Hungarian Radiology

[With renewed outlook and new fortitude]

LOMBAY Béla

APRIL 07, 2009

Hungarian Radiology - 2009;83(01)

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Hungarian Radiology

[Self-expanding metallic stents in intrahepatic biliary strictures after liver transplantation]

DOROS Attila, NÉMETH Andrea, HARTMANN Erika, DEÁK Pál Ákos, JUHAROSI Gyöngyi, LÉNÁRD Zsuzsa, KOZMA Veronika, GÖRÖG Dénes, GERLEI Zsuzsa, FEHÉRVÁRI Imre, NEMES Balázs, KÓBORI László

[INTRODUCTION - Bile duct complications remain a key problem of liver transplantation. Two main types are recognized: anastomotic and intrahepatic. In cases of anastomotic strictures good results can be achieved with surgery or minimally invasive therapy. Intrahepatic stenosis usually requires retransplantation. In this report the results of intrahepatic metallic stent placements are analyzed. PATIENTS AND METHODS - Since 1995, 20 patients with intrahepatic bile strictures were referred for percutaneous treatment. Of 34 percutaneous transhepatic cholangiography, 33 successful drainages were performed and 58 balloon dilatations were employed to overcome. In 13 patients, 20 metallic stents were implanted. One bleeding complication was successfully treated with selective embolization. RESULTS - The average follow up time was 35 months. 14 patients have no symptoms, 12 of them after metallic stent placements and 4 of them after retransplantation (2 patients had metallic stents at retransplantation). One patient has metallic stent and an external drain waiting for retransplantation. Three patients died after 7 retransplantations. Two patients died on the waiting list, one with and one without external drain. There were no deaths after successful metallic stent placement. CONCLUSION - After meticulous preparations metallic stent placement is safe and effective in intrahepatic biliary stenosis after liver transplantation. The patients can be stabilized till the retransplantation, or it can even be avoided.]

Hungarian Radiology

[Xanthogranulomatous cholecystitis]

BERÉNYI Zsolt, MORVAY Zita, PALKÓ András

[INTRODUCTION - The xanthogranulomatous cholecystitis is a rare and benign form of lesions associated with diffuse thickening of the gall bladder wall. It is important to recognize it radiologically because it can be mistaken easily for gall bladder carcinoma. The characteristic US, CT and MR findings, however, may be helpful in the differential diagnosis. CASE REPORT - We present the cases of two middleaged female patients suffering from right upper quadrant, radiating abdominal pain for several weeks without occurrence of fever. In both patients, the ultrasound examination revealed marked thickening of the gall bladder wall containing hypoechoic nodules. Further, non-specific sign such as cholecystolithiasis and fine infiltration of the adipose tissue surrounding the gall bladder and dilatation of extrahepatic or intrahepatic bile ducts were visible. On the post contrast CT images, rim enhancement was detectable. MR/MRCP examination showed a sharp delineation of the gall bladder from the liver parenchyma. Both patients underwent cholecystectomy. The pathological examination excluded malignancy and confirmed the diagnosis of xanthogranulomatous cholecystitis. CONCLUSION - The characteristic features of xanthogranulomatous cholecystitis (hypoechoic xanthogranulomas in the markedly thickened gall bladder wall and the presence of calculi) can be detected by ultrasound examination. CT or MRI may play an important role in confirmation of the diagnosis of an inflammatory process and provide useful information in exclusion of gall bladder carcinoma.]

Hungarian Radiology

[Transjugular intrahepatic portosystemic shunt implantation in a patient with severe dilatative cardiomyopathy]

SZALÁNCZY Katalin, LÁZÁR István, STEFÁN János, KALÓ Emil

[INTRODUCTION - Indications for TIPS (transjugular intrahepatic portosystemic shunt) are usually portal hypertension induced by alcoholic or viral cirrhosis. Reported patient underwent TIPS because of a rare indication where his rapidly progressing heart failure lead to rapid deterioration of the splanchnic hypertension. CASE REPORT - A 51 years old male was admitted with severe dilatative cardiomyopathy and atrial fibrillation, generalized edema refractory to conservative treatment, and rapidly worsening hepatic laboratory test results. TIPS implantation achieved improvement of all clinical signs, decreased edema and the patient could finally be discharged. CONCLUSION - TIPS can result in improved quality of life not only in primary hepatic cirrhosis but in other clinical circumstances with portal hypertension.]

Hungarian Radiology

[Difficulties in the diagnosis of ectopic ureter]

KONCZ Júlia, RÉTI Gyula, NYÁRI Edit, SHAIKH M. Shoaib

[INTRODUCTION - Ureter ectopy refers to the distal opening of the ureter at the site of the bladder neck or lower. 70-80% of the ectopic ureters are associated with pyelectasia and duplicated ureters. The incidence of this is 2-3 times higher in females. CASE REPORT - Following is a case report of a boy who was diagnosed with left-sided pyelectasia during a prenatal ultrasound scan. The postnatal ultrasound revealed a duplicated pelviceal cavity and ureter. The upper pole ureter and the pelvis demonstrated dilatation. At 8 months of age a left side heminehprectomy was performed. Two years postoperatively a follow-up ultrasound revealed a dilatation of the ureteral stump on the left side, which progressed. On MCUG the ureteral stump was identified inserting on to the proximal urethra. Cystography and MR urography demonstrated a ureteral stump which inserted on to the urethra. A repeat surgery was performed to remove the stump. Patient is symptom-free ever since. CONCLUSION - In ectopic, non-refluxing ureters long-term follow-up is necessary following heminephrectomy. A ureter stump besides the bladder can cause serious diagnostical difficulties. Also, it is possible that a dilating stump may lead to a reflux not identified earlier. MCUG and MR urography can help to clear delineate the pathology.]

Hungarian Radiology

[A rare pancreatic mass in childhood]

TORDAS Adél, PALOTAI Andrea, KISS Imre, KIS Éva

[INTRODUCTION - Malignant pediatric pancreas tumors are rare in the pediatric age group. Among these tumors the malignant hemangiopericytoma is an even more rare condition. CASE REPORT - We have diagnosed this soft tissue sarcoma in a three month old infant during a screening abdominal ultrasound examination. The examination showed a space-occupying lesion in the region of the pancreas and the adrenals. Following further diagnostic imaging, a complete surgical resection was performed. Histology showed malignant hemangiopericytoma. The child received a 5 month long, successful adjuvant chemotheraphy. CONCLUSIONS - Malignant hemangiopericytoma belongs to the non-rhabdomyosarcoma group of diseases. Two subtypes have been described: infantile-type ( hemangiopericytoma) in infants under 1 year, and the adult-type disease in children over 1 year of age. About one third of the infantile subtype are considered congenital. Most common anatomic locations are the retroperitoneum, the pelvis, the extremities, the head and neck region. Prognosis is favorable, the 10-year-survival rate is 80%. Differential diagnosis includes other tumors of the region, such as lesions of the adrenal gland, kidney, stomach and pancreas.]

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CAKAR Emel Nafiye, YILMAZBAS Pınar

Autism spectrum disorder is a neurodevelopmental disorder with a heterogeneous presentation, the etiology of which is not clearly elucidated. In recent years, comorbidity has become more evident with the increase in the frequency of autism and diagnostic possibilities of inborn errors of metabolism. One hundred and seventy-nine patients with diagnosis of autism spectrum disorder who presented to the Pediatric Metabolism outpatient clinic between 01/September/2018-29/February/2020 constituted the study population. The personal information, routine and specific metabolic tests of the patients were analyzed retrospectively. Out of the 3261 patients who presented to our outpatient clinic, 179 (5.48%) were diagnosed with autism spectrum disorder and were included in the study. As a result of specific metabolic examinations performed, 6 (3.3%) patients were diagnosed with inborn errors of metabolism. Two of our patients were diagnosed with classical phenylketonuria, two with classical homocystinuria, one with mucopolysaccharidosis type 3D (Sanfilippo syndrome) and one with 3-methylchrotonyl Co-A carboxylase deficiency. Inborn errors of metabolism may rarely present with autism spectrum disorder symptoms. Careful evaluation of the history, physical examination and additional findings in patients diagnosed with autism spectrum disorder will guide the clinician in the decision-making process and chose the appropriate specific metabolic investigation. An underlying inborn errors of metabolism may be a treatable cause of autism.

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Late simultaneous carcinomatous meningitis, temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting with mono-symptomatic vertigo – a clinico-pathological case reporT

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Although vertigo is one of the most common complaints, intracranial malignant tumors rarely cause sudden asymmetry between the tone of the vestibular peripheries masquerading as a peripheral-like disorder. Here we report a case of simultaneous temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting as acute unilateral vestibular syndrome, due to the reawakening of a primary gastric signet ring cell carcinoma. Purpose – Our objective was to identify those pathophysiological steps that may explain the complex process of tumor reawakening, dissemination. The possible causes of vestibular asymmetry were also traced. A 56-year-old male patient’s interdisciplinary medical data had been retrospectively analyzed. Original clinical and pathological results have been collected and thoroughly reevaluated, then new histological staining and immunohistochemistry methods have been added to the diagnostic pool. During the autopsy the cerebrum and cerebellum was edematous. The apex of the left petrous bone was infiltrated and destructed by a tumor mass of 2x2 cm in size. Histological reexamination of the original gastric resection specimen slides revealed focal submucosal tumorous infiltration with a vascular invasion. By immunohistochemistry mainly single infiltrating tumor cells were observed with Cytokeratin 7 and Vimentin positivity and partial loss of E-cadherin staining. The subsequent histological examination of necropsy tissue specimens confirmed the disseminated, multi-organ microscopic tumorous invasion. Discussion – It has been recently reported that the expression of Vimentin and the loss of E-cadherin is significantly associated with advanced stage, lymph node metastasis, vascular and neural invasion and undifferentiated type with p<0.05 significance. As our patient was middle aged and had no immune-deficiency, the promoting factor of the reawakening of the primary GC malignant disease after a 9-year-long period of dormancy remained undiscovered. The organ-specific tropism explained by the “seed and soil” theory was unexpected, due to rare occurrence of gastric cancer to metastasize in the meninges given that only a minority of these cells would be capable of crossing the blood brain barrier. Patients with past malignancies and new onset of neurological symptoms should alert the physician to central nervous system involvement, and the appropriate, targeted diagnostic and therapeutic work-up should be established immediately. Targeted staining with specific antibodies is recommended. Recent studies on cell lines indicate that metformin strongly inhibits epithelial-mesenchymal transition of gastric cancer cells. Therefore, further studies need to be performed on cases positive for epithelial-mesenchymal transition.

Clinical Neuroscience

Alexithymia is associated with cognitive impairment in patients with Parkinson’s disease

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Cognitive dysfunction (CD) is a common non-motor symptom of Parkinson’s disease (PD). Alexithy­mia is a still poorly understood neuropsychiatric feature of PD. Cognitive impairment (especially visuospatial dysfunction and executive dysfunction) and alexithymia share com­mon pathology of neuroanatomical structures. We hypo­thesized that there must be a correlation between CD and alexithymia levels considering this relationship of neuroanatomy. Objective – The aim of this study was to evaluate the association between alexithymia and neurocognitive function in patients with PD. Thirty-five patients with PD were included in this study. The Toronto Alexithymia Scale–20 (TAS-20), Geriatric Depression Inventory (GDI) and a detailed neuropsychological evaluation were performed. Higher TAS-20 scores were negatively correlated with Wechsler Adult Intelligence Scale (WAIS) similarities test score (r =-0.71, p value 0.02), clock drawing test (CDT) scores (r=-0.72, p=0.02) and verbal fluency (VF) (r=-0.77, p<0.01). Difficulty identifying feelings subscale score was negatively correlated with CDT scores (r=-0.74, p=0.02), VF scores (r=-0.66, p=0.04), visual memory immediate recall (r=-0.74, p=0.01). VF scores were also correlated with difficulty describing feelings (DDF) scores (r=-0.66, p=0.04). There was a reverse relationship bet­ween WAIS similarities and DDF scores (r=-0.70, p=0.02), and externally oriented-thinking (r=-0.77,p<0.01). Executive function Z score was correlated with the mean TAS-20 score (r=-62, p=0.03) and DDF subscale score (r=-0.70, p=0.01) Alexithymia was found to be associated with poorer performance on visuospatial and executive function test results. We also found that alexithymia was significantly correlated with depressive symptoms. Presence of alexithymia should therefore warn the clinicians for co-existing CD.

Clinical Neuroscience

Evaluation of the effectiveness of transforaminal epidural steroid injection in far lateral lumbar disc herniations

EVRAN Sevket, KATAR Salim

Far lateral lumbar disc herniations (FLDH) consist approximately 0.7-12% of all lumbar disc herniations. Compared to the more common central and paramedian lumbar disc herniations, they cause more severe and persistent radicular pain due to direct compression of the nerve root and dorsal root ganglion. In patients who do not respond to conservative treatments such as medical treatment and physical therapy, and have not developed neurological deficits, it is difficult to decide on surgical treatment because of the nerve root damage and spinal instability risk due to disruption of facet joint integrity. In this study, we aimed to evaluate the effect of transforaminal epidural steroid injection (TFESI) on the improvement of both pain control and functional capacity in patients with FLDH. A total of 37 patients who had radicular pain caused by far lateral disc herniation which is visible in their lumbar magnetic resonance imaging (MRI) scan, had no neurological deficit and did not respond to conservative treatment, were included the study. TFESI was applied to patients by preganglionic approach. Pre-treatment Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores of the patients were compared with the 3rd week, 3rd month and 6th month scores after the procedure. The mean initial VAS score was 8.63 ± 0.55, while it was 3.84 ± 1.66, 5.09 ± 0.85, 4.56 ± 1.66 at the 3rd week, 3rd month and 6th month controls, respectively. This decrease in the VAS score was found statistically significant (p = 0.001). ODI score with baseline mean value of 52.38 ± 6.84 was found to be 18.56 ± 4.95 at the 3rd week, 37.41 ± 14.1 at the 3rd month and 34.88 ± 14.33 at the 6th month. This downtrend of pa­tient’s ODI scores was found statistically significant (p = 0.001). This study has demonstrated that TFESI is an effective method for gaining increased functional capacity and pain control in the treatment of patients who are not suitable for surgical treatment with radicular complaints due to far lateral lumbar disc hernia.

Clinical Neuroscience

Electrophysiological investigation for autonomic dysfunction in patients with myasthenia gravis: A prospective study

NALBANTOGLU Mecbure, AKALIN Ali Mehmet, GUNDUZ Aysegul, KIZILTAN Meral

Myasthenia gravis (MG) is an autoimmune disorder of neuromuscular transmission. Autonomic dysfunction is not a commonly known association with MG. We conducted this study to evaluate autonomic functions in MG & subgroups and to investigate the effects of acetylcholinesterase inhibitors. This study comprised 30 autoimmune MG patients and 30 healthy volunteers. Autonomic tests including sympathetic skin response (SSR) and R-R interval variation analysis (RRIV) was carried out. The tests were performed two times for patients who were under acetylcholinesterase inhibitors during the current assessment. The RRIV rise during hyperventilation was better (p=0.006) and Valsalva ratio (p=0.039) was lower in control group. The SSR amplitudes were lower thereafter drug intake (p=0.030). As much as time went by after drug administration prolonged SSR latencies were obtained (p=0.043).Valsalva ratio was lower in the AchR antibody negative group (p=0.033). The findings showed that both ocular/generalized MG patients have a subclinical parasympathetic abnormality prominent in the AchR antibody negative group and pyridostigmine has a peripheral sympathetic cholinergic noncumulative effect.