Naman S. Desai

Pneumosinus dilatans: Is it more than an aesthetic concern?

BackgroundPneumosinus dilatans (PD) is a pathologic condition involving the hyperaeration of one or several of the paranasal sinuses that can lead to significant deformation of the overlying bone. Although the presenting complaint of patients with PD is most commonly aesthetic in nature, the condition has also been associated with intracranial tumors and several other serious conditions. Materials and MethodsA meta-analysis of all available clinical publications on the subject of PD was conducted. Patients were categorized on the basis of their sinus involvement. Associated conditions were also identified and categorized. The resulting data were used to further characterize the condition and describe previously unreported associations between PD and other conditions. ResultsTo date, a total of 123 cases of PD have been reported. The frontal sinus was the most commonly involved (63%), followed by the sphenoid sinus (24%), maxillary sinus (20%), and ethmoid sinus (19%). Of patients with symptomatic PD of the frontal sinus, 25% had intracranial pathology (meningioma or arachnoid cyst or orbital tumor). Patients with sphenoid PD had an 83% chance of having associated diagnosis of visual loss, meningioma, or arachnoid cyst, whereas patients with ethmoid PD had 83% chance of having associated diagnosis of exophthalmos, vision loss, or arachnoid cyst. ConclusionsAlthough the presenting complaint of patients with PD is most commonly aesthetic in nature, a significant percentage may have an associated diagnosis. Health care providers must be able to recognize the condition and carry out the appropriate clinical evaluation to avoid missing an associated diagnosis.

Aortic intramural hematoma and hepatic artery pseudoaneurysm: unusual complication following resuscitation

We present a case of a 71-year-old woman with an unusual complication of aortic intramural hematoma and hepatic artery pseudoaneurysm following cardiopulmonary resuscitation and thrombolysis done for sudden cardiopulmonary arrest and pulmonary embolism. Patient was on Warfarin treatment for a prior history of pulmonary embolism and experienced recurrent cardiac arrests, which finally resolved after intravenous administration of thrombolytic agents. However, follow-up computed tomographic angiography revealed descending aortic intramural hematoma with intramural blood pool and concomitant liver laceration with hepatic artery pseudoaneurysm. The patient received transcatheter embolization for the hepatic injury with careful follow-up for the aortic injury and was later discharged in a stable condition. Follow-up with subsequent computed tomographic angiography at a regular interval over 1 month shows near complete resolution of the intramural hematoma. The purpose of this report is to describe the rare complication of cardiopulmonary resuscitation and thrombolysis in the form of concomitant injuries of the aorta and liver. Although the use of thrombolytic agents in patients with pulmonary embolism and cardiac arrest is still a matter of debate, this case report supports the concept that thrombolysis has a role in restoring cardiopulmonary circulation, especially in recurrent cardiac arrests resulting from pulmonary embolism. On the other hand, this case also highlights the increased association of the bleeding-related complication as a result of vigorous efforts of cardiopulmonary resuscitation. Aggressive management with interventional radiology for hepatic pseudoaneurysm and conservative management of the aortic intramural hematoma resulted in favorable outcome for our patient.

Neuroimaging and renal ultrasound manifestations of Oculocerebrorenal syndrome of Lowe

Oculocerebrorenal syndrome of Lowe (OCRL) is a multisystem disorder characterized by congenital cataracts, hypotonia, and cognitive developmental delay with renal complications developing in the first few months of life. Clinical and laboratory findings of Lowe syndrome are well documented. Though a small number of case reports describe the neuroimaging features and the renal ultrasound manifestations of this disease, a comprehensive review of all the imaging manifestations has not been reported. The authors present a case of OCRL and review the neuroimaging and renal ultrasound manifestations of this multisystem disease.

Evidence‐based medicine in plastic surgery: where did it come from and where is it going?

Evidence‐based medicine, particularly randomized controlled trials, influence many of the daily decisions within plastic surgery as well as nearly every other medical specialty, and will continue to play a larger role in medicine in the future. Even though it is certainly not a new idea, evidence‐based medicine continues to remain a hot topic among members of the healthcare community. As evidence‐based medicine continues to grow and evolve, it is becoming more important for all physicians to understand the fundamentals of evidence‐based medicine: how evidence‐based medicine has changed, and how to successfully incorporate it into the daily practice of medicine.

Imaging in laparoscopic cholecystectomy—What a radiologist needs to know

Laparoscopic cholecystectomy is the gold standard treatment option for cholelithiasis. In order to properly assess for the complications related to the procedure, an understanding of the normal biliary anatomy, its variants and the normal postoperative imaging is essential. Radiologist must be aware of benefits and limitations of multiple imaging modalities in characterizing the complications of this procedure as each of these modalities have a critical role in evaluating a symptomatic post-cholecystectomy patient. The purpose of this article is describe the multi-modality imaging of normal biliary anatomy and its variants, as well as to illustrate the imaging features of biliary, vascular, cystic duct, infectious as well as miscellaneous complications of laparoscopic cholecystectomy. We focus on the information that the radiologist needs to know about the radiographic manifestations of potential complications of this procedure.

Correction of a Contour Deformity Associated With Frontal Pneumosinus Dilatans Using Surgical Navigation Technology

Pneumosinus dilatans (PD) is a pathologic hyperaeration of the paranasal sinuses of unknown etiology. Although benign itself, PD has been associated with a number of serious concomitant conditions, including meningioma, optic nerve tumors, and visual loss. Patients with PD often present with cosmetic complaints, desiring recontouring of the facial bones to achieve an improved appearance of the face. The present case illustrates one of the first attempts at intraoperative surgical navigation to map the frontal sinus during correction of the facial deformity caused by PD. The navigation device was used to give the surgical team real-time information during the case to prevent violation of the posterior table of the frontal sinus, allowing for facial bone contouring to occur in a more efficient and safer manner by way of accurate osteotomy placement with no wasted bone for reconstruction and no accidental intracranial involvement.

Gas-forming liver abscess in a patient with multi-organ failure: role of imaging and management.

Abstract We present an unusual case of air-containing liver abscess demonstrated on plain film and ultrasonography with successful treatment utilizing ultrasound-guided drainage in a patient in septic shock. Although surgical drainage is often indicated, ultrasound-guided catheter drainage along with supportive antibiotic therapy can be a safe treatment alternative in critical patients.

BWH emergency radiology—surgical correlation: sigmoid volvulus

We describe the radiological and intraoperative correlation of large bowel obstruction due to sigmoid volvulus in a 52-year-old female. The purpose of this article is to emphasize the importance of recognizing sigmoid volvulus as a cause of bowel obstruction in patients presenting with abdominal pain, since it can lead to bowel ischemia and necrosis.

Ganglion cyst causing finger dysesthesias.

The image presented below is of a 49-yr-old woman who presented with constant numbness and sharp stabbing shooting pains in the ring finger of the right hand. Physical examination revealed point tenderness along the base of the ring finger within the metacarpophalangeal (MCP) joint. Magnetic resonance imaging (MRI) demonstrated a 5-mm hyperintense T1 and short tau inversion recovery mass at the volar aspect of the MCP joint of the ring finger, proximal to the Webspace, abutting the palmar cutaneous branch of ulnar nerve (Fig. 1). The mass did not seem to be contiguous with the nerve sheath. Differential diagnosis of this mass included a ganglion cyst, nerve sheath tumor, and giant cell tumor of a tendon sheath. The patient was referred to plastic surgery and scheduled for exploration and removal of the mass. The mass was excised and confirmed to be a ganglion cyst on pathology. At 1-mo follow-up, the patient stated her numbness, and pain had significantly subsided after ganglion cyst removal. After 3-mo follow-up, the patient remains asymptomatic. Ganglion cysts are fluid-filled lesions, without an epithelial lining, caused by mucoid degeneration of joint capsule, tendon, or tendon sheath. These cysts can occur anywhere in the body and are often seen in the knee, in the hand, and even in the spine. Proposed etiologies include injury or overuse of the joints. The fluid in the cyst is similar to synovial fluid. Typically, ganglion cysts are incidental findings, and patients with them are asymptomatic. However, depending on the location and size of the cyst, a variety of symptoms can occur. Uncommonly, the cyst can impinge and cause nerve compression, resulting in motor and/or sensory loss. The treatment of MCP ganglion cysts includes aspiration or excision; however, excision has shown to be more efficacious than aspiration at this location. Numbness and tingling in the hand is a common chief complaint encountered by physiatrists. A peripheral neuropathy is an uncommon etiology, unless the symptoms are diffuse in nature arising from a systemic disease such as diabetes or in a typical nerve distribution as seen in carpal tunnel syndrome. Rarely, a mass or cyst can be identified causing compression, as seen in this patient. It is of utmost importance for the physician to recognize a ganglion cyst as the cause to direct appropriate care and prevent further injury. Had this patient’s condition been misidentified, the cyst could have caused irreversible sensory damage. We report this case to recommend consideration of hand MRI to rule out ganglion cyst if a palpable mass and/or point tenderness of a joint are present on physical examination.

Diffuse cutaneous allergic reaction to Dermabond.

Wound closure with 2-octyl cyanoacrylate (Dermabond; Ethicon, Somerville, New Jersey USA) has recently increased in popularity across a wide spectrum of physicians ranging from surgeons to emergency medicine practitioners. Generally, very few complications are associated with Dermabond and are usually related to application techniques. Uncommonly, patients present with allergic reactions to the adhesive compounds; these allergies are often misdiagnosed as cellulitis or another infectious process, and are incorrectly treated. This report describes a rare case of a diffuse cutaneous allergic reaction to Dermabond following its use to close a surgical incision, its prompt identification, and treatment after presentation to an emergency department.