used for the diagnosis of reflex sympathetic dystrophy but may help in assessing hemodynamic stages of the disease.

Degenerative lumbosacral transitional articulation: atypical increased sacral uptake on planar bone scintigraphy.

The authors describe an atypical appearance on bone scintigraphy of a degenerative transitional lumbosacral articulation, which has not been reported before. There was moderately increased uptake in the right superior aspect of the sacrum on planar imaging and markedly increased uptake medial to the upper sacroiliac joint on SPECT imaging in a patient with low back pain. These findings indicate that the enlarged transverse process of the transitional lumbosacral vertebra articulated with the sacrum and not with the ilium. This anomalous articulation shows active degenerative disease that may be responsible for the patients symptoms. Findings of planar imaging should be considered in the differential diagnosis of diseases involving this region and should raise the possibility of changes secondary to a degenerative transitional lumbosacral vertebra.

99mTc(V)-DMSA seintigraphy in monitoring the response of bone disease to vitamin D3 therapy in renal osteodystrophy

Renal osteodystrophy (ROD) is a common and serious complication for uremie patients and patients are treated with 1,25-dihydroxy vitamin D3. The bone scanning agent99mTc-phosphate has also been used to evaluate in ROD but it is not clear that bone scintigraphy has a role in the follow-up of treatment. In this study99mTc(V)-DMSA scintigraphy was performed in eleven patients [age 40.7 ± 17.3 (mean ± SD) yr] with ROD before and after vitamin D3 therapy. Images were obtained after hemodialysis performed following tracer injection to maintain normal blood levels of the radiopharmaceutical and to reduce soft tissue activity. Lumbar vertebra-to-soft tissue uptake ratios (LUR) were quantified with the planar99mTc(V)-DMSA images. Alkaline phosphatase and parathyroid hormone levels after treatment had significantly decreased compared with pre-therapy. In all patients there was visually decreased uptake in bone structures after treatment. After treatment the mean LUR ratio was significantly lower than those of before treatment (3.59 ± 2.63 vs. 1.65 ±0.62; p = 0.01). LUR values were correlated with pre-therapy alkaline phosphatase and parathyroid hormone. These findings indicated that99mTc(V)-DMSA scintigraphy is sensitive in evaluating the response of ROD to vitamin D3 therapy.