Serkan Senol

Value of multislice computed tomography in the diagnosis of acute mesenteric ischemia

OBJECTIVE To define the value of multislice computed tomography (CT) in the diagnosis of acute mesenteric ischemia (AMI). MATERIALS AND METHODS Two hundred patients (age range: 20-92 years) who were referred to the emergency CT department with a clinical suspicion of AMI were prospectively included in the study. CT examinations were performed with a multislice (16) CT scanner and the protocol included pre-contrast, arterial and venous phase acquisitions. Images were evaluated by using multiplanar reconstruction, maximum intensity projection and volume-rendering techniques at the CT workstation. RESULTS Ninety-four patients (47%) underwent surgery for AMI or for other causes of acute abdominal pain. One hundred-six patients (53%) were followed conservatively according to clinical, radiologic and laboratory findings. Of the 94 patients who underwent surgery, 49 (25%) were found to have AMI. All of these 49 patients with a proven AMI diagnosis were diagnosed with CT. In the other 45 patients who underwent surgery, CT findings were negative for AMI. None of the patients, who were followed conservatively, were eventually diagnosed as having AMI except 1 patient. This patient was unfit for surgery although his clinical and radiologic findings were consistent with AMI and died in 3 days. The sensitivity and specificity values of CT for the detection of AMI were calculated to be 100% for each. CONCLUSIONS Multislice CT is an effective imaging technique for the diagnosis of AMI with excellent sensitivity and specificity values.

EXTENSIVE INVESTIGATION OF 114 PATIENTS WITH SHEEHAN'S SYNDROME: A CONTINUING DISORDER

OBJECTIVE Sheehans syndrome (SS) is a well-known cause of hypopituitarism resulting from postpartum pituitary necrosis. Because of its rarity in Western society, its diagnosis is often overlooked. We aimed to investigate the clinical, laboratory, and radiological aspects of SS in a large number of patients. STUDY DESIGN A retrospective assessment of the medical records of 114 patients with SS was conducted. In addition, sella turcica volumes of 29 healthy women were compared with those of patients by magnetic resonance imaging examinations. RESULTS The mean period of diagnostic delay was 19.7 years in patients with SS. It was found that 52.6% of patients had nonspecific complaints, 30.7% had complaints related to adrenal insufficiency, and 9.6% had complaints related to hypogonadism when diagnosed. At the time of diagnosis, 55.3% of the patients had panhypopituitarism, while 44.7% had partial hypopituitarism. The number of deficient hormones was found to be increased over the years. None of the patients whose basal prolactin was below 4.0 ng/ml had adequate prolactin responses to TRH test, while all patients whose basal prolactin was above 7.8 ng/ml had adequate responses. Mean sella volume was found to be significantly lower in the SS group (340.5±214 mm(3)) than that in the healthy group (602.5±192 mm(3)). CONCLUSIONS SS is a common cause of hypopituitarism in underdeveloped and developing countries. The main reasons for diagnostic delay seem to be the high frequency of patients with nonspecific complaints and neglect of SS. In addition, the TRH stimulation test was found to have a high sensitivity and specificity to recognize PRL deficiency. Furthermore, small sella size may have an important contributing role in the etiopathogenesis of SS.

Preferences of referring physicians regarding the role of radiologists as direct communicators of test results.

PURPOSE Currently, there is a growing need for patient-centered radiology in which radiologists communicate with patients directly. The aim of this study is to investigate the preferences of referring physicians (RPs) regarding direct communication between radiologists and patients. METHODS This study was conducted in a single academic hospital using a survey form. The survey items investigated the preferences of RPs regarding: 1. who should be the communicator of test results when a patient with abnormal findings requests information (the options were the radiologist; another health professional with communication skills training (CST); and the RP with CST); and 2. how the communication activity should be conducted if the radiologist is obliged (or chooses) to communicate with the patient directly (the options were that the disclosure should be limited to the findings in the radiology report; the radiologist should emphasize that the RP is the primary physician; and the communication activity should be conducted in accordance with guidelines established by consensus). The respondents were 101 RPs from various fields of specialty; they were asked to rate the items using a 5-point Likert scale. The effects of age, sex, field of specialty (surgical vs. nonsurgical), and total years of experience as a medical specialist on the ratings were statistically compared. RESULTS Most RPs preferred that the radiologist transmit the information to the RP without communicating directly with the patient (89.1%). Although 69.3% of the RPs declared that health professionals with CST have priority in communication, 86.1% declared that the RP should be the person who received CST. If the radiologist communicates with patients directly, the RPs favored that 1. the disclosure should be limited to the findings in the radiology report (95%); 2. the communication activity should include an emphasis on the RP as the patients primary agent (84.1%); and 3. communication should be conducted in accordance with guidelines established by consensus (73.2%). The percentage of strong opinions did not change significantly with regard to age, sex, field of specialty, or total years of experience, except that surgeons expressed strong disagreement with delegating the communication activity to another health professional who received CST (χ² = 9.9; P = 0.042). CONCLUSION These findings may serve as a basis to implement institutional and national policies for patient-centered radiology.

Vertebrojugular arteriovenous fistula and pseudoaneurysm formation due to penetrating vertebral artery injury: case report and review of the literature.

Vertebral artery injury including thrombosis, arteriovenous fistula (AVF), pseudo-aneurysm and hemorrhage may be iatrogenic or due to penetrating or blunt trauma. Although mostly asymptomatic, vertebral artery injury may also present with vertebrobasilar insufficiency findings, cephalgia, radicular pain or myelopathy due to blockade of arterial flow, arterial steal phenomenon and venous hypertension. The gold standard for diagnosis is digital subtraction angiography (DSA). Doppler ultrasonography, magnetic resonance-angiography and computerized tomography-angiography are also helpful. Endovascular treatment is now used more commonly. We present a case with sharp bread knife injury of the vertebral artery that was also complicated with a vertebrojugular fistula and pseudo-aneurysm together with the diagnostic and management options and a review of the current literature.

Unusual Reason of Groin Pain: Pelvic Polycystic Kidney Disease

To the Editor: A 42-year-old woman was admitted to our hospital with the complaints of intermittent groin and low back pain for 6 months. The patient had been under losartan treatment due to hypertension for 2 years. On admission, she was fully oriented and hemodynamically stable. Physical examination revealed a heterogenous mass that was palpable over the left lower abdomen and suprapubic region. The left groin was painful with palpation as well. Laboratory test results showed that the hemoglobin level was 12.5 g/dL, blood urea nitrogen was 24 mg/dL, and creatinine level was 0.9 mg/dL; urine analysis revealed 2 positive red blood cells, negative white blood cells, and no casts. Urine culture test results were negative. Clotting tests were all within the normal range. Abdominal ultrasound showed that the patient had polycystic kidneys without kidney stones and ectasia; however, the left kidney was located in the pelvis. Magnetic resonance imaging revealed multiple renal cysts in the right kidney, absence of the left kidney, and an ectopic kidney with multiple cysts in the true pelvis (Figure 1). Autosomal-dominant polycystic kidney disease (ADPKD) may present with acute or chronic pain. Chronic pain is generally due to enlarged cystic kidneys causing stretching of the capsule or traction of the renal pedicle. Mechanical pain also occurs due to enlarged cysts that resulted in lumbar lordosis and back pain. Paraspinal muscle group hypertrophy has been observed in ADPKD patients with back pain. In fact, groin pain is not a usual complaint in patients with ADPKD in the absence of kidney stones or urinary tract infection. In this case, we presented a patient with groin pain with ADPKD and pelvic left kidney localization to diagnose the disease. There were only 2 cases in the literature with pelvic polycystic kidney disease. In conclusion, we suggest that groin pain—with or without urinary tract infection or kidney stones—should alert the clinician to the possible presence of an ectopic organ in the pelvic area.

SURGICAL STRATEGIES IN SPONDYLODISCITIS DUE TO LUMBAR DISC SURGERY.

AIM Despite different surgical treatment protocols at different centers for spondylodiscitis due to lumbar surgery, there is no consensus on its surgical indications. In this study, we aimed to clarify the steps to be followed in the management and treatment of postoperative spondylodiscitis. MATERIAL AND METHODS The data of 20 cases with postoperative spondylodiscitis were evaluated. C-reactive protein (CRP) was used for diagnosis and follow-up. According to culture results of the infected material obtained from the operated cases, appropriate antibiotic treatment was initiated. In non-operated cases, parenteral empirical antibiotic treatment was implemented. Surgical treatment was planned for cases with clinical and radiological instability, abscess on imaging and those who were nonrespondent to empirical antibiotic treatment. For the cases that clinically recovered and had normal CRP levels, oral antibiotic treatment was continued after parenteral antibiotic treatment. RESULTS Of the cases; 13 were male (65%) and 7 were femals (35%). The mean age was 56.3 years (32-74). The most prevalent complaints in referral were waist and leg pain. Except one, all cases had increased CRP levels. All patients had spondylodiscitis on magnetic resonance imaging. Seven had radiological and clinical instability and 3 had epidural abscess. The most commonly growing microorganism in culture was Staphylococcus aureus. Surgical treatment was applied to seven cases and medical treatment to 13 cases. CONCLUSION In cases with waist pain in the postoperative period, the first potential diagnosis to be considered is spondylodiscitis. Surgical treatment should be implemented for cases resistant to empirical antibiotic treatment, with abscess on imaging, or with lumbar instability.

An Unusual Case of Laryngeal Paraganglioma in a Patient with Carotid Body Paraganglioma: Multimodality Imaging Findings

Multiple paragangliomas of the head and neck are rare conditions. Carotid paragangliomas are most common multiple paragangliomas. Laryngeal paragangliomas are very rare neuroendocrine tumors and usually are seen as symptomatic solitary lesions. We present multimodality imaging findings of incidentally detected laryngeal paraganglioma in a woman with synchronous carotid body paraganglioma and positive family history. To the best of our knowledge, this is the first case of laryngeal and carotid body paragangliomas in a patient with positive family history. Radiologists should keep in mind that paragangliomas may occur in various locations as multiple tumors.

A rare incidence of metal artifact on MRI

We present a rare example of metal artifacts observed in magnetic resonance imaging (MRI). A 32-year-old male patient was referred to our radiology department for brain MRI. T1-weighted spin echo, T2-weighted turbo spin echo, diffusion-weighted, and fluid attenuated inversion recovery (FLAIR) images were acquired on a 1.5 Tesla scanner (Magnetom Aera, Siemens Erlangen, Germany). Unusual circular shapes resembling water bubbles were observed at the vertex on the conventional MR images ( Figure 1 ). The patient was contacted if he had anything on his head, such as hair gel, etc. during MR imaging. It was found out that the patient was a metal worker who cuts metals and shapes things out of them and there were residual metal dusts on his scalp despite he had a shower before coming to the hospital.

Flow void artifact mimicking aneurysm in the anterior communicating artery region on T1- and T2-weighted images.

We observed an unusual magnetic resonance imaging (MRI) artifact on T1- and T2-weighted sequences resembling an aneurysm in the region of anterior communicating artery (ACoA) in a child patient. A 6-year-old patient with neurofibromatosis underwent brain MRI for a follow-up investigation. Imaging was performed at 1.5 T scanner (Philips Gyroscan Intera, Best, Netherlands). The protocol consisted of axial and coronal T2-weighted turbo spin echo images [repetition time (TR) =4,616 ms, echo time (TE) =100 ms, slice thickness =5 mm, spacing between slices =1 mm, field of view (FOV) =260 mm × 182 mm, acquisition matrix: 228×150, echo train length =15], and 3D T1-weighted turbo field echo [TR =8.27 ms, TE =3.83 ms, flip angle =8°, FOV =256 mm × 192 mm, acquisition matrix: 116×93, Sensitivity Encoding (SENSE) acceleration factor (out-of-plane) =3]. Signal void near ACoA resembling an aneurysm was observed on axial and coronal T2-weighted and T1-weighted images ( Figure 1A-C ). The signal void was initially interpreted as an aneurysm based on its appearance on three sequences. Time-of-flight (TOF) angiography was requested and performed on a different scanner (1.5 T, Magnetom Aera, Siemens, Erlangen, Germany) together with conventional MRI. The second MRI showed no evidence of aneurysm ( Figure 1D-F ) indicating the findings in the first acquisition to be an artifact. What is interesting about this artifact is its appearance on three sequences (T2 axial, T2 coronal, and 3D T1) contrary to the acknowledged radiological rule that artifacts usually appear in one sequence. In practice, if a radiologist suspects an unseemly signal to be an artifact on an axial image, he/she checks with coronal/sagittal images and other sequences to confirm his interpretation. Since the signal void appeared on both turbo spin echo (T2-weighted) and turbo field echo (T1-weighted) sequences, it was independent of magnetic resonance (MR) sequence. We came to the conclusion that it is a flowvoid artifact in the region of ACoA where flow dynamics is complex (1). ACoA bridges two anterior cerebral arteries, separates the junction between A1 and A2 segments, and gives rise to a number of small branches. Due to its complex anatomy, flow direction changes at ACoA. This may cause disorderly and turbulent flow and formation of eddy currents. Turbulent flow causes dephasing of proton signal, resulting in signal loss artifacts on conventional MRI, mimicking aneurysms. False aneurysms in the ACoA due to flow effects were reported to occur on TOF MR angiograms (2,3). When evaluating such lesions on conventional MRI, the possibility of being a flow artifact should be kept in mind and the techniques such as TOF angiography should be exploited prior to invasive techniques such as catheter angiography (2).

Neuro-Behçet's disease mimicking a cranial tumour

Behçets disease affects many systems and has been described as a multisystem disorder. In Behçets disease, neurological involvement is responsible for morbidity and mortality, and can sometimes mimic other neurological disorders. We present a case of neuro-Behçets disease that mimicked a cranial tumour.