Ranka Štern-Padovan

Consensus statement on screening, diagnosis, classification and treatment of endemic (Balkan) nephropathy

Currently used diagnostic criteria in different endemic (Balkan) nephropathy (EN) centers involve different combinations of parameters, various cut-off values and many of them are not in agreement with proposed international guidelines. Leaders of EN centers began to address these problems at scientific meetings, and this paper is the outgrowth of those discussions. The main aim is to provide recommendations for clinical work on current knowledge and expertise. This document is developed for use by general physicians, nephrologists, urologist, public health experts and epidemiologist, and it is hoped that it will be adopted by responsible institutions in countries harboring EN. National medical providers should cover costs of screening and diagnostic procedures and treatment of EN patients with or without upper urothelial cancers.

Symptomatic cardiac metastases of breast cancer 27 years after mastectomy: a case report with literature review - pathophysiology of molecular mechanisms and metastatic pathways, clinical aspects, diagnostic procedures and treatment modalities

Metastases to the heart and pericardium are rare but more common than primary cardiac tumours and are generally associated with a rather poor prognosis. Most cases are clinically silent and are undiagnosed in vivo until the autopsy. We present a female patient with a 27-year-old history of an operated primary breast cancer who was presented with dyspnoea, paroxysmal nocturnal dyspnoea and orthopnoea. The clinical signs and symptoms aroused suspicion of congestive heart failure. However, the cardiac metastases were detected during a routine cardiologic evaluation and confirmed with computed tomography imaging. Additionally, this paper outlines the pathophysiology of molecular and clinical mechanisms involved in the metastatic spreading, clinical presentation, diagnostic procedures and treatment of heart metastases. The present case demonstrates that a complete surgical resection and systemic chemotherapy may result in a favourable outcome for many years. However, a lifelong medical follow-up, with the purpose of a detection of metastases, is highly recommended. We strongly call the attention of clinicians to the fact that during the follow-up of all cancer patients, such heart failure may be a harbinger of the secondary heart involvement.

Hemangioma of the Interatrial Septum: CT and MRI Features

Hemangioma of the heart is a rare primary benign tumor mainly appearing as enhancing, homogenous, well-circumscribed mass. We report a case of a 61-year-old asymptomatic woman, whose echocardiography showed a cardiac mass, which was described as the atypical myxoma of the right atrium. For further imaging, contrast-enhanced computed tomography and cardiac magnetic resonance imaging were undertaken, which showed a tumor located in the interatrial septum with imaging characteristics of hemangioma. In the literature, cardiac hemangioma is usually described as an intensely enhancing mass. In our opinion, early peripheral puddling of contrast material with filling in on delayed images is a typical pattern of its enhancement. This characteristic, in addition to high signal intensity on T2-weighted images, allows differentiation of a hemangioma from other benign and malignant tumors.

Leptomeningeal and intramedullary metastases of glioblastoma multiforme in a patient reoperated during adjuvant radiochemotherapy

Despite huge advances in medicine, glioblastoma multiforme (GBM) remains a highly lethal, fast-growing tumour that cannot be cured by currently available therapies. However, extracranial and extraneural dissemination of GBM is extremely rare, but is being recognised in different imaging studies. To date, the cause of the GBM metastatic spread still remains under discussion. It probably develops at the time of intracranial progression following a surgical procedure. According to other hypothesis, the metastases are a consequence of spontaneous tumour transdural extension or haematogenous dissemination. We present a case of a 59-year-old woman with symptomatic leptomeningeal and intramedullary metastases of GBM who has been previously surgically treated with primary subtotal resection and underwent a repeated surgery during adjuvant radiotherapy and chemotherapy with temozolomide. Today, the main goal of surgery and chemoradiotherapy is to prevent neurologic deterioration and improve health-related quality of life. With this paper, we want to present this rare entity and emphasise the importance of a multidisciplinary approach, a key function in the management of brain tumour patients. The prognosis is still very poor although prolongation of survival can be obtained. Finally, although rare, our case strongly suggests that clinicians should be familiar with the possibility of the extracranial spread of GBM because as treatment improvements provide better control of the primary tumour and improving survival, metastatic disease will be increasingly encountered.

Intracardiac shrapnel in a polytraumatized child

Penetrating cardiac trauma is a life-threatening condition and presents a therapeutic challenge for the surgeon. Additional multiple organ-system injuries, as are common in the setting of war, further complicate the management of such patients. We present the case of a 9-year-old girl who sustained multiple injuries from an unexploded artillery shell, resulting in a retained intracardiac shrapnel. Her cardiac pathology consisted of a shrapnel located in the interventricular septum accompanied by a pneumopericardium and a right-sided hemopneumothorax. The presentation and management of this patient are the subjects of this report.

Combined surgical and angioplasty management of coronary artery aneurysms including the giant form.

Coronary artery aneurysms are a rare form of coronary artery disease. Due to the rarity of these aneurysms, particularly of the giant form, it is difficult to establish a standardized treatment. We report the case of a 65-year-old man who presented with symptoms of an acute coronary syndrome. A posterobasal myocardial infarction was diagnosed with a giant right coronary artery aneurysm as the underlying pathology. Two aneurysms of the left anterior descending artery were also revealed. The management strategy included ligation of the giant aneurysm coupled with distal coronary artery bypass grafting of the right coronary artery. This was complemented with a delayed percutaneous coronary intervention of the left anterior descending artery aneurysms.

Cranial base kyphosis and the surface morphology of the anterior cranial fossa

We investigated the relationship between the surface morphology of the anterior cranial fossa and cranial base kyphosis (sphenoid angle) in 52 cephalometric craniograms. Among them there were 25 female (mean age 54 +/- 15; range 31-82) and 27 male (mean age 43 +/- 18, range 19-85) skulls. The sphenoid angle and the altitudes of the highest elevation of the endofrontal eminence (cranial base over the orbital roof in the anterior cranial fossa) and the middle point of the sphenoid planum, measured according to the Frankfort horizontal, were analysed using classical cephalometric and morphometric analysis. Statistical analysis was performed by Pearsons product-moment correlation and simple linear regression. The sphenoid angle ranged from 97 degrees to 137 degrees (mean 118 +/- 9 degrees). The altitude ratio of the highest elevation of the endofrontal eminence and the middle point of the sphenoid planum ranged from 1.5 to 1.8 (mean 1.6 +/- 0.1). A significant correlation was found between this ratio and the sphenoid angle (r = -0.65; p < 0.001; coefficient of determination = 0.43). The elevation of the endofrontal eminence relative to the sphenoid planum was higher in skulls with increased cranial base kyphosis, whereas reduced sphenoid angle was associated with an increase in the elevations of the endofrontal eminence. Although the sphenoid angle has a significant effect on the morphology of the anterior cranial fossa, only 43% of the variance in altitude of the endofrontal eminence is likely to be explained by its relationship with the sphenoid angle.

Should we use CT or MRI for detection and characterization of benign adrenal lesions

OBJECTIVES Computed tomography (CT) and magnetic resonance imaging (MRI) are the main imaging modalities used for analysis of adrenal lesions. We compared the ability of CT and MRI to detect and characterize benign adrenal lesions. PATIENTS AND METHODS Unenhanced abdominal CT and MRI were performed in 16 patients (age range 39-77), and reviewed by a radiologist with 6years of experience in abdominal imaging. The presence, number, size and structure of each mass were analyzed and compared between the two modalities. RESULTS There were 18 adrenal masses in 11 patients, four patients had adrenal hyperplasia (AH), whereas one patient had left-sided AH and right-sided adenoma. Ten masses were≥2cm in diameter, and were perfectly depicted using CT and all MRI techniques. There were nine masses with diameter<2cm detected by CT, three of them were missed using MRI. AH was detected in five patients using CT, but its mild form was missed in one patient using MRI. Four masses with attenuation values of>10Hounsfield units could not be characterized using unenhanced CT, but three of them were characterized using MRI. CONCLUSION CT has higher sensitivity for detection of small adrenal tumours and adrenal hyperplasia than MRI. MRI is an important tool in characterization of adrenal masses that could not be characterized using unenhanced CT.

Respiratory arrest due to hematoma caused by thyreocervical trunk branch laceration and confluence of sinuses perforation.

Introduction Central venous catheterization plays an important role in the treatment of emergency patients who require renal replacement therapy. Emergency patients with end-stage renal disease are at high risk for development of complications because of coagulation disorders, tissue, and organ changes due to uremia, anatomic variations, and obstruction of the large central veins. Complications associated with catheter placement can be mechanical, infectious, and thrombotic, and may occur during or following insertion of central venous catheterization which is a life-saving procedure for patients. Case presentation We report a case of respiratory arrest in a 76-year-old woman suffering from end-stage renal disease for 14 years, because of large soft tissue subcutaneous hematoma in the right upper thoracic outlet. The rapid development of hematoma was a consequence of arterial bleeding from the branch of the thyreocervical trunk. Laceration of the thyreocervical trunk branch during central venous catheterization is a rare complication. Later diagnostic images revealed catheter perforation of confluence of sinuses which also complicated this case. We briefly discuss signs, symptoms, and management of the patient. Conclusion Although arterial puncture of the carotid artery during the Seldinger technique is well-known life-threatening complication which can be recognized by light red pulsatile blood during aspiration, smaller arteries such as the thyreocervical trunk branch can be punctured during the procedure and lead to serious complications.

Massive retroperitoneal haemorrhage in a neonate with severe haemophilia A

A case report of neonate with severe haemophilia A and massive retroperitoneal haemorrhage.