Magnetic resonance dacryocystography: Its role in the diagnosis and treatment plan of lacrimal drainage system obstructions

Objective: To evaluate the role of magnetic resonance dacryocystography (MR-DCG) technique in patients with obstruction of lacrimal drainage system. Methods: A total of 40 patients who had presented to the ophthalmology clinic were suspected to have obstruction of lacrimal drainage system, were evaluated with MR-DCG after instillation of 0.5% Gd-DTPA conjunctival contrast medium. Dacryocystorhinostomy (DCR) was performed in patients who were found to have lacrimal drainage system obstruction on either side on MR-DCG. Results: Obstruction of lacrimal drainage system was successfully detected in a total of 49 eyes of 40 patients undergoing examination with MR-DCG. The MR-DCG findings of 29 nasolacrimal systems were compared with the intraoperative findings in 28 out of 40 patients who had undergone the DCR operation. The sensitivity of MR-DCG was determined as 100% and specificity as 96.7% for identification of nasolacrimal system obstruction when compared with the intraoperative findings, and MR-DCG was found to detect obstruction with high accuracy. Conclusion: MR-DCG has a high success rate in detection of lacrimal drainage system obstructions and the level and cause of the obstruction

Neuobičajeni klinički slučajevi koji oponašaju akutni diseminirani encefalomijelitis

Acute disseminated encephalomyelitis (ADEM) is an immune-mediated monophasic inflammatory demyelinating disorder of the central nervous system which poses a diagnostic challenge. We report on six cases of different etiologies that mimicked the clinical and radiologic findings of ADEM. The cases were collected from four different reference hospitals in Turkey. The same radiologist from the Akdeniz University Faculty of Medicine examined the magnetic resonance images of all patients. Three (50%) patients had antecedent infections. Initial symptoms of the patients were as follows: fever in 50%, altered consciousness in 33.3% and convulsions in 16.7% of patients. Neurologic examination showed long tract signs in 83.3%, ataxia in 50% and altered consciousness in 50% of patients. Cerebrospinal fluid examination revealed lymphocytic pleocytosis only in case 6. Four patients received steroid pulse therapy and one of these initially underwent intravenous immunoglobulin therapy. The patients’ definitive diagnoses were as follows: paraspinal neuroblastoma-associated paraneoplastic syndrome; histiocytic sarcoma; mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes; and cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy in one patient each, while two patients had hemophagocytic syndrome. The present case series demonstrated difficulties in diagnosing ADEM while revealing extremely rare disorders that mimic ADEM radiologically and clinically.Akutni diseminirani encefalomijelitis (ADEM) je immuno posredovana monofazna upalna demijelinizacijska bolest središnjega živčanog sustava koja je dijagnostički vrlo zahtjevna. Prikazuje se šest slučajeva različite etiologije gdje su klinički i radiološki nalazi oponašali ADEM. Slučajevi su prikupljeni iz četiri različite referentne bolnice u Turskoj. Slikovne prikaze dobivene magnetskom rezonancom u svih bolesnika pregledao je isti radiolog s Medicinskog fakulteta Sveučilišta u Akdenizu. Troje (50%) bolesnika imalo je prethodnu infekciju. Početni simptomi bili su groznica u 50%, poremećaj svijesti u 33,3% te konvulzije u 16,7% bolesnika. Neurološki pregled pokazao je znakove oštećenja srednjeg ili gornjeg dijela leđne moždine (long tract signs) u 83,3%, ataksiju u 50% te poremećaj svijesti u 50% bolesnika. Pregled likvora otkrio je limfocitnu pleocitozu samo u slučaju br. 6. Četiri bolesnika primilo je pulsnu steroidnu terapiju, a jedan od njih je prvotno bio na terapiji intravenskim globulinom. U bolesnika su postavljene sljedeće konačne dijagnoze: paraneoplastični sindrom udružen s paraspinalnim neuroblastomom; histiocitni sarkom; mitohondrijska miopatija, encefalopatija, laktična acidoza i epizode slične moždanom udaru (MELAS); i cerebralna autosomna dominantna arteriopatija sa subkortikalnim infarktima i leukoencefalopatijom (CADASIL) u po jednog bolesnika, te hemofagocitni sindrom u dvoje bolesnika. Ovaj niz slučajeva ukazuje na teškoće u dijagnosticiranju ADEM-a i istodobno pokazuje iznimno rijetke bolesti koje radiološki i klinički oponašaju ADEM

Single and double injection paravertebral block comparison in reduction mammaplasty cases: a randomized controlled study

Background This study compares the analgesic effects and dermatomal blockade distributions of single and double injection bilateral thoracic paravertebral block (TPVB) techniques in patients undergoing reduction mammaplasty. Methods After obtaining ethics committee approval, 60 patients scheduled for bilateral reduction mammaplasty were included in the study. Preoperatively, the patients received one of single (Group S: T3–T4) or double (Group D: T2–T3 & T4–T5) injection bilateral TPVBs using bupivacaine 0.375% 20 ml per side. All patients were operated under general anesthesia. The T3–T6 dermatomal blockade distributions on the midclavicular line were followed by pin-prick test for 30 min preoperatively and 48 h postoperatively. All patients received paracetamol 1 g when numeric rating scale (NRS) pain score was ≥ 4, and also tramadol 1 mg/kg when NRS was ≥ 4 again after 1 h. The primary endpoint was NRS pain scores at postoperative 12th h. The secondary endpoints were dermatomal blockade distributions and NRS scores through the postoperative first 48 h, time until first pain and the analgesic consumption on days 1 and 2. Results Fifty-two patients completed the study. The NRS pain scores at 12th h were similar (right side: P = 0.100, left side: P = 0.096). The remaining NRS scores and other parameters were also comparable within the groups (P ≥ 0.05). Only single injection TPVB application time was shorter (P < 0.001). Conclusions The single injection TPVB technique provided sufficient dermatomal distribution and analgesic efficacy with the advantages of being faster and less invasive

Feasibility of Board Tilt Angle on Critical Organs during Hippocampus-Sparing whole-Brain Radiotherapy

The objective of this study was to investigate the impact of altering the board angle on critical organ doses during whole-brain irradiation. Tomography images of the head region of the rando phantom were taken at angles of 0°, 10°, 20°, 30°, and 40°. Target volume (PTV) and organ at risk (OAR) contours were created on CT images using RTOG 0933 criteria. Tomography images of the head region of the rando phantom were taken at angles of 0°, 10°, 20°, 30°, and 40°. Target volume (PTV) and critical organ contours were created on CT images using RTOG 0933 criteria. During this comparative study, we aimed to achieve a standardized dose distribution in the PTV. We evaluated the doses received by D2 (minimum dose received by 2% of the target volume), D98 (minimum dose received by 98% of the target volume), D50 (dose received by 50% of the target volume), and organs at risk (OAR) in the PTV using CT scans taken at different angles. Additionally, we compared the homogeneity index (HI), conformity index (CI), and treatment time (MU) values. This method aimed to decrease the dose of the OAR region near the target volume, specifically the hippocampus. Our findings indicate that a board angle of 300 offers the greatest protection in terms of critical organ doses

Central neurogenic hyperventilation related to post-hypoxic thalamic lesion in a child

Central neurogenic hyperventilation (CNH) is a rare clinical condition, whose mechanism is still unclear. Here, we report a 3-year-old male patient, who had bilateral thalamic, putaminal and globus pallideal infarction resulted in CNH without brainstem involvement. This case may illustrate a possible role for the thalamus in regulating ventilation

Coexistence of Myotonic Dystrophy and Normal Pressure Hydrocephaly: Causative or Incidental?

OBJECTIVE: Myotonic dystrophy type 1 (DM1) is the most common adult muscular dystrophy involving not only the striated muscle but also multiple systems including central nervous system, resulting from an autosomal dominantly inherited gene mutation causing trinucleotid repeats. Neuroimaging findings in patients with DM1 are ventricular enlargement, hyperintensity of white matter at the posterior-superior trigone (HWMPST), hyperostosis frontalis interna and thining of corpus callosum. Although ventriculomegaly is reportedly the most common finding, DM1 in association with normal pressure hydrocephalus (NPH) has been reported in anecdotal case reports. The aim of the study is investigate the frequency of ventriculomegaly and also clinical diagnosis of NPH in patients with DM1 in a retrospective case series. METHODS: Neuroimaging (mostly cranial MRI) findings in 20 patients (9 women; mean age: 38,25 years ± 10,26[range: 18-60]; mean disease duration: 18,9 years ± 10,5 [5-43]) with DM1 diagnosed with clinical and electromyographic findings are examined retrospectively. RESULTS: The available neuroimaging data came from MRI scans in 19 cases and CT scans in the remaining case. Ventriculomegaly as decided by increased ventriculocerebral index (VCI) was evident in only two patients who were siblings, one of whom also had classical NPH clinical triad. After ventriculoperitoneal shunt his urinary incontinence and gait difficulty had improved. CONCLUSION: This retropective analysis did not support the view that the ventriculomegaly is a frequent neuroimaging finding in adult DM1. A prospective study, preferably with genetic data that would also allow the correlation of the number of trinucleotid repeats with the abnormal neuroimaging findings, might better answer the question whether ventriculomegaly is causally associated with adult DM1, and NPH could be its secondary clinical presentation, thus further complicating the late course of this already disabling disease, since that latter condition is reversable when recognized early. Keywords: Myotonic dystophy Type 1, neuroimaging, ventriculomegaly, normal pressure hydrocephal

Herpes Zoster Myelitis Presented with Brown-Sequard Syndrome

Brown Séquard syndrome, is caused by a lesion effecting one half of the spinal cord in a segment or more than one segments. Below the lesion level, there is loss of deep sensory and motor functions on the ipsilateral side, whereas loss of pain and temparature sensations are present on the contralateral side. Most common causes are trauma, radiation necrosis and spinal metastases. Here, we aimed to present a case of herpes Zoster virus myelitis, that was presented as Brown Séquard sydrome, which is very rare. A 55-year-old male was presented with acute paresia of the right arm and leg. Three days after the start of these complaints, painful, itchy and vesicular blisters appeared on the extensor surface of the right arm. On neurological examination, there were 4+/5 paresis on the right arm and leg, loss of proprioception on the right upper and lower extremities, and loss of temparature sensation on the left upper and lower extremities. Servical MRI showed an expansile hyperintense lesion which was located on C5-C6 level within spinal cord, on T2-weighted images. Lesion diameter was 3 centimeters. Skin lesions showed regression within 15 days, whereas motor deficits remained stable. After 4 months, MRI showed marked regression of the spinal cord lesion. We aimed to share the findings of this HZV myelitis case, which is very rare and its MRI findings may easily misinterpreted as a spinal mass lesion