Hungarian Radiology

[Stories of Professor Zsebők Zoltán told by his pupil]

MÓZSA Szabolcs

JULY 15, 2009

Hungarian Radiology - 2009;83(02)

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Hungarian Radiology

[Beginning of a new section: Pathology without borders - Integrative medical papers]

LOMBAY Béla

Hungarian Radiology

[Can magnetic resonance imaging play a role in planning the method of delivery after Caesarean section?]

GERGELY István, CSÉCSEI Károly, DORFFNER Roland, BARANYAI Tibor

[INTRODUCTION - The number of Caesarean sections has been dramatically increasing worldwide, and also in Hungary in the last decade. In case of pregnancy following a preliminary Caesarean section it is always questioned if repeated Caesarean section or vaginal birth is required. The authors try to draw a conclusion from the thickness and the structure of the uterinal scar. The aim of the current study is to assess the additional role of uterinal MR examination undertaken between two births. PATIENTS AND METHODS - During our retrospective preliminary study T2 weighted sagittal images of uterinal MR examinations of 13 female patients were analysed. The presence of scar line was evaluated for thickness (millimetres, mm). This measurement was compared with the surgical report following consequent Caesarean section. Thus, a correlation was made between the surgical scar found at the repeated Caesarean section and the structure of the uterine scar seen by MR examination (between two births) which could play a role in the indication of the next birth. RESULTS - Three of our 13 patients gave birth via vagina (VBAC), and 10 via repeated Caesarean sections. According to the descriptions of the surgical scar the scars thinned out in six cases, whereas they made thickness in four. According to the appearance of the place of incision the scar was homogeneous and hypointens in nine cases, and inhomogeneous but basically hypointense in one case. According to the description of surgery in the MR examination the thinned out scar was thinner than 6 mm in 4 cases, and thicker than 6 mm in two cases. According to the description of surgery in the MR examination the nonthinned out scar was thinner than 6 mm in three cases, and thicker than 6 mm in one case. In two patients of three who gave birth via vagina the scar was thicker than 6 mm in the MR examination, and thinner than 6 mm in one case, the MR appearance of the scar was homogeneous and hypointens in two cases and complied with the original zonal anatomy in one case. CONCLUSION - In case repeated Caesarean section is not necessary from the aspect of the foetus or the mother, uterinal MR examination is of an additional significance in the complex indication of birth following a previous Caesarean section. The thickness, structure and signal intensity of the uterinal scar may provide a useful additional information.]

Hungarian Radiology

[Balloon dilatation and metallic stent placement in inferior vena cava stenosis complicating liver transplantation]

DOROS Attila, NÉMETH Andrea, HARTMANN Erika, DEÁK Pál Ákos, FEHÉRVÁRI Imre, TÓTH Szabolcs, NEMES Balázs, KÓBORI László

[INTRODUCTION - The only successful therapy for end stage liver cirrhosis is liver transplantation. The anastomotic stenosis of the inferior vena cava is rare but serious complication. In these cases surgery is a high risk procedure; therefore interventional radiological methods are recommended. PATIENTS AND METHODS - Eleven patients developed 12 caval stenosis from 365 liver transplant recipients in Budapest. One of the patients had caval stenosis again after retransplantation. Dilatation was performed with 10- 25 mm large balloon catheters in 6 cases and 6 metallic stents (12-24 mm in diameter) were implanted. All the procedures were performed via the common femoral vein. RESULTS - The success of the intervention was measured by the morphological results, clinical signs and by the changes of superior-inferior vena cava pressure gradients. Before the intervention 14 Hgmm mean pressure gradient was measured, which decreased to 8 Hgmm post intervention. Eleven patients developed renal insufficiency before treatment; this was reversible in 6 cases. One patient had impaired renal function before treatment, and later on again, after retransplantation. Three of 4 patients with renal insufficiency died in the post operative period. One stent migration was noticed prompting surgical fixation of the stent. CONCLUSION - Inferior vena cava stenosis represents a serious complication after liver transplantation, causing ascites, hydrothorax and venous congestion in the kidneys and the liver. In the critical post operative period surgery is not recommended, risking the viability of the liver and the life of the patient. Interventional radiology with balloon dilatation and stent implantation is the method of choice in these cases, primary stenting with large self expanding metallic stents is necessary in elastic stenosis caused by torsion of the anastomosis.]

Hungarian Radiology

[Mediastinal hamartoma in childhood]

KISS Regina Judit, VERES Lukács

[INTRODUCTION - Mediastinal hamartoma is a rare entity in children. Exact diagnosis can be given virtually only after surgical exploration, which is also the ultimate choice of treatment due to its benign nature. CASE REPORT - A 4-year-old boy with recurrent upper respiratory tract infections and pneumonias, had a huge tumour mass in his left upper lung lobe, which infiltrated the mediastinum. After a negative bronchoscopy and an unsuccessful CT-guided biopsy, surgery was performed. The final histological result revealed the mass to be mediastinal hamartoma. CONCLUSION - Mediastinal masses are relatively common in childhood, but mediastinal hamartoma is rare, and its preoperative diagnosis appears to be difficult.]

Hungarian Radiology

[Monteggia fracture]

SHAIKH Shoaib, LOMBAY Béla, KISS Ákos

[The Monteggia fracture is a very challenging injury, not only for the treating surgeon but also for the radiologist. The correct and timely identification of the injury is vital for a favourable outcome. Following is an overview of the Monteggia fracture.]

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Neuroscience highlights: Main cell types underlying memory and spatial navigation

KRABOTH Zoltán, KÁLMÁN Bernadette

Interest in the hippocampal formation and its role in navigation and memory arose in the second part of the 20th century, at least in part due to the curious case of Henry G. Molaison, who underwent brain surgery for intractable epilepsy. The temporal association observed between the removal of his entorhinal cortex along with a significant part of hippocampus and the developing severe memory deficit inspired scientists to focus on these regions. The subsequent discovery of the so-called place cells in the hippocampus launched the description of many other functional cell types and neuronal networks throughout the Papez-circuit that has a key role in memory processes and spatial information coding (speed, head direction, border, grid, object-vector etc). Each of these cell types has its own unique characteristics, and together they form the so-called “Brain GPS”. The aim of this short survey is to highlight for practicing neurologists the types of cells and neuronal networks that represent the anatomical substrates and physiological correlates of pathological entities affecting the limbic system, especially in the temporal lobe. For that purpose, we survey early discoveries along with the most relevant neuroscience observations from the recent literature. By this brief survey, we highlight main cell types in the hippocampal formation, and describe their roles in spatial navigation and memory processes. In recent decades, an array of new and functionally unique neuron types has been recognized in the hippocampal formation, but likely more remain to be discovered. For a better understanding of the heterogeneous presentations of neurological disorders affecting this anatomical region, insights into the constantly evolving neuroscience behind may be helpful. The public health consequences of diseases that affect memory and spatial navigation are high, and grow as the population ages, prompting scientist to focus on further exploring this brain region.

Lege Artis Medicinae

[Second game, 37th move and Fourth game 78th move]

VOKÓ Zoltán

[What has Go to do with making clinical decisions? One of the greatest intellectual challenges of bedside medicine is making decisions under uncertainty. Besides the psychological traps of traditionally intuitive and heuristic medical decision making, lack of information, scarce resources and characteristics of doctor-patient relationship contribute equally to this uncertainty. Formal, mathematical model based analysis of decisions used widely in developing clinical guidelines and in health technology assessment provides a good tool in theoretical terms to avoid pitfalls of intuitive decision making. Nevertheless it can be hardly used in individual situations and most physicians dislike it as well. This method, however, has its own limitations, especially while tailoring individual decisions, under inclusion of potential lack of input data used for calculations, or its large imprecision, and the low capability of the current mathematical models to represent the full complexity and variability of processes in complex systems. Nevertheless, clinical decision support systems can be helpful in the individual decision making of physicians if they are well integrated in the health information systems, and do not break down the physicians’ autonomy of making decisions. Classical decision support systems are knowledge based and rely on system of rules and problem specific algorithms. They are utilized widely from health administration to image processing. The current information revolution created the so-called artificial intelligence by machine learning methods, i.e. machines can learn indeed. This new generation of artificial intelligence is not based on particular system of rules but on neuronal networks teaching themselves by huge databases and general learning algorithms. This type of artificial intelligence outperforms humans already in certain fields like chess, Go, or aerial combat. Its development is full of challenges and threats, while it presents a technological breakthrough, which cannot be stopped and will transform our world. Its development and application has already started also in the healthcare. Health professionals must participate in this development to steer it into the right direction. Lee Sedol, 18-times Go world champion retired three years after his historical defeat from AlphaGo artificial intelligence, be­cause “Even if I become the No. 1, there is an entity that cannot be defeated”. It is our great luck that we do not need to compete or defeat it, we must ensure instead that it would be safe and trustworthy, and in collaboration with humans this entity would make healthcare more effective and efficient. ]

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A rare entity of acquired idiopathic generalised anhidrosis which has been successfully treated with pulse steroid therapy: Does the histopathology predict the treatment response?

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Acquired idiopathic generalised anhidrosis is an uncommon sweating disorder characterized by loss of sweating in the absence of any neurologic, metabolic or sweat gland abnormalities. Although some possible immunological and structural mechanisms have been proposed for this rare entity, the definitive pathophysiology is still un­clear. Despite some successfully treated cases with systemic corticosteroid application, the dose and route of steroid application are controversial. Here, we present a 41-year-old man with lack of genera­lised sweating who has been successfully treated with high dose pulse intravenous prednisolone. We have discussed his clinical and histopathological findings as well as the treatment options in view of the current literature.

Clinical Neuroscience

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The syndrome of headache with neurologic deficits and cerebrospinal fluid lymphocytosis (HaNDL) is a rare entity. This disease has been related to migrainous headaches. It is a benign, self-limited disorder, which is characterized by fluctuating neurological symptoms and cerebrospinal fluid lymphocytosis. We describe a case of a 47 years old man with acute onset of headache and aphasia. Cerebrospinal fluid analysis revealed a lymphocytic pleocytosis (25 cells/μl, 100% lymphocytes). Electroencephalogram showed moderate slow rhythm in the left hemisphere, with temporoparietal predominance, and without epileptiform activity. His blood tests as well as magnetic resonance imaging (MRI) results were normal. With the diagnosis of HaNDL syndrome the patient was accepted in the Department of Neurology and discharged with full recovery.

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Isolated hypoglossal nerve palsy due to a jugular foramen schwannoma

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Introduction – Although the involvement of the hypoglossal nerve together with other cranial nerves is common in several pathological conditions of the brain, particularly the brainstem, isolated hypoglossal nerve palsy is a rare condition and a diagnostic challenge. Case presentation – The presented patient arrived to the hospital with a history of slurred speech and an uncomfortable sensation on his tongue. Neurological examination showed left-sided hemiatrophy of the tongue with fasciculations and deviation towards the left side during protrusion. Based on the clinical and MRI findings, a diagnosis of hypoglossal nerve schwannoma was made. Discussion – Hypoglossal nerve palsy may arise from multiple causes such as trauma, infections, neoplasms, and endocrine, autoimmune and vascular pathologies. In our case, the isolated involvement of the hypoglossal nerve was at the skull base segment, where the damage to the hypoglossal nerve may occur mostly due to metastasis, nasopharyngeal carcinomas, nerve sheath tumors and glomus tumors. Conclusion – Because of the complexity of the region’s anatomy, the patient diagnosed with hypoglossal nerve schwannoma was referred for gamma knife radiosurgery.