Murvet Yuksel

Occipitocervical vertical distraction injuries: anatomical biomechanical, and 3-tesla magnetic resonance imaging investigation.

Study Design. Biomechanical load-to-failure findings correlated with anatomic dissection measurements and intact (prefailure) 3-Tesla (3-T) magnetic resonance images (MRI). Objective. To better understand why the same distractive force to the head can result in occipitoatlantal dislocation (OAD) in some individuals and atlantoaxial dislocation (AAD) in others. Summary of Background Data. Distraction injuries to the cranio-vertebral junction have been studied biomechanically but have not been studied relative to ligamentous anatomic variations. We theorized that morphologic variations in the ligaments should influence the injury pattern during axial distraction. Methods. After obtaining 3-T MRI scans, 10 occiput-C2 specimens were loaded to failure under axial tension. Direct anatomic measurements were also obtained from the distracted and injured specimens. Results. AAD was observed in 7 specimens (mean force ± standard deviation 1229 ± 181 N) at a significantly higher magnitude than OAD, which was observed in 3 specimens (823 ± 127 N; P = 0.009, nonpaired t test). In OAD specimens, the superior cruciate ligament (SCL), which was smaller than the inferior cruciate ligament (ICL), failed. The apical ligament was unidentifiable in these 3 specimens. In 5 of the 7 AAD specimens, the ICL ruptured and was smaller than the SCL. In the remaining 2 specimens, both SCL and ICL ruptured. The apical ligament, which ruptured, was identifiable in all 7 specimens. Conclusion. Axial distraction across the cranio-vertebral junction can produce either OAD or AAD. The SCL and ICL dimensions, alar ligament orientations, and apical ligament presence may affect the injury site. Visualization with 3-T MRI allows better understanding of the injury mechanism and location, which is important clinically in selecting single- or multilevel fixation.

Case of large placental chorioangioma associated with diffuse neonatal hemangiomatosis.

Chorioangioma is the most frequent nontrophoblastic tumor of the placenta with a incidence ranging from 0.01 to 1.3%. Vascular anomalies of the placenta coincidental with infantile hemangioendothelioma (IH) of the liver are rarely described. Here we report a case of a large chorioangioma of the placenta associated with cutaneous hemangiomatosis and IH of the liver. The relationship between hemangiomas and placental chorioangioma is discussed.

Magnetic resonance imaging of the craniocervical junction at 3-T: observation of the accessory atlantoaxial ligaments.

OBJECTIVE:Instability of the craniocervical junction can cause neurological sequelae or pain. Stability of this region depends on extensive ligamentous support structures, most of which are well studied by magnetic resonance imaging (MRI) scanning. Although the contribution of the accessory atlantoaxial ligament to rotational stability has been described, this ligament has not been identified by imaging. Therefore, we investigated the imaging characteristics of this ligament and its relationship to the ligamentous complex of the craniocervical junction using the high resolution offered by 3-T MRI scans. METHODS:Ten healthy volunteers underwent MRI scanning at 3-T to determine the normal anatomy of this ligament. RESULTS:The atlantoaxial (C1–C2) segment of the ligament was identified in all 10 subjects bilaterally and symmetrically. Its mean dimensions were 2.8 × 1.8 mm. In four out of 10 subjects, the occipitoatlantal (C0–C1) segment was observed. At this level, the mean dimensions of the ligament were 1.6 × 1.2 mm on the right and 1.8 × 1.4 mm on the left. Its size varied between the right and left sides. CONCLUSION:The accessory atlantoaxial ligament can be visualized using high-resolution MRI scans at 3-T. The ligament was most consistent and robust at C1–C2. The ligament may, therefore, contribute to rotational stability at this level. Future studies will determine the biomechanical importance of this ligament, especially in the setting of trauma.

Symptomatic vertebral hemangioma related to pregnancy

In this paper, we report a case of vertebral hemangioma during pregnancy in a 21-year-old woman presenting with paraparesis of rapid onset. An emergency MRI scan of the dorsal spine showed a lesion of the ninth thoracic vertebra with extradural extension and marked spinal cord compression. A cesarean section was done, and this was followed by emergent laminectomy. Her symptoms and neurologic deficits quickly improved. The etiopathogenesis, clinical, radiological features, and treatment modalities are discussed in the light of the literature.

Sonographic Evaluation of Subclinical Entheseal Involvement in Patients With Behçet Disease

OBJECTIVE The aim of the current study was to determine the prevalence of subclinical entheseal involvement in patients with Behçet disease via ultrasound using a newly developed method, the Madrid sonography enthesitis index. SUBJECTS AND METHODS The study was conducted with 36 patients with Behçet disease and 46 healthy sex- and age-matched control subjects. All patients with Behçet disease who had no clinical evidence of arthritis or enthesitis underwent an ultrasound examination. All sonographic findings were identified according to the Madrid sonography enthesitis index. Madrid sonography enthesitis index values of patients and control subjects were compared by Student t test and Mann-Whitney U test. Validity was analyzed by receiver operating characteristic curve. RESULTS Total enthesitis score was 12.16 ± 6.16 among patients with Behçet disease and 2.06 ± 2.18 among healthy control subjects (p < 0.001). The receiver operating characteristic curve established an ultrasound score greater than 4.5 in the Behçet disease group as the best cut-off point differentiating case subjects from control subjects. This cutoff was exceeded by 88.8% of the patients with Behçet disease. When the Madrid sonography enthesitis index score in each affected enthesis was evaluated, patients with Behçet disease had significantly higher scores than did control subjects when all entheseal sites were compared (all p values < 0.05). CONCLUSION This is the first study to our knowledge to show significant subclinical enthesopathy of the triceps tendon enthesis in patients with Behçet disease who had no arthritic involvement. These data suggest that the Madrid sonography enthesitis index scoring system for sonographic detection of enthesopathy should be incorporated into the clinical protocol for evaluating patients with Behçet disease in routine clinical practice.

Frequency of peripheral arterial disease and venous insufficiency in toenail onychomycosis

Onychomycosis in toenails is a common fungal infection and vascular abnormalities of lower extremities have been thought as one of the predisposing conditions. The aim of this study was to evaluate predisposition effect of venous insufficiency and peripheral arterial disease on toenail onychomycosis. Thirty‐three patients with bilateral onychomycosis in toenails and 37 control subjects, who had healthy nails, were enrolled in the study. Veins and arteries of lower extremities were examined with Doppler ultrasound in terms of venous insufficiency or peripheral arterial disease. Patients with onychomycosis presented more frequent venous insufficiency than the control group (42.4% and 10.8%, respectively; P = 0.003). Although all patients had bilateral onychomycosis, reflux was bilateral in six out of 14 patients with onychomycosis (42.8%). No significant difference in frequency of peripheral arterial disease was found in patients, compared to healthy controls. Our study demonstrated a significant relationship between onychomycosis and venous insufficiency, but not with peripheral arterial disease. Also, we point out discordance with bilateral onychomycosis and unilateral venous insufficiency.

Carotid CT angiography: comparison of image quality for left versus right arm injections.

PURPOSE To evaluate the differences in image quality of carotid computed tomographic angiography (CTA) of patients injected with contrast material in their right arms versus patients injected with contrast material in their left arms. MATERIALS AND METHODS Patients who had cerebrovascular accidents and subsequently underwent CTA were included in the study. Contrast material was injected into the right arms of 44 patients and into the left arms of 46 patients. Source images of a total of 90 CTAs were retrospectively evaluated for perivenous streak artifacts and contrast material reflux into the veins of the neck and upper thorax. After adjusting for differences in gender, the relationship between the injection site and the intensity of perivenous streak artifacts and venous reflux was determined. RESULTS Perivenous streak artifacts and venous reflux were demonstrated in patients who underwent either right or left arm injections. However, the intensity of perivenous streak artifacts was stronger in patients who were injected with contrast material in the left arm. Venous reflux into the neck and upper thorax veins was also more severe and more frequent with left arm injections. A decreased retrosternal distance facilitated reversed flow into the veins when the left arm injection was used. CONCLUSION Perivenous beam hardening streak artifacts and venous reflux could not be prevented with right or left arm injections. However, patients who were injected with contrast material in their right arms showed fewer artifacts, thus allowing for better quality images on CTA.

Increased Enthesopathy in Patients With Familial Mediterranean Fever Evaluation With a New Sonographic Enthesitis Index

The aim of this study was to determine the frequency of enthesopathy in familial Mediterranean fever by using a newly developed sonographic method, the Madrid Sonographic Enthesitis Index (MASEI).

Diagnostic Importance of 3D CT Images in Klippel-Feil Syndrome with Multiple Skeletal Anomalies: A Case Report

We present here the case of a 12-year-old boy who had Klippel-Feil syndrome with renal, cardiac and multiple skeletal anomalies, and we show the relevent three-dimensional computed tomography images. Our patient had a triple renal pelvis, mitral valve prolapsus, multiple cervical vertebrae fusions, cervical ribs, hypoplasia of the right thumb, spina bifida of L5, lumbalization at the right side of S1 and a sacral curved defect. In this study, we discuss the atypical clinical features and the diagnostic value of three-dimensional CT for evaluating the skeletal anomalies of the Klippel-Feil syndrome cases.

Isolated Pancreatic Tuberculosis Mimicking Malignancy and Causing Obstructive Jaundice

Isolated pancreatic tuberculosis (TB) is unusual, but obstructive jaundice secondary to pancreaticobiliary TB is extremely rare. The mechanisms by which tuberculosis causes bile duct obstruction are varied. Here, we describe a patient with pancreatic tuberculosis which mimicked pancreatic carcinoma with biliary obstruction clinically–radiologically. A 60-year-old woman presented with a history of progressive jaundice, nausea, vomiting, and weight loss. There was no prior history of tuberculosis or family history of contact. Chest X-ray was normal. Abdominal ultrasound examination revealed an irregular hypoechoic lesion of 3 cm in the pancreatic head with dilation of entire bile duct system, mild dilated pancreatic duct, and distended gall bladder. Contrast-enhanced computed tomography (CT) scan showed a heterogeneous hypodense mass in the pancreatic head that cannot be a clear margin from pancreas and mild dilated pancreatic duct (Fig. 1). In addition, peripancreatic peripherally enhancing enlarged necrotic lymph nodes were seen (Fig. 2). A preliminary diagnosis of a periampullary carcinoma was made. Exploratory laparotomy revealed a mass and multiple peripancreatic lymph nodes. Histological examination of intraoperative frozen section of nodal biopsies showed granulomas with giant cells and no evidence of malignancy. Cholecystectomy and bilioduodenal anastomosis were performed. More lymph nodes and the mass biopsies were obtained for specific histological examination. This confirmed caseous granulomatous inflammation with abundant acid-fast bacilli on Ziehl–Neelsen staining (Fig. 3). Specific antituberculosis treatment was started. Six months later, the patient has no symptoms, neither jaundice; the CT control shows a complete resolution of the pancreatic mass (Fig. 4). Only 32 patients with obstructive jaundice due to isolated pancreatic tuberculosis have been reported in detail so far [1–25]. Four mechanisms have been identified [26]: Isolated TB of the pancreas itself may cause pseudoneoplastic obstructive jaundice [1–13], as in our case; it may be secondary to TB lymphadenitis causing compression [26–28]; biliary stricture after biliary tuberculosis, mimicking cholangiocarcinoma [29–31]; and TB can create a retroperitoneal mass leading to biliary tree obstruction [32, 33]. Several studies have reported that common bile duct (CBD) and the pancreatic duct are usually normal in patients with pancreatic tuberculosis, even with a centrally located head mass [18, 34, 35]. However, in our case, both the ducts were dilated. A recent study described that pancreatic duct was dilated in approximately 80% patients of pancreatic adenocarcinoma, whereas it was dilated in 17% of patients with pancreatic tuberculosis [7]. F. Ozkan (*) : E. Bulbuloglu :M. Yuksel Faculty of Medicine, Department of Radiology, Kahramanmaras Sutcu Imam University, 46050 Kahramanmaras, Turkey e-mail: sanjiv@ummc.edu.myc