Koray Akkan

Unfused or twig-like middle cerebral artery.

INTRODUCTION The knowledge of anatomic variations of the cerebral arterial circulation may be important to decide on the safest surgical or endovascular treatment method. Variations in the middle cerebral artery (MCA) territory seems to be less frequent than the other intracranial arteries. During the embryonic stage the primitive MCA is hypothesized to be made up of arterial twigs and these twigs will generate the definitive MCA at the end of the development stage. As in our cases, an early interruption in this period will prevent the evolution of MCA normally and a plexiform arterial network will create the M1 segment of MCA which is the so-called extremely rare unfused or twig-like (Uf/Tw) MCA variation. Our aim is to define and evaluate the angiographical features of Uf/Tw MCA. METHODS The diagnosis of Uf/Tw MCA was evaluated in a total of 4855 diagnostic cerebral catheter angiograms, retrospectively. The coexisting intracranial pathologies were also interpreted with former radiological examinations. A review of the literature is provided. RESULTS A total of six cases of Uf/Tw MCA was identified on angiograms accompanying ipsilateral internal carotid artery (ICA) occlusion and contralateral ICA supraclinoid segment aneurysm in one case, and cingulate gyrus AVM in the other. In two different cases, CT or MRI examinations revealed coexisting subarachnoid hemorrhage and misdiagnosis of forniceal AVM in one case, and temporal arachnoid cyst and parenchymal hematoma in the other. CONCLUSION Lack of data and knowledge about the Uf/Tw MCA variation may cause misdiagnosis and unnecessary treatment attempts.

Assessment of 3D T2-weighted high-sampling-efficiency technique (SPACE) for detection of cerebellar tonsillar motion: new useful sign for Chiari I malformation

OBJECTIVE To describe tonsillar blackout sign (TBS) on three-dimensional (3D)-SPACE, evaluate its performance in identifying Chiari malformation (CM1) as diagnostic marker, and investigate its role in differentiation of symptomatic and asymptomatic CM1. METHODS One-hundred fifty-six patients were divided into two groups based on caudal displacement of cerebellar tonsils: CM1 (Group I) and non-CM1 (Group II). Group I was subclassified as symptomatic and asymptomatic by a neurosurgeon. Two radiologists evaluated TBS and cerebrospinal fluid flow abnormality. RESULTS All subjects presenting TBS had CM1. Difference in presence of TBS between Group I and Group II was highly significant (P<.001).Grading of TBS in symptomatic patients was significantly higher than that in asymptomatic patients (P<.001). CONCLUSION TBS is highly suggestive of CM1 and potentially useful in differentiation of symptomatic and asymptomatic CM1.

Misplaced central venous catheter in the vertebral artery: endovascular treatment of foreseen hemorrhage during catheter withdrawal

Purpose We report on the endovascular management of hemorrhage with stent-graft due to a misplaced central venous catheter in the vertebral artery (VA) during percutaneous internal jugular vein catheterization in a child. Methods A 16-year-old female was presented with the diagnosis of familial Mediterranean fever related chronic renal insufficiency. An attempt was made to place a central venous catheter via the right internal jugular vein without image guidance and the patient experienced dyspnea and pain at the catheter insertion site. Computerized tomography (CT) showed hemorrhage in the cervical region and upper mediastinum, also reformatted images showed that the catheter was passing through the proximal part of the VA and terminating in the right mediastinum. The catheter was removed during manual compression under angio-flouroscopic monitoring and ongoing extravasation was observed. A stent-graft was placed to the bleeding site of the VA. Results Angiography immediately after the stent-graft placement revealed complete disappearance of extravasation and patency of vertebral and subclavian arteries. Conclusion Central venous catheterization (CVC) is not a risk-free procedure and arterial injuries are in a wide spectrum from a simple puncture to rupture of the artery. Inadvertent VA cannulation is a rare and serious complication necessitating prompt diagnosis and early treatment. If an arterial injury with a large-caliber catheter occurs, endovascular treatment with stent-graft seems to be a safe and effective option in terms of achieving hemostasis and preserving arterial patency. Recent findings suggest that endovascular management of inadvertent cervical arterial injury secondary to CVC seems to be the safest strategy.

Evaluation of Aqueductal Patency in Patients with Hydrocephalus: Three-Dimensional High-Sampling-Efficiency Technique (SPACE) versus Two-Dimensional Turbo Spin Echo at 3 Tesla

Objective To compare the accuracy of diagnosing aqueductal patency and image quality between high spatial resolution three-dimensional (3D) high-sampling-efficiency technique (sampling perfection with application optimized contrast using different flip angle evolutions [SPACE]) and T2-weighted (T2W) two-dimensional (2D) turbo spin echo (TSE) at 3-T in patients with hydrocephalus. Materials and Methods This retrospective study included 99 patients diagnosed with hydrocephalus. T2W 3D-SPACE was added to the routine sequences which consisted of T2W 2D-TSE, 3D-constructive interference steady state (CISS), and cine phase-contrast MRI (PC-MRI). Two radiologists evaluated independently the patency of cerebral aqueduct and image quality on the T2W 2D-TSE and T2W 3D-SPACE. PC-MRI and 3D-CISS were used as the reference for aqueductal patency and image quality, respectively. Inter-observer agreement was calculated using kappa statistics. Results The evaluation of the aqueductal patency by T2W 3D-SPACE and T2W 2D-TSE were in agreement with PC-MRI in 100% (99/99; sensitivity, 100% [83/83]; specificity, 100% [16/16]) and 83.8% (83/99; sensitivity, 100% [67/83]; specificity, 100% [16/16]), respectively (p < 0.001). No significant difference in image quality between T2W 2D-TSE and T2W 3D-SPACE (p = 0.056) occurred. The kappa values for inter-observer agreement were 0.714 for T2W 2D-TSE and 0.899 for T2W 3D-SPACE. Conclusion Three-dimensional-SPACE is superior to 2D-TSE for the evaluation of aqueductal patency in hydrocephalus. T2W 3D-SPACE may hold promise as a highly accurate alternative treatment to PC-MRI for the physiological and morphological evaluation of aqueductal patency.

Successful embolization in childhood hemoptysis due to abnormal systemic arterial bleeding of the lung and review of the literature

Hemoptysis in children is a rare but potentially life‐threatening symptom of an underlying respiratory tract abnormality. Hemoptysis, when massive and untreated, has a mortality rate of more than 50%. With interventional radiological procedures and surgery, this rate has dropped to 7%–18%. The experience with bronchial arterial embolization in childhood is very limited; only a few case reports with short‐term follow‐up have been reported.

Juvenile Nasopharyngeal Angiofibroma: Magnetic Resonance Imaging Findings

Purpose: Juvenile nasopharyngeal angiofibroma (JNA) is a rare tumor that exhibits a predictable spreading pattern. Radiologist’s prior knowledge on the tumor’s characteristics aids in establishing a diagnosis. We aimed to report the characteristic Magnetic Resonance Imaging (MRI) findings and the spread patterns of JNA. Materials and methods: We retrospectively evaluated the MRI findings and extension pathways of 6 cases of JNA. Results: The patients’ age ranged from 8 to 16 years and all patients were male. The tumors were classified according to the Onerci system. Tumors were largely isointense to muscle on T1-weighted images and hyperintense on T2-weighted images. All lesions had internal signal-void regions and all exhibited intense enhancement after IV contrast injection. Diffusion restriction was not an associated feature. ADC values for these tumors were high. The evaluation of the available MR angiography studies of three patients showed the blood supply to the tumor to be mainly from the internal maxillary branch of the external carotid artery. In all patients, the diagnosis was based on MR images and a surgical excision was planned. Conclusion: The diagnosis can be established based on the characteristic imaging findings and the clinical history without performing a biopsy.

Isolated abducens palsy of advanced age: a rare presentation of dural carotid cavernous fistula: a case report

Abducens palsy is the most common isolated cranial nerve palsy due to its long peripheral course. Multiple anatomical relationships, particularly within the cavernous sinus and orbita, make the nerve vulnerable. 67 year-old female patient was admitted with worsened headache and lateral gaze restriction of the left eye, which appeared recently. She had no prior history of trauma. Prominent appearance of the left cavernous sinus on cranial magnetic resonance imaging, raised the need of digital substraction angiography which revealed the presence of bilateral type D dural arteriovenous fistula of cavernous sinuses. Cavernous sinus pathologies, which are usually known to manifest with multiple ocular motor palsies because of the close relationship between 3rd, 4th and 6th nerves inside, might rarely present with isolated abducens palsy. The clinician should pay particular attention to headache in such kind of patients and dural carotid-cavernous fistula should be taken into account, even in the absence of previous trauma history.

Ultrasound elastography in assessment of salivary glands involvement in primary Sjögren's syndrome

OBJECTIVE Our study aimed to assess the pathological sonoelastographic changes in the major salivary glands and to demonstrate the diagnostic effectiveness of Sonoelastography as an additional method to US in Sjögrens syndrome. METHODS Fifty eight patients with primary Sjögrens syndrome (pSS) were selected according to the American-European Consensus Group Classification criteria. Twenty five healthy volunteers involved in this study. All patients were evaluated with B-mode and elastography by using Hitachi EUB 7500 digital ultrasound equipment. All subjects were female. The sonoelastography examination, which allowed us to assess the elasticity of the parenchyma, was performed and strain ratios were measured by comparing with the adjacent tissues. RESULTS Statistically significant differences were found between the pSS and control groups for the elastographic scores and strain ratios (p < 0.001). The highest sensitivity and specificity levels were obtained when the strain ratio cut-off value was taken as 1.55 for the submandibular gland and 2.45 for the parotid gland (sensitivity and specificity were 83% and 88% respectively for the submandibular gland and 83% and 92% respectively for the parotid gland). However, no statistically significant differences were found between the disease duration and the elasticity scores or strain ratios in pSS group (p > 0.05). CONCLUSION US examination is an efficient method to assess major salivary gland involvement in the diagnosis of pSS. Sonoelastography is a modality which can contribute to the diagnosis by improving specificity in the differential diagnosis of pSS. Strain ratio measurement, which is a semi-quantitative method, increases the diagnostic effectiveness by providing high sensitivity, specificity, and negative predictive values.

Endovascular treatment of intracranial anterior circulation aneurysms with flow diverters: a single centre experience with mid and long-term results

AIM We report our experience with flow diverter devices in the treatment of intracranial aneurysms arising from anterior circulation with mid and long-term follow-up. MATERIAL AND METHODS 78 aneurysms in 61 patients (range 25-81 years, 13 male, 48 female) were treated with flow diverter devices. 40 (51,3%) aneurysms were treated with pipeline embolization device (PED), 24 (30,8%) aneurysms were treated with SILK stent, 12(15,4%) aneurysms were treated with flow redirection endoluminal device (FRED) and two aneurysms were treated with P64 Flow Modulation Device (P64). Angiographic follow-up data at six month and one yea were recorded and the occlusion degrees of aneurysms were evaluated according to the scale which was formed by Kamran et al. RESULTS At six month follow-up, complete occlusion (grade 4) rate was 60,8% and at one year increased to 74,3%. Statistical analysis revealed significant difference (p=0,002) between six month and one year follow-up results but there was no significant association (p=0,531, p=1,000) between aneurysm occlusion rate and aneurysm diameter. Two patient (3,2%) died due to hemorrhagic complication. CONCLUSION Endovascular treatment of intracranial anterior circulation aneurysms with flow diverters is a safe and effective treatment option. A high rate of stable occlusion is achieved at long term follow-up.

An unusual cause of acute abdomen in an adolescent with concurrent disease: Answers

1Angiographic findings showing occlusion of a middlesized artery and tissue biopsy findings demonstrating necrotizing non-granulomatous inflammation of the wall of a middle-sized artery confirm the diagnosis of polyarteritis nodosa (PAN) 2The mainstays of treatment for PAN are systemic steroids and cyclophosphamide.We started with oral steroids (2mg/ kg prednisolone) and pulse cyclophosphamide (CYX). After steroid tapering and the third dose of pulse CYX, she is symptom free and has normal acute-phase reactants. This regimen was highly effective in the control of her disease: the patient was discharged after 29 days with steroid tapering (1.5 mg/kg/day) and a treatment regimen of steroids and monthly pulse CYX for 6 months. After the third dose of CYX, she has been in complete remission.