Yelda Özsunar

Pituitary apoplexy: an overview of 186 cases published during the last century

BackgroundPituitary apoplexy is a rare and life-threatening complication occurring in 0.6–10.5% of all cases of pituitary adenomas. Although the association between pituitary apoplexy and visual dysfunction has been recognized for a long time, the optimal management of this problem still remains controversial. The purpose of this overview was to present the surgical experience by analyzing the literature on the management of pituitary apoplexy for better treatment of these cases.Materials and methodTo establish a new guideline for the surgical treatment of this entity, publications reported during the last century and databases containing medical literature were analyzed. In addition, an illustrative case with pituitary apoplexy presenting with complaints of sudden onset severe headache associated with nausea, vomiting, and a sudden loss of vision was described. In fact, the experience in our complicated patient prompted us to review the available literature on the management of pituitary apoplexy to date.ConclusionsBased on an overview of 186 cases of apoplectic pituitary adenoma presenting with monocular or binocular blindness, we highlight the importance of correct diagnosis and an early, but not necessarily emergency, surgery within the first week of admission to optimize visual outcome of such patients. The illustrative case further exemplifies the value of close interaction between members of the management team for optimal outcome.

Glioma recurrence versus radiation necrosis? A pilot comparison of arterial spin-labeled, dynamic susceptibility contrast enhanced MRI, and FDG-PET imaging.

RATIONALE AND OBJECTIVES Distinguishing recurrent glial tumor from radiation necrosis can be challenging. The purpose of this pilot study was to preliminarily compare unenhanced arterial spin-labeled (ASL) imaging, dynamic susceptibility contrast-enhanced cerebral blood volume (DSCE-CBV) magnetic resonance imaging, and positron emission tomographic (PET) imaging in distinguishing predominant glioma recurrence or progression from predominant radiation necrosis in postoperative patients treated with proton-beam therapy. METHODS Patients with grade II to IV glioma previously treated with surgery and proton-beam therapy were enrolled on the basis of new enhancing nodules or masses with primary differential diagnoses of predominant tumor recurrence or progression versus radiation necrosis. ASL, DSCE-CBV, and PET examinations were assessed by visual qualitative and quantitative analysis for the detection of predominant tumor recurrence. Imaging results were correlated with a clinical-pathologic reference standard. RESULTS Thirty patients were studied, resulting in 33 ASL, 32 DSCE-CBV, and 26 PET examinations. On the basis of visual inspection, the sensitivities of PET, ASL, and DSCE-CBV examinations for detecting high-grade tumor foci were 81%, 88%, and 86%, respectively. The highest sensitivity values for quantitative ASL imaging were obtained using a normalized cutoff ratio of 1.3, resulting in sensitivity of 94% for ASL imaging and 71% for DSCE-CBV imaging. When predominant high-grade tumors with superimposed regions of predominant mixed radiation necrosis were excluded, DSCE-CBV sensitivity improved to 90%, but ASL sensitivity remained unchanged. CONCLUSIONS Compared with DSCE-CBV imaging, ASL imaging may more accurately distinguish predominant recurrent high-grade glioma from radiation necrosis, especially in regions with mixed radiation necrosis, for which DSCE-CBV imaging may underestimate true blood volume because of leakage artifacts.

Diffusion- and perfusion-weighted magnetic resonance imaging in human acute ischemic stroke: technical considerations.

Diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) are recently developed yet steadily evolving magnetic resonance techniques. DWI and PWI typically interrogate the microscopic diffusion and microcirculatory perfusion, and they can provide early, highly sensitive, and specific delineation of ischemic tissue. These techniques also can play a role in selecting patients who may benefit from thrombolytic therapy. This article reviews physical, technical, and pathophysiological background material that can be helpful in the acquisition and interpretation of DWI and PWI.

Orbital blood flow parameters in unilateral pseudoexfoliation syndrome.

Purpose The evaluation of orbital blood flow parameters in patients with unilateral pseudoexfoliation syndrome (XFS) and in age–sex-matched control subjects using color Doppler imaging. Methods This prospective, comparative case series included 33 unilateral XFS patients and 33 age–sex-matched control subjects. Color Doppler imaging was used to evaluate the XFS-affected (Group 1) and -unaffected (Group 2) eyes that were matched with the corresponding side (Groups 3 and 4) of control subjects. All subjects were given a complete ophthalmological examination. A masked radiologist obtained the peak systolic velocity (PSV) and end diastolic velocity (EDV) of ophthalmic (OA), central retinal (CRA), nasal posterior ciliary (NPCA) and temporal posterior ciliary arteries (TPCA) as well as mean velocity of central retinal vein (CRV). Resistivity indices (RI) were calculated. Results Analysis of peak systolic and end diastolic velocity (PSV, EDV) and RI between Groups 1–2 and 3–4 did not show any significant difference. Comparing Groups 1–3 (corresponding eyes of pseudoexfoliation-affected and control subjects) and Groups 2–4 (corresponding eyes of pseudoexfoliation-unaffected and control subjects) revealed significantly low values for OA, PSV and EDV in both eyes of the XFS patients. The OA RI value in Group 1 was found to be significantly higher than that in Group 3 with the cut-off value of 0.72. Conclusion These findings suggest that ophthalmic artery hemodynamic parameters change in both eyes of unilateral XFS patients, illustrating out the systemic nature of the disease. We conclude that XFS decreases OA blood flow velocities and increases vascular resistance through progressive build-up.

Spontaneously ruptured uterine angioleiomyoma

Angioleiomyoma is an uncommon type of leiomyoma of the uterus that originates from smooth muscle cells and contains thick-walled vessels. A 45-year-old woman with the complaint of lower abdominal pain was admitted to the hospital. In the operation a ruptured, bleeding uterine tumor was seen. She underwent total hysterectomy and bilateral salpingo-oophorectomy. On pathologic examination of the specimen, the tumor was diagnosed as angioleiomyoma. Here, an unusual clinical presentation of uterine angioleiomyoma was reported.

Age-related changes in the incidence of pineal gland calcification in Turkey: A prospective multicenter CT study

The goal of this cross-sectional observational study was to determine the incidence of pineal gland calcification (PGC), to investigate the interaction of PGC and aging, and to compare the incidence of PGC among the populations living in Turkey. In a prospective study the rate of PGC on CT scans of 1376 individuals in six referral centers from different regions of Turkey was investigated, with emphasis on effects of climatological parameters and aging on PGC. It was found that the incidence of PGC increased rapidly after first decade and the increase remains gradual thereafter, higher in males than in females for all age groups. There was a significant difference for incidence and degree of PGC between different clinics and between both sexes (p<0.001). In addition, there was a significant difference for the degree of PGC between the clinics in low altitude group and those in high altitude group (p<0.001 for each). Logistic regression analysis revealed that age, sex, altitude and intensity of sunlight exposure significantly affected the risk of PGC (odds ratios (OR) 1.335, 95% confidence intervals (CI) 1.261-1.414, p<0.001; OR 1.900, 95% CI 1.486-2.428, p<0.001; OR 0.715, 95% CI 0.517-0.990, p<0.05; OR 0.997, 95% CI 0.994-0.999, p<0.01, respectively). Furthermore, by multiple linear regression analysis, high altitude and increased intensity of sunlight exposure were found to affect the degree of PGC (beta=0.003, p<0.001). It is concluded that there is a close relationship between PGC and the aforementioned parameters, supporting a link between the development of PGC and these. This study provides some reference data for new clinical studies on the putative role of pineal gland in future.

Magnetic resonance imaging of cerebral hemorrhagic stroke.

Despite a traditional perception of reliance on computed tomography and lack of acceptance of magnetic resonance imaging (MRI) for detecting acute hemorrhage, MRI appears to be used increasingly in hemorrhagic stroke. This review addresses the MRI findings of acute hemorrhagic stroke obtained using relatively new imaging techniques. These new techniques have resulted in more acute stroke patients undergoing MRI examination. New information about the frequency and appearance of hemorrhage is emerging: for example, approximately 15–26% of cases of acute cerebral infarctions appear to be complicated by intracerebral hemorrhage. The MRI appearances of hemorrhagic transformation of ischemic infarction, as well as acute hypertensive intracerebral hemorrhage, are discussed based on clinical, biochemical, and technical aspects.

Diagnostic accuracy and tolerability of contrast enhanced CT colonoscopy in symptomatic patients with increased risk for colorectal cancer.

OBJECTIVE We compared the accuracy and tolerability of intravenous contrast enhanced spiral computed tomography colonography (CTC) and optical colonoscopy (OC) for the detection of colorectal neoplasia in symptomatic patients for colorectal neoplasia. METHODS A prospective study was performed in 48 patients with symptomatic patients with increased risk for colorectal cancer. Spiral CTC was performed in supine and prone positions after colonic cleansing. The axial, 2D MPR and virtual endoluminal views were analyzed. Results of spiral CTC were compared with OC which was done within 15 days. The psychometric tolerance test was asked to be performed for both CTC and colonoscopy after the procedure. RESULTS Ten lesions in 9 of 48 patients were found in CTC and confirmed with OC. Two masses and eight polyps, consisted of 1 tubulovillous, 1 tubular, 2 villous adenoma, 4 adenomatous polyp, 4 adenocarcinoma, were identified. Lesion prevalence was 21%. Sensitivity, specificity, accuracy, positive and negative predictive values were found 100%, 87%, 89%, 67% and 100%, respectively. Psychometric tolerance test showed that CTC significantly more comfortable comparing with OC (p=0.00). CTC was the preferred method in 37% while OC was preferred in 6% of patients. In both techniques, the most unpleasant part was bowel cleansing. CONCLUSION Contrast enhanced CTC is a highly accurate method in detecting colorectal lesions. Since the technique was found to be more comfortable and less time consuming compare to OE, it may be preferable in management of symptomatic patients with increased risk for colorectal cancer.

Correlation of serum trace elements and melatonin levels to radiological, biochemical, and histological assessment of degeneration in patients with intervertebral disc herniation.

The aim of our study was to assess the blood concentrations of some trace elements and melatonin (MLT) in patients with intervertebral disc herniation (IDH) and to investigate the interaction of histological and biochemical degeneration findings with aging. The present study was carried out on 13 subjects (8 women and 5 men) diagnosed with IDH. They were divided into three groups according to their ages. Nighttime serum MLT, zinc (Zn), and magnesium (Mg) levels were determined in all patients. In addition, computed tomography (CT) scan of the brain and magnetic resonance imaging examination of the lumbar spine were obtained in this study. The Zn level and Zn/Mg ratio showed a decline in patients with IDH with aging, whereas the serum Mg level and tissue hydroxyproline content increased. A positive correlation between serum Zn and MLT concentrations was found (r=0.104, p=0.734). In addition, there was a positive correlation between serum Zn level and Zn/Mg ratio (r=0.835 and p<0.01), and a negative correlation between serum Mg level and Zn/Mg ratio (r=−0.571, p<0.05). On CT study, both volume percentage of calcified pineal gland and density of calcification were found to increase progressively with advancing age. The results of semiquantitative evaluation of disc tissues of patients with IDH for histological degeneration findings showed that 66.7% of discs treated had slight degeneration in younger age group, but 75.0% and 100% of discs had moderate or marked degeneration in older age groups. Our data indicated that there is a close relationship between MLT and Zn or Mg levels in the serum samples of patients with IDH, and the levels of these elements might be affected by the presence of degeneration process and serum MLT level, or vice versa.

Unusual migration of a foreign body from the gut to a vertebral body

Abstract We report a unique case in which a needle was accidentally swallowed and migrated into the vertebral body. Plain films and CT of the spine revealed fragmented, linear, metallic-density material in the L3 vertebral body. The possible mechanisms of the migration are discussed.