Koray Kilic

Quantitative and qualitative comparison of standard-dose and low-dose pediatric head computed tomography: a retrospective study assessing the effect of adaptive statistical iterative reconstruction.

Objectives Our aim was to assess the effect of adaptive statistical iterative reconstruction (ASIR) on pediatric head computed tomography (CT) examinations. Methods We retrospectively reviewed 305 pediatric head CT examinations. The study population consisted of standard dose (STD, n = 152) examinations reconstructed with filtered back projection and low dose (LD, n = 153) examinations reconstructed with 30% (LD30) and 0% (LD0) ASIR. We compared groups by means of radiation dose, noise measures, and visual grading. Student t test, 1-way analysis of variance test, and Mann-Whitney U test were used for statistical analysis. Results The dose in the LD30 group was significantly lower (29%) than that in the STD group (P < 0.001). The noise in the white matter (P < 0.001), SNR (P < 0.001), and subjective image noise (P = 0.044) was significantly better in the STD group than those in the LD30 group. There was no significant difference between LD30 and STD groups in the sharpness (P = 0.141), diagnostic acceptability (P = 0.079), and artifacts (P = 0.750) and contrast-to-noise ratio (P = 0.718). Conclusions In conclusion, we found that a blend of 30% ASIR in a 16-slice multidetector CT produces diagnostically acceptable pediatric head CT examinations with a 29% less dose.

Are spinal or paraspinal anatomic markers helpful for vertebral numbering and diagnosing lumbosacral transitional vertebrae

Objective To evaluate the value of spinal and paraspinal anatomic markers in both the diagnosis of lumbosacral transitional vertebrae (LSTVs) and identification of vertebral levels on lumbar MRI. Materials and Methods Lumbar MRI from 1049 adult patients were studied. By comparing with the whole-spine localizer, the diagnostic errors in numbering vertebral segments on lumbar MRI were evaluated. The morphology of S1-2 disc, L5 and S1 body, and lumbar spinous processes (SPs) were evaluated by using sagittal MRI. The positions of right renal artery (RRA), superior mesenteric artery, aortic bifurcation (AB) and conus medullaris (CM) were described. Results The diagnostic error for evaluation of vertebral segmentation on lumbar MRI alone was 14.1%. In lumbarization, all patients revealed a well-formed S1-2 disc with squared S1 body. A rhombus-shaped L5 body in sacralization and a rectangular-shaped S1 body in lumbarization were found. The L3 had the longest SP. The most common sites of spinal and paraspinal structures were: RRA at L1 body (53.6%) and L1-2 disc (34.1%), superior mesenteric artery at L1 body (55.1%) and T12-L1 disc (31.6%), and AB at L4 body (71.1%). CM had variable locations, changing from the T12-L1 disc to L2 body. They were located at higher sacralization and lower lumbarization. Conclusion The spinal morphologic features and locations of the spinal and paraspinal structures on lumbar MRI are not completely reliable for the diagnosis of LSTVs and identification on the vertebral levels.

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.

Unenhanced urinary CT: Value of parenchymal attenuation measurements in differentiating acute vs. chronic renal obstruction

OBJECTIVE We aimed to search if the renal parenchymal attenuation measurements on unenhanced CT scans could be useful in differentiating acutely obstructed kidneys from chronic cases or unobstructed kidneys. MATERIAL AND METHODS Unenhanced CT scans of 101 patients were retrospectively reviewed. Thirty-two patients with unilateral acute renal obstruction, 34 patients with unilateral chronic renal obstruction due to various reasons and 35 control subjects were included in the study. The parenchymal densities of both kidneys were measured, from the upper poles, middle portions, and lower poles of each kidney. The mean parenchymal densities of both kidneys were calculated in all three groups of subjects. Secondary signs of renal obstruction such as perinephric stranding, size of ureteral stone, degree of hydronephrosis were also noted for each kidney. RESULTS The mean parenchymal attenuation value on the acutely obstructed side was lower than the unobstructed side, 24.21 ± 3.68 and 30.68 ± 4.75 respectively (p<0.001). The mean parenchymal attenuation value on the acutely obstructed side (24.21 ± 3.68) was lower than both the chronically obstructed side (30.85 ± 4.53), and the control subjects (29.62 ± 3.03 on corresponding side). There was no statistically significant attenuation difference between right and left kidneys in the control group and chronic obstruction group. CONCLUSION Renal parenchymal attenuation measurements and attenuation differences of both kidney of same patient could be useful in differentiating acute unilateral obstruction from chronic cases.

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.

THU0543 Comparison of the effectiveness of low level laser therapy and steroid injection in moderate carpal tunnel syndrome: a randomised controlled trial

Background Recent studies have reported that low-level laser therapy (LLLT) reduces pain and improves function in carpal tunnel syndrome (CTS). However, to the best of our knowledge, there exist no studies that compares the effectiveness of LLLT and steroid injections in moderate CTS. Objectives Is to evaluate the effectiveness of LLLT and steroid injection in moderate CTS, by comparing the symptoms, the electrophysiologic and the Magnetic Resonance Imaging (MRI) findings of the patients. Methods 87 patients with moderate CTS were included in the study. 87 patients were randomised to the steroid or LLLT groups. LLLT was applied to the carpal tunnel area (6 joules/5 min) five times per week, for a total of 10 sessions. Steroid injections were performed once after randomization. Numbness and pain of the patients were assessed using a Visual Analogue Scale (VAS), disability was assesses using the Quick arm-shoulder-hand (Quick DASH) disability questionnaire. Rough and fine grasping strength tests, Tinel and Phalen tests and electrophysiological test were performed. All the patients were evaluated by MRI in terms of median nerve cross-sectional area, median nerve intensity and intensity rate, and median nerve palmary spring rate. All tests were performed before the treatment, and 1. month and 6. months after the treatment, except the MRI evaluations, which were done before and after 6. months of the treatment. Results The study was completed with 80 patients, 133 wrists at the end of six months. There were no significant differences between the groups in terms of dermographic and baseline clinic characteristics, electrophysiologic and MRI findings of the patients (p>0,05). While the VAS scores of numbness and pain and Quick Dash symptom scores were better in the steroid group in the first month, there were no significant differences between the groups in the sixth month. In both groups, there were similar significant improvements in the Phalen and Tinel tests, rough and fine grasping forces, median nerve motor distal latency value in the first and sixth months after the treatment in comparison to pretreatment values (p<0.05). Median nerve sensory distal latency and median sensory NCV showed significant improvements in the 1st and the 6th months after treatment in comparison to pretreatment only in the steroid group (p<0.05). In both groups, there were similar significant improvements in the median nerve intensity rate in the radioulnar plane and median nerve palmary spring rate on the MRI after the treatment. Median nerve intensity rate was improved in both groups also at the pisiform plane but this improvement was significant only in the steroid group. Conclusions It is possible to conclude that LLLT reduces the signs and symsptoms of the patients who has moderate CTS as well as the steroid treatment. Our study offers a data regarding LLLT’s efficiency in short-intermediate terms. Further studies are needed to make comments about long-term efficiency of LLLT. LLLT is a noninvasive treatment option in moderate CTS and with a similar efficacy as steroid treatment. Reference [1] Evcik D, Kavuncu V, Cakir T, Subasi V, Yaman M. Laser therapy in the treatment of carpal tunnel syndrome: a randomized controlled trial. Photomed Laser Surg2007;25:34–39. Disclosure of Interest None declared

Comparison of Resorbable Mesh (Poly L-Lactide/Glycolic Acid) and Porous Polyethylene in Orbital Floor Fractures in an Experimental Model

Background: Resorbable mesh and porous polyethylene are frequently used alloplastic materials for the treatment of the orbital blowout fractures. The literature lacks reports comparing their long-term effects on experimental models. Objective: Our aim was to radiologically and histologically evaluate the effectiveness and safety of porous polyethylene and resorbable mesh in a rabbit orbital blowout fracture model. Methods: Twelve New Zealand white rabbits (24 orbits) were randomized to 4 groups. In group 1, only orbital floor dissection was done. In group 2, following orbital floor dissection, a 10-mm defect was created without any extra procedure. In group 3, following a 10-mm defect creation, a 12-mm-round cut porous polyethylene was placed on the defect. In group 4, following a 10-mm defect creation, a 12-mm-round cut resorbable mesh was placed on the defect. Computed tomographic analysis was performed during follow-up period. Orbital floors were evaluated histologically at month 6. Results: No clinical complications were observed during follow-up period. In radiological evaluation, there was no statistically significant difference between groups regarding bone formation. In histological evaluation, the connective tissue was denser, and organized and better bone formation was observed in group 3 and 4 when compared with other groups. Conclusion: Although no significant radiological changes were present, porous polyethylene and resorbable mesh performed better histologically. They were effective and well tolerated for reconstruction of the isolated orbital floor defects.

Spontan hepatosellüler karsinoma kanaması: Olgu sunumu

Bleeding from hepatocellular carcinoma is the third leading cause of mortality in hepatocellular carcinoma. Difficulties in diagnosis and treatment represent the greatest challenges. A 49-year-old man with cirrhosis due to hepatitis B virus had admitted to the hospital because of abdominal pain lasting for two days. The patient had tachycardia and hypotension, and abdominal distension. The levels of bilirubin and albumin were 8.2 mg/dl and 2 g/dl, respectively. The abdominal tomography revealed a 5x6 cm mass and hemorrhagic fluid. In the paracentesis, hemorrhagic fluid was aspirated. The patient underwent emergency surgery because of the hemorrhagic paracentesis fluid and existing shock. Bleeding from the mass in the 6th segment of the liver was controlled by suturing. The bleeding stopped, but the patient died on the 5th day due to liver insufficiency. Diagnostic difficulties, liver insufficiency, hemorrhagic shock, coagulation problems, and unknown masses are the risk factors for increasing mortality. Risk factors for bleedings should be evaluated during the follow-up of patients with cirrhosis.