Selim Kervancioglu

Assessment of mastoid air cell size versus sigmoid sinus variables with a tomography-assisted digital image processing program and morphometry

We assessed the mastoid air cell size and variables of the sigmoid sinus in healthy ears and ears with chronic otitis media (COM). Thirty-eight patients with unilateral COM [15 with cholesteatoma (COM/+) and 23 without cholesteatoma (COM/−)], and 20 subjects with healthy ears, were included in the study. Assessment was performed using a quantitative digital image processing computed tomography (CT) program, and the volume of the mastoid bone was measured using the morphometric method of Cavalieri. In both COM/+ and COM/− patients the sigmoid to suprameatal spine distance and mastoid size were greater on the healthy side than on the diseased side (p<0.05). The distance and area were significantly greater in the healthy control subjects than in either the healthy or the diseased ears of the patients with COM (p<0.05). In the healthy ears of COM patients, there was significant correlation between the sigmoid to suprameatal spine distance and air cell size and mastoid volume (p<0.05). In the diseased ears of COM patients, this correlation was absent (p>0.05). The sigmoid sinus shape was of the half-moon type (62%), protrusive type (22%) and saucer type (16%). The digital image processing CT program allowed us to estimate the individual area of the air and soft tissue filled mastoid air cells. The mastoid size in both intact and disease ears of COM patients was smaller than in the healthy controls. The mastoid size may be determined genetically. However, environmental factors such as infection may also affect the mastoid size. Therefore, both genetic and environmental factors may be related to COM as far as the size of the mastoid air cells is concerned.

Simple testicular cyst: A rare cause of scrotal swelling in infancy

A simple testicular cyst is a rare cause of scrotal swelling in infancy. Only 10 cases have been reported in children less than two years of age in the English literature. Pathogenesis of the lesion is unclear. Preoperative diagnosis is possible using ultrasonography (US). Testis‐sparing surgery with simple enucleation of the cyst has a favorable outcome. We report two patients with a simple testicular cyst, who were 9 and 8 months of age. The first case was referred with a presumptive diagnosis of hydrocele, and the second infant was admitted with a history of testicular swelling. Ultrasonography provided accurate preoperative diagnosis in both of the cases. The patients were successfully treated with testis‐sparing surgery with outstanding long‐term results. This unusual lesion of infancy should be considered in the differential diagnosis of a scrotal mass.

Radiological Findings and Outcomes of Bronchial Artery Embolization in Cryptogenic Hemoptysis

Management of cryptogenic massive hemoptysis is difficult, and conservative treatment may be inadequate to stop the hemorrhage. Surgery is not a reasonable option because there is no underlying identifiable pathology. This study aimed to investigate the radiologic findings and bronchial artery embolization outcomes in cryptogenic hemoptysis, and to compare the results with non-cryptogenic hemoptysis. We evaluated 26 patients with cryptogenic hemoptysis and 152 patients with non-cryptogenic hemoptysis. A comparison of the bronchial artery abnormalities between the cryptogenic and non-cryptogenic hemoptysis groups showed that only extravasation was more statistically significant in the cryptogenic hemoptysis group than in the non-cryptogenic hemoptysis group, while the other bronchial artery abnormalities, such as bronchial artery dilatation, hypervascularity, and bronchial-to-pulmonary shunting, showed no significant difference between groups. Involvement of the non-bronchial systemic artery was significantly greater in the non-cryptogenic hemoptysis group than in the cryptogenic hemoptysis group. While 69.2% of patients with cryptogenic hemoptysis also had hypervascularity in the contralateral bronchial arteries and/or ipsilateral bronchial artery branches other than the bleeding lobar branches, this finding was not detected in non-cryptogenic hemoptysis. Embolization was performed on all patients using polyvinyl alcohol particles of 355-500 µm. Hemoptysis ceased in all patients immediately after embolization. While recurrence of hemoptysis showed no statistically significant difference between the cryptogenic and non-cryptogenic hemoptysis groups, it was mild in cryptogenic hemoptysis in contrast to mostly severe in non-cryptogenic hemoptysis. Transarterial embolization is a safe and effective technique to manage cryptogenic hemoptysis.

Large rectus muscle hematoma with intraperitoneal bleeding and fatal abdominal compartment syndrome complicating anticoagulant therapy.

A 46-year-old woman who underwent mitral and aortic valve replacement 3 months previously reported sudden onset of abdominal pain while taking warfarin and enoxaparin because of poorly controlled international normalized ratio. She had no history of abdominal trauma. The patient was an obese woman who appeared fatigued. On physical examination, the abdomen was massively distended and a mass was felt in the right side of the abdomen. Both palpebral conjunctivae were pale. Except for tachycardia, the remainder of the physical examination, including the heart and lungs, was normal. She was taking enoxaparin with coumadin 5 mg daily for 5 days. The hemoglobin level was 4.7 g/dL, and the prothrombin time was 120.6 seconds (international normalized ratio was 21). Computed tomography showed intraperitoneal bleeding, pressed bladder, large right rectus muscle hematoma, and infiltrations suggesting bleeding into the left rectus muscle, subcutaneous fat tissues, and the bilateral abdominal wall (Figs. 1 and 2). Anticoagulant treatment was discontinued. We gave her 2 units of packed fresh-frozen plasma and red cells. On the following day, abdominal distention persisted. Urine output indicated oliguria with difficulty in ventilation. The hemoglobin level was 7.5 g/dL, and the prothrombin time was 14 seconds (international normalized ratio was 1.18). The patient died suddenly despite vigorous supportive care. We could not obtain approval for postmortem examination. Because abdominal compartment syndrome during the anticoagulation period is reported rarely in the literature, we decided to share this case to indicate potential errors in diagnosis. DISCUSSION

Carotid and brachial intima-media thickness, arterial diameter and resistivity indices in aortic regurgitation.

Purpose: To evaluate signs of atherosclerosis in carotid and brachial arteries in patients with aortic regurgitation (AR). Material and Methods: The sonograms of 33 patients (24 M and 9 F, 16-67 years old) with pure AR and 20 control subjects (15 M and 5 F, 19-49 years old) were evaluated. Patients with AR and control subjects completed a questionnaire with SMART risk score based on pre-existing vascular disease and risk factors. AR patients and control subjects were assessed for intima-media thickness (IMT) of common carotid artery (CCA), IMT of brachial artery (BA), CCA diameter, and resistivity index (RI) of CCA and RI of internal carotid artery (ICA). Results: There was no significant difference in the cardiovascular risk score between the patients with AR and control subjects. All measured parameters were statistically significantly greater in AR patients than in control subjects with P values 0.0233 for CCA IMT, 0.0034 for BA IMT, 0.0429 for CCA diameter, <0.0001 for CCA RI, and 0.0002 for ICA RI. Conclusion: AR is associated with signs generally considered to represent atherosclerosis, such as increased CCA and BA IMT, CCA diameter, and CCA and ICA RI.

Reflex Anuria After Renal Tumor Embolization

We report a case of reflex anuria after transarterial embolization of a renal tumor. Anuria developed immediately after embolization and resolved 74 hr following the procedure. We postulate that reflux anuria in our case was related to mechanoreceptors, chemoreceptors, or both, as these are stimulated by the occluded blood vessels, ischemia, and edema of the normal renal tissue of an embolized kidney.

Duplex sonography of the carotid arteries in patients with pure aortic regurgitation: pulse waveform and hemodynamic changes and a new indicator of the severity of aortic regurgitation.

Purpose: To determine the changes of multiple hemodynamic parameters and pulse wave contour in pure aortic regurgitation (AR) and to present a new indicator of the severity of AR (shrink ratio of proximal common carotid artery). Material and Methods: The sonograms of 42 patients (31 M, 11 F; 16–68 years) with pure AR and 18 control subjects (15 M, 3 F; 20–47 years) were assessed for velocities and indices, and change of pulse wave contour (bisferious pattern, zero level and retrograde diastolic flow) in each carotid artery. Shrink ratio (maximum diameter–minimum diameter/maximum diameter) of each proximal common carotid artery was calculated. Results: Bisferious waveforms seen in patients with AR grade 1, grade 2, and grade 3–4 were 66%, 83%, and 88%, respectively. Diastolic reversed flow was determined in 7 (39%) of 18 patients with AR grade 3–4. Three patients (25%) with AR grade 2 and 4 patients (22%) with AR grade 3–4 had zero level diastolic flow in the common carotid artery. Statistically significant changes of decreased end‐diastolic velocity, increased peak systolic velocity/end‐diastolic velocity, resistivity index, and pulsatility index were revealed, especially in AR grade 3–4 compared to controls. Significantly increased shrink ratio was seen only in AR grade 3–4. Conclusion: Increased shrink ratio or changes in hemodynamics or pulse waveform can be used in recognition of AR.

Takayasu arteritis: association with focal segmental glomerulosclerosis

We herein report on a 29-year-old woman who presented with edema and proteinuria. In light of her blood pressure differences and, finally, with the angiographic findings, Takayasu arteritis (TA) was the diagnosis. Renal biopsy showed focal segmental glomerulosclerosis (FSGS) and other possible etiologic alternatives were excluded. This was a very rare association and we could not find any other cases reported on TA accompanied with FSGS before. A poor treatment response was observed at the end of a 1-year therapy.

Bronchial Artery Embolization in the Management of Pulmonary Parenchymal Endometriosis with Hemoptysis

Pulmonary parenchymal endometriosis is extremely rare and usually manifests itself with a recurrent hemoptysis associated with the menstrual cycle. The therapies proposed for women with endometriosis consist of medical treatments and surgery. Bronchial artery embolization has become a well-established and minimally invasive treatment modality for hemoptysis, and to the best of our knowledge, it has not been reported in pulmonary endometriosis. We report a case of pulmonary parenchymal endometriosis treated with embolotheraphy for hemoptysis.

Traumatic bilateral vertebral artery dissection at the dural entry point site in a 10-year-old boy

We present a 10-year-old boy who was admitted with headache and neurological symptoms after a trauma in the schoolyard. Cerebral MRI revealed an extensive ischaemia in the bilateral cerebellar hemispheres, left middle cerebellar peduncle, and right vermis. Digital substraction angiography demonstrated bilateral vertebral artery dissections at the dural entry point site. This case emphasises the management of patients with traumatic vertebral artery dissection.