Kanupriya Vijay

Fractured Bard Recovery, G2, and G2 Express Inferior Vena Cava Filters: Incidence, Clinical Consequences, and Outcomes of Removal Attempts

PURPOSE To increase the understanding of risks of inferior vena cava (IVC) filter fracture and embolization and the safety of removing fractured filters via retrospective review of a prospectively collected database of fractured IVC filters. MATERIALS AND METHODS A total of 63 fractured IVC filters were discovered among 548 patients presenting for retrievable filter removal between April 2004 and November 2010 at a single institution. Device type, duration of implantation, component fracture, and embolization events were recorded. Success rates and techniques for removal of components were recorded. RESULTS A total of 63 fractured Recovery, G2, and G2 Express IVC filters were identified, for an overall fracture rate of 12%. Excluding foot process fractures, the fracture rate for only filter arms and/or legs was 6%. The incidence of fracture increased with longer filter dwell times. Success rates for removal of the nonfractured component (ie, main body) and fractured components (ie, arm or leg) were 98.4% and 53.4%, respectively. The distal embolization rate of fractured filter components was 13%. There were no immediate clinically significant complications associated with fracture component embolization or filter removal. A single patient was encountered with symptoms related to their fractured filter. CONCLUSIONS IVC filter fracture rates increase with longer dwell times; however, removal of fractured filters and fractured components (ie, arms and legs) can be achieved safely and effectively. Clinically significant complications of IVC filter fracture are rare, and there were no immediate clinical sequelae related to embolization of fracture components.

Human botfly (Dermatobia hominis) larva in a child’s scalp mimicking osteomyelitis

Furuncular myiasis caused by Dermatobia hominis is endemic throughout Central and South America. However, because of widespread travel, furuncular myiasis has become more common in North America. Misdiagnosis and mismanagement can occur owing to limited awareness of the condition outside endemic areas. We report a case of furuncular myiasis in an immigrant from El Salvador with magnetic resonance imaging findings. The case is unique because neuroimaging was obtained upon the clinical suspicion of calvarial osteomyelitis. Parasitic infestation should be included in the differential diagnosis of a new skin lesion in patients who have traveled to endemic areas.

Radiation-induced spinal cord hemorrhage (hematomyelia)

Intraspinal hemorrhage is very rare and intramedullary hemorrhage, also called hematomyelia, is the rarest form of intraspinal hemorrhage, usually related to trauma. Spinal vascular malformations such intradural arteriovenous malformations are the most common cause of atraumatic hematomyelia. Other considerations include warfarin or heparin anticoagulation, bleeding disorders, spinal cord tumors. Radiation-induced hematomyelia of the cord is exceedingly rare with only one case in literature to date. We report the case of an 8 year old girl with Ewing’s sarcoma of the thoracic vertebra, under radiation therapy, presenting with hematomyelia. We describe the clinical course, the findings on imaging studies and the available information in the literature. Recognition of the clinical pattern of spinal cord injury should lead clinicians to perform imaging studies to evaluate for compressive etiologies.

Sensitivity of 3D Gradient Recalled Echo Susceptibility-Weighted Imaging Technique Compared to Computed Tomography Angiography for Detection of Middle Cerebral Artery Thrombus in Acute Stroke.

We aimed at comparing the sensitivity of magnetic resonance (MR) susceptibility-weighted imaging (SWI) with computed tomography angiography (CTA) in the detection of middle cerebral artery (MCA) thrombus in acute stroke. Seventy-nine patients with acute MCA stroke was selected using our search engine software; only the ones showing restricted diffusion in the MCA territory on diffusion-weighted images were included. We finally selected 35 patients who had done both MRI (including SWI) and CTA. Twenty random subjects with completely normal MRI (including SWI) exam were selected as control. Two neuroradiologists (blinded to the presence or absence of stroke) reviewed the SW images and then compared the findings with CT angiogram (in patients with stroke). The number of MCA segments showing thrombus in each patient was tabulated to estimate the thrombus burden. Thrombus was detected on SWI in one or more MCA segments in 30 out of 35 patients, on the first review. Of the 30, SWI showed thrombus in more than one MCA segments in 7 patients. CTA depicted branch occlusion in 31 cases. Thrombus was seen on both SWI and CTA in 28 patients. Thrombus was noted in two patients on SWI only, with no corresponding abnormality seen on CTA. Two patients with acute MCA showed no vascular occlusion or thrombus on either CTA or SWI. Only two case of false-positive thrombus was reported in normal control subjects. Susceptibility-weighted images had sensitivity and specificity of 86% and 90% respectively, with positive predictive value 94%. Sensitivity was 86% for SWI, compared with 89% for CTA, and this difference was statistically insignificant (P>0.05). Of all the positive cases on CTA (31) corresponding thrombus was seen on SWI in 90% of subjects (28 of 31). Susceptibility-weighted imaging has high sensitivity for detection of thrombus in acute MCA stroke. Moreover, SWI is a powerful technique for estimation of thrombus burden, which can be challenging on CTA.

Spontaneous thrombosis of developmental venous anomaly (DVA) with venous infarct and acute cerebellar ataxia

Developmental venous anomaly (DVA), formally known as venous angioma, is a congenital anatomic variant of the venous drainage of the brain. Although they typically have a benign clinical course and a low symptomatic rate, thrombosis of a drainage vein may occur, leading to potentially debilitating complications. We report a unique case of spontaneous thrombosis of a posterior fossa developmental venous anomaly with cerebellar infarct in a 61-year-old man who presented with acute onset cerebellar ataxia. DVA thrombosis was well-depicted on CT and MR studies. Patient was put on anticoagulant therapy and complete recanalization was seen on follow-up imaging.

Neonatal hypoglycemia resulting in occipital cerebral injury

A 3-day-old girl with transient hypoglycemia, born to a 27year-old mother with gestational diabetes, presented with seizures within 24 hours of birth. MRI of the brain revealed near symmetric areas of restricted diffusion involving bilateral occipital lobes and the splenium of corpus callosum, with bright signal on diffusion weighted imaging (DWI) (Fig. 1) and signal loss on apparent diffusion coefficient (ADC) maps (Fig. 2). These imaging findings were most consistent with hypoglycemic brain injury. Radiological findings of neonatal hypoglycemia vary considerably depending on the degree and duration of hypoglycemia. The occipital lobes are most severely

Multiple scalp epidermoid cysts in a child with Gardner syndrome

A 12-year-old boy presented with cystic swelling over his scalp. MRI of the brain revealed multiple non-enhancing cystic lesions in the scalp. These cysts were of varying sizes. They appear T1 hypointense (Fig. 1), bright on T2-W images, and show restricted diffusion on diffusion-weighted images (Fig. 2). These findings are characteristic of epidermoid cysts. The boy was known to have Gardner syndrome and had a complete colectomy at the age of 3 years for adenomatous polyposis. Gardner syndrome is characterized by gastrointestinal polyposis with osteomas, as well as multiple skin and soft-

Is sarcopenia and sarcopenic obesity associated with clinical and pathological outcomes in patients undergoing radical nephroureterectomy

PURPOSE To investigate the association between sarcopenia and sarcopenic obesity on clinical, perioperative, and oncologic outcomes in patients with upper-tract urothelial carcinoma (UTUC) undergoing radical nephroureterectomy (RNU). METHODS Retrospective review of our institutional UTUC database was performed to identify all patients who underwent radical nephroureterectomy from 2002-2016. Skeletal Muscle Index (SMI) was measured at the L3 vertebral level and standardized according to patient height (cm2/m2). Sarcopenia was defined as<55cm2/m2 for men and<39cm2/m2 for women. Sarcopenic obesity was also assessed in patients with BMI>30kg/m2. Unadjusted logistic regression and Wilcoxon rank sum tests examined the relationship between sarcopenia and variables. RESULTS A total of 100 patients (66 men and 34 women) with a mean age of 68 years, BMI of 30, Charlson comorbidity index of 4.0, tumor size of 3.5, and SMI of 50.8cm2/m2 were included. Furthermore, 42 patients (42%) were sarcopenic, and 18 patients (18%) had sarcopenic obesity. Median EBL was 150ml, OR duration was 322 minutes, and length of stay was 5.0 days. Sarcopenia was associated with several clinical factors including decreasing BMI, male sex, and coronary artery disease, albeit without association with any perioperative or oncologic outcomes. Sarcopenic obesity was similarly associated with several clinical variables including male sex, diabetes mellitus, hyperlipidemia, as well as increased EBL (P = 0.047) and non-bladder cancer disease relapse (P = 0.049). CONCLUSIONS This contemporary cohort of patients undergoing RNU highlights the association of nonmodifiable risk factors with sarcopenia and disease relapse with sarcopenic obesity. Larger studies are necessary to further validate these observations.

Anterior pattern disease in adrenoleukodystrophy

An 8-year-old boy presented in the emergency department with seizures. An MRI revealed symmetrical areas of T2 FLAIR hyperintensity and contrast enhancement involving the frontal white matter, the anterior commissure and the genu of corpus callosum (Figs. 1 and 2). There was no involvement of the parieto-occipital lobes or peritrigonal white matter, but there was a lesion in the splenium. There was sparing of the subcortical-U fibers. This was most consistent with the predominant frontal pattern of adrenoleukodystrophy (ALD), which was later confirmed with biochemical and cytogenetic examinations.