Yahya Paksoy

Epidural venous plexus enlargements presenting with radiculopathy and back pain in patients with inferior vena cava obstruction or occlusion

Study Design. In the last 2 years, we have examined 9640 patients experiencing back pain or sciatica, using MRI. There were 13 (0.13%) patients who had radicular symptoms that clinically mimicked lumbar disc herniation or spinal stenosis. All of these patients had inferior vena caval obstruction or occlusion that caused engorgement in the epidural and paravertebral venous system, causing nerve root compression. Objective. To illustrate the imaging characteristics of 13 patients with epidural engorged veins due to inferior vena cava obstruction or occlusion causing sciatica and low back pain. Summary of the Background Data. Abnormalities or pathological changes of epidural venous network may give rise to symptoms similar to or mimicking lumbar disc herniation or spinal stenosis. Multiple lumbar epidural varices can cause nerve root and thecal sac compression. Lumbar epidural varices have been infrequently described in the literature. To date, the cause of anterior epidural venous enlargement has been poorly understood, and both congenital and acquired causes have been proposed. This report describes enlarged epidural veins in patients with inferior vena caval thrombosis or obstruction presenting with radicular syndromes. Methods. The authors have seen 13 patients with radicular symptoms. All of the patients had inferior vena caval obstruction or occlusion that caused engorgement in the epidural veins, causing nerve root compression. The ages of these patients ranged from 20 to 53 (mean, 30) years. All of the patients were examined with color Doppler ultrasonography and magnetic resonance scanner. Results. Ten of 13 patients had inferior vena cava thrombosis located just under the renal vein orifices. In two patients, there was compression to inferior vena cava due to parity. In the remaining patient, a huge intra-abdominal mass was observed, and this mass was causing inferior vena cava obstruction and invasion. Enlargements of epidural venous plexus were demonstrated in all of these cases. All of the patients presented with the acute onset of low back pain followed shortly thereafter by acute radicular symptoms. The compression to inferior vena cava could not be treated in one patient because of intra-abdominal malignancy. The remaining 12 patients with inferior vena cava obstruction or occlusion experienced complete resolution of symptoms after treatment or delivery. Conclusion. The authors believe that epidural venous engorgement should be considered when the symptoms of patients with deep venous and inferior vena cava thrombosis are accompanied by radicular and/or back pain, because pathologic processes compressing a nerve root can cause pain.

Klippel-Feil syndrome associated with persistent trigeminal artery.

Study Design. In the present report, radiologic find-ings of the patient with the Klippel-Feil syndrome associated with persistent trigeminal artery are reviewed. In same case, there was also spina bifida occulta, cervical spondylosis, atlanto-occipital assimilation, bilateral cervical ribs, and lack of flow signal in the C4 segment of contralateral vertebral artery. The persistent trigeminal artery and Klippel-Feil syndrome can be seen together and with the other anomalies. It should be considered that they might be related with the insufficiency or dysfunction of the embryologic developmental process. Objectives. To draw attention to this rare presentation of Klippel-Feil syndrome associated with persistent trigeminal artery. Summary of Background Data. Klippel-Feil syndrome is a congenital spinal malformation characterized by the failure in segmentation of 2 or more cervical vertebrae. Although the anomaly is defined by its skeletal component, Klippel-Feil Syndrome may also be associated with developmental defects in many other organ systems including the inner ear, spinal cord, heart, and genitouri-nary tract. The primitive trigeminal, otic, hypoglossal, and proatlantal intersegmental arteries are persistent fetal anastomoses between the carotid and vertebrobasilar circulations. The authors report the association of a persistent trigeminal artery with the Klippel-Feil syndrome. Methods. Radiologic findings of a case of Klippel-Feil syndrome associated with persistent trigeminal artery are described. Results. There was vertebral fusion, spina bifida oc-culta, bilateral cervical ribs, atlanto-occipital assimilation, and cervical spondylosis. Magnetic resonance angiography showed the persistent trigeminal artery between the left internal carotid and basilar artery, but there was no sign of flow in the C4 segment of right vertebral artery. Conclusions. It should be kept in mind that a persistent trigeminal artery and Klippel-Feil syndrome can be seen together and with the other anomalies. Because of this reason, this type of case should prompt a search for the other related anomalies, and magnetic resonance angiography can be used as a noninvasive diagnostic technique in the persistent trigeminal artery determination.

Vertebral artery loop formation: A frequent cause of cervicobrachial pain

Study Design. Patients with cervicobrachial pain were examined in detail with special attention to vertebral artery loop formation. Objectives. To determine the incidence, short-time natural course and response to a conservative approach to vertebral artery loop formation in a group of patients with cervicobrachial pain. Summary of the Background Data. Vertebral artery loop formation is reported to be a rare cause of cervicobrachial neuralgia, discovered incidentally during the search for its cause. It can be congenital or acquired, occurring equally in both sexes. Surgical decompression has been the preferred method in the majority of reported cases, with favorable results. Methods. One hundred seventy-three patients with cervicobrachial pain were examined in a period of 7 months using physical examination, radiography, and magnetic resonance imaging with or without angiography. Results. Thirteen patients with a mean age of 43.9 ± 13.5 years were diagnosed with vertebral artery loop formation. The most common level was C6–C7. Four patients presented with loop formation at two levels. None of the patients had symptoms attributable to intervertebral disc pathology. The complaints were in accordance with the level of the vascular pathology. Complete relief or decrease in pain was observed in all patients with the conservative approach. Conclusions. In patients with cervicobrachialgic symptoms and without established discopathy, during the examination of sagittal magnetic resonance images, vertebral artery loop formation should be kept in mind, and in suspected cases, the vertebral artery should be visualized using three-dimensional time of flight magnetic resonance angiography. Vertebral artery-nerve root relation should also be demonstrated using the multiplanar reformatting method from time of flight images. A conservative course of treatment has a favorable outcome.

Congenital left ventricular wall abnormalities in adults detected by gated cardiac multidetector computed tomography: clefts, aneurysms, diverticula and terminology problems.

OBJECTIVES Our aim was to evaluate congenital left ventricular wall abnormalities (clefts, aneurysms and diverticula), describe and illustrate imaging features, discuss terminology problems and determine their prevalence detected by cardiac CT in a single center. MATERIALS AND METHODS Coronary CT angiography images of 2093 adult patients were evaluated retrospectively in order to determine congenital left ventricular wall abnormalities. RESULTS The incidence of left ventricular clefts (LVC) was 6.7% (141 patients) and statistically significant difference was not detected between the sexes regarding LVC (P=0.5). LVCs were single in 65.2% and multiple in 34.8% of patients. They were located at the basal to mid inferoseptal segment of the left ventricle in 55.4%, the basal to mid anteroseptal segment in 24.1%, basal to mid inferior segment in 17% and septal-apical septal segment in 3.5% of cases. The cleft length ranged from 5 to 22 mm (mean 10.5 mm) and they had a narrow connection with the left ventricle (mean 2.5 mm). They were contractile with the left ventricle and obliterated during systole. Congenital left ventricular septal aneurysm that was located just under the aortic valve was detected in two patients (0.1%). No case of congenital left ventricular diverticulum was detected. CONCLUSION Cardiac CT allows us to recognize congenital left ventricular wall abnormalities which have been previously overlooked in adults. LVC is a congenital structural variant of the myocardium, is seen more frequently than previously reported and should be differentiated from aneurysm and diverticulum for possible catastrophic complications of the latter two.

Comparison of apparent diffusion coefficient values among different MRI platforms: a multicenter phantom study

PURPOSE We aimed to compare apparent diffusion coefficient (ADC) values among magnetic resonance imaging (MRI) scanners from different vendors. MATERIALS AND METHODS We used a custom-made phantom solution consisting of distilled water, 0.9% NaCl, 25% NaCl, and shampoo for diffusion-weighted MRI (DW-MRI) examinations. DW-MRI was performed with similar sequence parameters using six different 1.5 Tesla MR scanners (scanners A-F). ADC maps were automatically constructed for all DW-MR images (b factors of 0 and 1000 s/mm(2)). ADC measurements were performed using regions of interest and seven different software programs, including four different postprocessing workstations, two different picture archiving and communication systems, and operator console software for each MR scanner. RESULTS The ADC values generated by scanners A and F were higher and those of scanner B were lower than those generated by the other scanners (P = 0.002). The intravendor difference in the ADC values averaged from scanners D, E, and F was statistically significant (P < 0.001). The difference between the ADC values obtained by scanners C and E was not statistically different (P = 0.15). CONCLUSION ADC values may differ among different MRI systems used for DW-MRI. Thus, the MRI vendor should be considered when using DW-MRI in a clinical setting.

Percutaneous Sonographically Guided Treatment of Hydatid Cysts in Sheep Direct Injection of Mebendazole and Albendazole

Objective. The purpose of this study was to investigate the scolicidal effect of intracystic injection of benzimidazolic solutions in naturally infected sheep with hydatid disease. Methods. Twenty‐four sheep with 37 hydatid cysts were included in this study for percutaneous treatment with benzimidazolic solutions. The animals were divided into 3 groups: group I, treatment group with mebendazole; group II, treatment group with albendazole; and group III, control group with distilled water. All solutions were given percutaneously under sonographic guidance. Cyst contents were aspirated with a needle, and then scolicidal solutions were injected into the cysts; reaspiration was not done. Routine follow‐up sonographic images were taken on the 15th day after treatment, then once per month for 3 months, and then at 3‐month intervals thereafter. At the 1‐month follow‐up, the percutaneous aspirate yielded orange juice–like material containing necrotic debris without living scolices. Results. Sonography showed a reduction in cyst size in the benzimidazolic groups (groups I and II) and progressive changes in echo patterns. An anaphylactic reaction was observed during the procedure in 1 animal. After 12 months of sonographic follow‐up, the animals in all groups were killed, and macroscopic and microscopic changes in tissue samples were evaluated. At autopsy, no cysts with living scolices were found in the benzimidazolic groups, and the appearance of the treated cysts was different from that of those in the control group. Microscopic examination showed the degeneration, necrosis, and thickening of the cyst walls in the treatment groups. Conclusions. Intracystic injection of benzimidazolic solutions as scolicidal agents may be used for percutaneous treatment of hepatic hydatid cysts in sheep.

Acquired ocular motor apraxia from bilateral frontoparietal infarcts associated with Takayasu arteritis

The relatively rare syndrome of acquired ocular motor apraxia is characterised by difficulty in initiating saccades to command and to visual targets, usually in all directions.1 ### Case report Our patient was a 52 year old left handed and non-literate man. He was admitted to a local hospital with the complaint of acute and persistent thoracic and epigastric pain radiating to his back. Five days later he developed acute loss of consciousness and was sent to our hospital. Blood pressure was 170/100 mm Hg from the right arm and 160/100 mm Hg from the left, the right femoral artery was pulseless, and the epigastrium was painful on palpation. He was stuporose, disoriented, and his cooperation was limited to simple commands only. He had bilateral ptosis with his eyes fixed in the primary position. Convergence was absent. However, an oculocephalic reflex could be elicited in both vertical and horizontal directions. His left nasolabial sulcus was somewhat reduced. He had paresis of both his arms and his left leg, while the motor strength in his right leg was almost completely normal. Hoffman and Babinski signs were positive on the left side, with hyperreflexia. The tendon reflexes were normal on the right side and no pathological reflexes were elicited. He had urinary incontinence. On the third day of admission he appeared apathetic. Although his thinking was slowed, and his affect was flattened, he could answer simple questions and obey simple commands. He still had difficulty in understanding complex orders. His ptosis had resolved …

Diagnostic efficacy of diffusion‐weighted MRI for pre‐operative assessment of myometrial and cervical invasion and pelvic lymph node metastasis in endometrial carcinoma

To determine the diagnostic accuracy of diffusion‐weighted magnetic resonance imaging (DW‐MRI) for the pre‐operative assessment of patients with endometrial carcinoma and to assess myometrial and cervical invasion as well as pelvic lymph node metastasis.

An investigation of the anatomical variations of left atrial appendage by multidetector computed tomographic coronary angiography

PURPOSE The left atrial appendage (LAA) is usually known as a long, tubular, hooked structure derived from the left atrium. However, it varies widely in terms of anatomical shape. In this study, anatomical shape variations of the LAA were investigated and classified in vivo in a large group of patients by multidetector computed tomography (MDCT) coronary angiography. MATERIALS AND METHODS The study included 320 consecutive patients (223 men and 97 women, with a mean age of 58 years) who underwent MDCT coronary angiography. MDCT was performed with a 64-detector-row computed tomographic scanner. LAA anatomical variations were classified as five main types and further divided into subtypes. In addition, we gave the classifications descriptive names according to the anatomical external appearance of the LAA: horseshoe (type 1), hand-finger (type 2a), fan (type 2b), wing (type 2c), hook (type 3), wedge (type 4) and swan (type 5) shapes. The types and subtypes of the LAA variations and the presence of thrombus were recorded. RESULTS In our study, the LAA tip orientation was used and the LAA was divided into type 1, type 2a, 2b, 2c, type 3, type 4 and type 5 in 44 (13.8%), 65 (20.3%), 155 (48.4%), 8 (2.5%), 27 (8.4%), 6 (1.9%) and 15 (4.7%) patients, respectively. LAA thrombus was detected in four patients (1.25%), who had classified LAA shapes of type 2a and type 2b. CONCLUSIONS The LAA has multiple anatomical shape variations. We demonstrated previously undefined new shape types of LAA. Knowledge of LAA variations is important in order to avoid procedure-related complications when ablative treatment is to be performed or if surgical procedures are indicated in this region. MDCT coronary angiography provides important and detailed information about determining and evaluating these variations before undertaking a planned procedure in this region.

Omental fibroma: CT and US findings

Abstract. The US, CT, and X-ray findings in a patient with omental fibroma of the lesser omentum are described. Ultrasound showed a solid mass with cystic areas in the central region. At CT the lesion showed peripheral enhancement and central hypodensity. On X-ray studies with barium, there was border distortion in the lesser curvature of the stomach. The mass was resected surgically. A pathologic diagnosis of fibroma was confirmed.