Sho-Jen Cheng

Prenatal diagnosis of choledochal cyst using ultrasound and magnetic resonance imaging

A 25-year-old primigravid woman was referred at 30 weeks’ gestation to evaluate a fetal intra-abdominal cystic mass. Sonographic examinations revealed a singleton fetus with biometry consistent with 30 weeks of gestation. An intra-abdominal cystic mass measuring 22 × 12 mm was noted. The amniotic fluid volume was normal. Color Doppler ultrasound revealed no flow within the mass. The cyst connected via the cystic duct to the gallbladder, raising the suspicion of a choledochal cyst (Figure 1). Ultrafast magnetic resonance imaging (MRI) scans further depicted a detailed anatomical relationship of the choledochal cyst to the liver, gallbladder and biliary tract (Figure 2). The choledochal cyst consisted of a cystic dilation of the common bile duct without dilation of the gallbladder and intrahepatic bile ducts. A diagnosis of Type IA choledochal cyst was thus made. The size of the cyst remained unchanged during follow-up ultrasound examinations. At 39 weeks’ gestation a female infant was born by vaginal delivery with Apgar scores of 10 and 10 at 1

Bilateral Neuralgic Amyotrophy Presenting with Left Vocal Cord and Phrenic Nerve Paralysis

This article reports the difference between neuralgic amyotrophy and neuropathy caused by chemotherapy and radiation treatment which manifested with severe shoulder pain followed by marked weakness of bilateral upper arms and involvement of cranial nerves. A 62-year-old man presented with acute severe neuropathic pain at the left shoulder, bilateral shoulder weakness, hoarseness of voice from vocal cord palsy, and respiratory insufficiency from left diaphragm palsy, which all occurred sequentially over a 1-month period. The diagnosis of neuralgic amyotrophy was supported and differentiated from tumor-induced and radiation-induced neuropathy by clinical presentation, electrophysiologic and imaging studies. Unlike previous reports of the onset of neuralgic amyotrophy being associated with initiation of radiation treatment in cancer patients, this report demonstrates that neuralgic amyotrophy can occur at any point of the malignant disease process after radiation and chemotherapy.

Postcesarean Subarachnoid Hemorrhage as the Initial Presentation of Cerebral Venous Thrombosis

The risk of stroke is increased in the peripartum period because of the hypercoagulable state that accompanies pregnancy [1]. The reported incidence of pregnancyrelated stroke varies from 19.2 to 46.2 per 100,000 pregnancies [2,3], with cerebral venous thrombosis (CVT) accounting for a reported 22%. CVT is also more common in parturient women, with 73% of CVT cases occurring postpartum [4]. It is also strongly associated with cesarean delivery. CVT results from thrombus in one of the outflow tracts of the brain and causes venous hypertension. The clinical manifestations include headache (the most common, occurring in 70% to 90%), nausea, changes in mental status, seizures, and focal neurologic deficits [5]. Diagnosis of CVT may be very challenging, because the symptoms are common and nonspecific. Acute subarachnoid hemorrhage (SAH) has been reported as an initial sign of CVT [6], which further complicates the diagnosis, since other causes of SAH must also be considered. We report a case of postcesarean section CVT with SAH. A previously healthy 38-year-old woman, gravida 3, para 1, abortion 1, was admitted at 38 weeks’ gestation with ruptured membranes and uterine contractions. She had a previous elective cesarean section. She was a non-smoker and denied a history of hypertension. She had regular prenatal care at our obstetric clinic, with no evidence of any complications. A cesarean section was performed under spinal anesthesia, with 12 mg of 0.5% heavy bupivacaine administered uneventfully using a 27-gauge spinal needle and with only one attempt. A live 3,250 g baby girl was delivered without difficulty and the placenta removed completely. Total blood loss was about 300 mL. In the recovery room, the patient complained of severe headache with neck stiffness approximately 20 minutes after surgery had completed. An electrocardiogram showed bradycardia with heart rate of 42 beats/minute. A brain computed tomography scan showed SAH with blood accumulation within the cerebral cortical sulci (Figure). The ventricular system showed negative findings. Thus, cerebral angiography was immediately performed to find the source of SAH. Cerebral angiographic study for SAH was performed using a right femoral arterial approach, with catheterization of the bilateral internal and external carotid arteries. No evidence of aneurysm or vascular malformation was noted. A prominent transcerebral vein with absence of cortical vein was noted at the right parietal lobe. The study suggested the possibility of CVT. Heparin was not given

Congenital Nasal Pyriform Aperture Stenosis and Single Central Maxillary Incisor: Preoperative Evaluation with Three-Dimensional Computed Tomography

BACKGROUND AND PURPOSE Congenital nasal pyriform aperture stenosis (CNPAS) is an uncommon cause of nasal airway obstruction in neonates and infants. It is frequently associated with a single central maxillary incisor (SCMI). The purpose of this study was to assess whether 3-dimensional spiral computed tomography (3D spiral CT) could be used for the diagnosis of CNPAS and for detecting SCMI in CNPAS patients before tooth eruption. METHODS From January 1996 to December 2001, 16 patients (mean age, 2 +/- 3 months) with clinically suspected CNPAS and 13 normal control subjects (mean age, 28 +/- 32 months) were studied prospectively by 3D spiral CT. On the 3D CT image of each subject, the middle pyriform aperture width (MPAW), upper 1/4 PA width (UPAW), and middle internasal process width (MINPW) were measured. In addition, the ratios of MINPW to MPAW and of MINPW to UPAW were calculated. SCMI was identified as a bigger tooth with singular convexity. RESULTS SCMI was diagnosed in 11 of the 16 CNPAS patients. In the CNPAS patient group, the mean MINPW (5 +/- 1 mm) was significantly shorter than the mean MPAW (9 +/- 1 mm) and the mean UPAW (8 +/- 1 mm) [p < 0.001]. However, in the normal control group, the mean UPAW (13 +/- 2 mm) was significantly shorter than the mean MPAW (16 +/- 3 mm) and the mean MINPW (16 +/- 3 mm) [p < 0.01]. In the CNPAS patients, the mean ratios of both MINPW to MPAW (0.5 +/- 0.1) and of MINPW to UPAW (0.6 +/- 0.1) were significantly lower than the corresponding mean ratios in the normal control subjects (1.0 +/- 0.1 and 1.3 +/- 0.2, respectively; both p < 0.001). CONCLUSION Our results indicate that CNPAS is frequently associated with a SCMI and CNPAS patients have a significant reduction in the MINPW and in the ratios of MINPW to MPAW and of MINPW to UPAW. We conclude that 3D spiral CT can be used for diagnosis of CNPAS and for detecting SCMI in CNPAS patients before tooth eruption.

Percutaneous transhepatic placement of metallic stents in the treatment of complicated intrahepatic biliary stricture with hepatolithiasis: a preliminary report

OBJECTIVE:We aimed to study the effect of the metallic modified Gianturco-Rosch Z-stent in the management of refractory intrahepatic long-segment biliary strictures with hepatolithiasis.METHODS:Six symptomatic patients with hepatolithiasis and coexisting intrahepatic long-segment biliary strictures, who failed to respond to the silastic external-internal biliary stenting, were selected. The metallic modified Gianturco-Rosch Z-stent was placed via percutaneous transhepatic cholangiography at the strictured site. Patients were followed regularly to evaluate for recurrence of cholangitis, stones, or strictures.RESULTS:No complications were observed during the procedures. No recurrent strictures or formed calculi were found in these six patients during follow-up periods of 29 to 64 months. However, cholangitis and intrahepatic biliary muddy sludge occurred at 7 and 30 months in two patients after the placement of the metallic Z-stent. Percutaneous transhepatic cholangioscopy was used to clear sludge completely.CONCLUSIONS:Our experience suggests that the metallic stent is a well-tolerated and promising alternative in the management of refractory intrahepatic long-segment biliary strictures with hepatolithiasis. Though biliary sludge may develop, it can be detected and cleared early. Repeated surgery can thus be avoided.

Hepatocellular Carcinoma with Acute Spinal Cord Compression as the Initial Presentation

Primary hepatocellular carcinoma (HCC) ranks as the most lethal malignancy in Taiwan. Its initial presentation as acute spinal cord compression from epidural metastasis is rare. Because of newer treatment modalities and better control of the primary tumor, the mean survival has increased, making early diagnosis and detection of distant metastases of utmost importance. The authors describe a 60-year-old man presented with a sudden onset of bilateral lower limb weakness and a sensory level at T8. Plain film of the thoracic spine was normal. Magnetic resonance imaging of the thoracic spine showed a large intraspinal epidural tumor at T6 level causing spinal cord compression. A diagnosis of HCC with epidural metastasis was made after surgical removal of the tumor mass.