Sedat Giray Kandemirli

Preliminary experience with precipitating hydrophobic injectable liquid in brain arteriovenous malformations

Advancement in microcatheter design and emergence of new embolic agents offer better results in endovascular treatment of brain arteriovenous malformations (AVMs). Precipitating hydrophobic injectable liquid (PHIL) (Microvention) is a newly introduced dimethyl sulfoxide-based embolic agent for endovascular use. Herein, we present three patients who underwent endovascular treatment of brain AVMs with PHIL, followed by surgical resection. Endovascular features and same-day surgical handling of the new embolic agent PHIL are presented along with histopathologic changes in the acute stage in brain AVMs are presented, and its major differences from Onyx. In our series, PHIL had moderate inflammatory reaction in the acute stage without any associated angionecrosis that is different than Onyx which cause mild inflammatory reaction with angionecrosis. Smallest vessel containing PHIL was 2.9 μm compared to 5 μm with Onyx, which suggests better penetration.

Ex Vivo Assessment of Sentinel Lymph Nodes in Breast Cancer Using Shear Wave Elastography.

Axillary lymph node status is one of the important prognostic factors in early‐stage breast cancer. Despite the combined use of sonography, fine‐needle aspiration, and sentinel lymph node (SLN) dissection, there is a gap between the potential effectiveness of those techniques and current success to determine the axillary lymph node status. The main aim of this study was to evaluate the baseline accuracy of shear wave elastography for differentiation of benign versus malignant SLNs in an ex vivo artifact‐free environment.

Perianal Fistula With and Without Abscess: Assessment of Fistula Activity Using Diffusion-Weighted Magnetic Resonance Imaging

Background: Magnetic resonance imaging (MRI) is highly accurate for the depiction of both the primary tract of fistula and abscesses, in patients with perianal disease. In addition, MRI can be used to evaluate the activity of fistulas, which is a significant factor for determining the therapeutic strategy. Objectives: This study aimed to determine the usefulness of diffusion-weighted (DW) MRI for assessing activity and visibility of perianal fistula. Patients and Methods: Fifty-three patients with 56 perianal fistulas were included in the current retrospective study. The T2-weighted imaging (T2WI) and DWMRI were performed and apparent diffusion coefficient (ADC) values of fistulas were measured. Fistulas were classified into two groups: only perianal fistulas and fistulas accompanied by abscess. Fistulas were also classified into two groups, based on clinical findings: positive inflammatory activity (PIA) and negative inflammatory activity (NIA). Results: Mean ADC value (mm2/s) of PIA group was significantly lower than that of NIA group, regarding lesions in patients with abscess-associated fistulas (1.371 × 10-3 ± 0.168 × 10-3 vs. 1.586 × 10-3 ± 0.136 × 10-3; P = 0.036). No statistically significant difference was found in mean ADC values between PIA and NIA groups, in patients with only perianal fistulas (P = 0.507). Perianal fistula visibility was greater with combined evaluation of T2WI and DWMRI than with T2WI, for two reviewers (P = 0.046 and P = 0.014). Conclusion: The DWMRI is a useful technique for evaluating activity of fistulas with abscess. Perianal fistula visibility is greater with combined T2WI and DWMRI than T2WI alone.

Intrathoracic Gossypiboma After Spinal Operation

Gossypiboma is a rare surgical complication, with an estimated incidence of 1/1,000 to 1/10,000 per operation. Gossypiboma is an aseptic foreign body reaction with fibrosis and granuloma formation secondary to retained surgical sponges. The main sites of involvement are the abdomen, pelvis, and thorax. Intrathoracic gossypiboma poses diagnostic challenges because the surgical history may include extrathoracic operations and imaging findings can be atypical. We describe a patient with intrathoracic gossypiboma secondary to posterior vertebral body screw fixation after a traumatic injury. This case illustrates that thoracotomy history may not necessarily be found in intrathoracic gossypiboma.

Primary angiosarcoma of the breast: Diagnosis with computer-assisted MRI-guided radio-guided occult lesion localization (ROLL) technique.

Primary angiosarcoma of the breast is a rare type of breast cancer that represents approximately 0.04% of all primary breast tumors. We report herein a case of primary breast angiosarcoma that was only visible on magnetic resonance imaging (MRI) examination. The patient presented with a palpable right breast lump that was not visible either on ultrasonography and mammography. MRI showed a lesion of the right breast that presented washout kinetics. MRI-guided biopsy allowed histopathological examination of the tumor that was further confirmed as primary angiosarcoma. Subsequently, MRI guided ROLL (radio-guided occult lesion localization) technique was used for localizing the lesion prior to surgery.

Evaluation of median nerve by shear wave elastography and diffusion tensor imaging in carpal tunnel syndrome

PURPOSE The aim of the current study is to investigate the diagnostic role of shear-wave elastography and diffusion tensor imaging in patients with carpal tunnel syndrome. MATERIAL AND METHODS The study included a total of 77 wrists; 18 normal, 35 wrists with mild, 9 wrists with moderate and 15 wrists with severe carpal tunnel syndrome. Elastography of the median nerve was performed by defining the boundaries of a segment of the nerve at sagittal plane at the level of proximal carpal row. Additionally, the cross-sectional area of the median nerve was evaluated. Fractional anisotropy and apparent diffusion coefficient measurements were carried out by placing region-of-interest at three levels: at pisiform bone (carpal tunnel inlet), mid carpal tunnel, and hook of hamate (carpal tunnel outlet). RESULTS Patients with carpal tunnel syndrome had higher elasticity values of median nerve (53.0 kPa; IQR 40.8-77.0 kPa) compared to control subjects. (36.8 kPa; IQR 31.0-39.9 kPa) Patients with moderate-severe carpal tunnel syndrome had higher elasticity values (82 kPa; IQR 64.0-95.5 kPa) compared to patients with mild carpal tunnel syndrome. (44 kPa; IQR 32.5-59.5 kPa) Patients with carpal tunnel syndrome had lower fractional anisotropy at mid-carpal level (0.382; IQR 0.330-0.495) compared to the control group. (0.494; IQR 0.434-0.537) Patients with moderate-severe carpal tunnel syndrome had lower fractional anisotropy values (0.366; IQR 0.331-0.407) and higher apparent diffusion coefficient values (1.509 mm2/s; IQR 1.374-1.733 mm2/s) compared to patients with mild carpal tunnel syndrome. (0,423; IQR 0.324-0.526 and 1.293 mm2/s; IQR 0.967-1.514 mm2/s) CONCLUSION: Shear-wave elastography and diffusion tensor imaging are helpful imaging modalities in diagnosing carpal tunnel syndrome and assessing its severity.

Amyloid Goiter: A Diagnosis to Consider in Diffuse Fatty Infiltration of the Thyroid

An amyloid goiter is the presence of amyloid protein in the thyroid in sufficient amounts to produce enlargement of the gland, accompanied by fat deposition of varying extents. It can be seen in long‐standing inflammatory disorders such as familial Mediterranean fever. Imaging findings depend on the amount of fat and amyloid deposition; however, the main imaging finding is diffuse fatty infiltration of the thyroid. Herein, the multimodality imaging features in 3 cases of amyloid goiters secondary to familial Mediterranean fever are presented.

In vivo assessment of placental elasticity in intrauterine growth restriction by shear-wave elastography

PURPOSE In this study, we evaluated the placental elasticity in vivo by shear-wave elastography in pregnant women under follow-up for intrauterine growth restriction (IUGR) and compared the elasticity values to normal pregnancies. MATERIAL AND METHODS This prospective study included 42 pregnant women with a possible diagnosis of intrauterine growth restriction based on obstetrical grayscale and Doppler ultrasonography and 42 women with a normal pregnancy during the 2nd and 3rd trimester. During follow-up examinations, seven fetuses showed an increased growth and were delivered with a birth-weight above the 10 percentile. However, for statistical purposes we included these seven patients in the IUGR group due to prospective nature of the study. All patients initially underwent obstetrical grayscale and Doppler ultrasonography with measurement of resistivity and pulsatility indices from uterine arteries. Subsequently, elasticity values of the peripheral and central part of the placentas from fetal and maternal surfaces were measured by shear-wave elastography. Following delivery, Apgar scores at 1st and 5th minute, birth weight were collected. For statistical analysis, Mann-Whitney U test was used. ROC curves were plotted and cut-off values for elasticity values were analyzed. RESULTS Median elasticity values of the central part of the placentas from maternal (28kPa vs 6kPa) and fetal sides (21.5kPa vs 5kPa) were significantly higher in IUGR pregnancies compared to the control group (p<0.001). Similarly, median elasticity values of peripheral part of placentas from maternal (22kPa vs 5.35kPa) and fetal sides (22.5kPa vs 5.3kPa) were significantly higher in IUGR pregnancies compared to the control group (p<0.001). CONCLUSION Placental stiffness values are significantly higher in patients with IUGR. Shear-wave elastography can be used as a non-invasive, complementary method to gray-scale and Doppler ultrasound for diagnosing IUGR.

Vein of foramen caecum: imaging findings

Vein of foramen caecum has been classically described as a vein that connects nasal mucosa to the superior sagittal sinus in classic anatomy textbooks. However, its existence is controversial in literature. Herein, we demonstrated computed tomography and contrast enhanced magnetic resonance imaging findings of a tubular vascular structure extending to nasal mucosa and superior sagittal sinus.

Detection of wall and neck calcification of unruptured intracranial aneurysms with flat-detector computed tomography.

Object Microsurgical clipping is a widely used surgical technique in intracranial aneurysm treatment. It can be difficult in large sized aneurysms, and those with wide necks, thick walls and calcification located in the vicinity of the neck. This study reviewed calcification of the intracranial aneurysm wall and its relation to patient age, gender, location and size of the aneurysm. A possible cut-off value after which the aneurysm calcification rate increases was also investigated to classify patients’ risk factors for microclipping. Methods A retrospective review of all unruptured intracranial aneurysms that underwent digital subtraction angiography at a single centre was performed. Flat-detector computed tomography images of the aneurysm were reviewed for aneurysm location, size and calcification. The independent samples t test and χ2 test were used to show the relation between aneurysm wall calcification and patient age, gender, aneurysm localisation and size. Results None of the reviewed factors were statistically significantly related to aneurysm calcification except aneurysm size (P < 0.01). Receiver operating characteristic curves showed aneurysms greater than 10.5 mm could be predicted to be calcified with a sensitivity of 80% and specificity of 63%. Conclusion In this study, the presence of calcification was related to aneurysm size. Larger aneurysms were more likely to be calcified. Aneurysms greater than 10.5 mm should be further investigated with a modality such as flat-detector computed tomography to show the calcification in detail, especially if microclipping is considered.