Cesarean scar pregnancy: MRI feature

A 34-year-old woman, gravida 4, para 2, presented at the emergency room with severe abdominal pain and red vaginal bleeding. Medical history revealed 2 previous cesarean sections at term gestation. Laboratory findings showed an elevated b-HCG consistent with an estimated gestational age of 6-7 weeks. Transabdominal ultrasound showed a well-circumscribed, thick-walled cystic mass within the lower part of the anterior myometrium. In the central cystic cavity a small mural nodule with discrete pulsatile flow was noticed. Subsequently a pelvic MRI exam was performed confirming the presence of the thick-walled, well-circumscribed mass in the lower part of the uterine wall (Fig. A). The mass extended beyond the expected contour of the uterus and no overlying myometrial tissue could be identified at the anterior border. At the cranial and posterior border of the mass a non-enhancing, T2 hypointense fibrous band was noticed, consistent with scar tissue of the two previous cesarean sections (Fig. B). The wall of the mass was T2 hyperintense, T1 iso-intense and showed a strong and heterogeneous enhancement following intravenous administration of gadolinium (Fig. C). The central portion of the mass was T2 hyperintense, T1 hypo-intense and showed no contrast enhancement. The cavity of the uterus was filled with T1 hyperintense, hemorrhagic fluid. A corpus gravidarum was seen on the left side. These findings were consistent of an ectopic pregnancy in a cesarean scar. Patient was successfully treated with a combination of chemotherapy and bilateral uterine artery embolization followed by a planned hysterectomy several weeks late

Agenesis of the infrarenal inferior vena cava

A 71-year-old man presented to the emergency room with complaints of progressive dyspnoe and pain in both lower extremities. His medical history consisted of multiple idiopathic deep vein thrombosis, familial deafness and cholecystolithiasis. Clinical examination revealed large varicose veins in both lower extremities. A following electrocardiogram, echocardiography and radio graphy of the thorax were normal (not shown). D-dimeren had risen for which an angio CT of the thorax was performed. This showed no pulmonary embolism (not shown). A venous duplex of the lower extremities revealed insufficiency of both the superficial and deep venous system (not shown). An abdominal CT with intravenous contrast injection showed absence of the infrarenal inferior vena cava (Fig. A), absence of the common iliac veins, enlarged ascending lumbar veins (Fig. B) and prominent anterior paravertebral collateral veins (Fig. C) which lead to a prominent azygos vein (Fig. C). A complex venous collateral circulation was found infrarenally (Fig. A) as well as in the abdominal wall (Fig. D). The suprarenal IVC was normal (Fig. E), formed by confluence of the renal veins. Multiple calcifications in the enlarged internal and external iliac veins confirm a history of deep vein thrombosis (Fig. F)

Eosinophilic cystitis mimicking bladder tumor

A 48-year-old man presented to the Urology Department with acute dysuria and macroscopic hematuria for 2 days. There was no frequency or nocturnal enuresis. Analysis of midstream urine showed hematuria and pyuria

Migraine in women: the role of hormones and their impact on vascular diseases

Migraine is a predominantly female disorder. Menarche, menstruation, pregnancy, and menopause, and also the use of hormonal contraceptives and hormone replacement treatment may influence migraine occurrence. Migraine usually starts after menarche, occurs more frequently in the days just before or during menstruation, and ameliorates during pregnancy and menopause. Those variations are mediated by fluctuation of estrogen levels through their influence on cellular excitability or cerebral vasculature. Moreover, administration of exogenous hormones may cause worsening of migraine as may expose migrainous women to an increased risk of vascular disease. In fact, migraine with aura represents a risk factor for stroke, cardiac disease, and vascular mortality. Studies have shown that administration of combined oral contraceptives to migraineurs may further increase the risk for ischemic stroke. Consequently, in women suffering from migraine with aura caution should be deserved when prescribing combined oral contraceptives

Transjugular intrahepatic portosystemic shunt placement for symptomatic non-bleeding anorectal varices in nodular regenerative hyperplasia

In this paper we present the case of a male 55-year old patient with known ulcerative colitis and nodular regenerative hyperplasia, a rare form of noncirrhotic portal hypertension. He presented four visits to the emergency department with rapidly progressive anal discomfort. After two weeks a transjugular intrahepatic portosystemic shunt was placed using the gun-sight technique with immediate relief of the unbearable anal pain and pressure. To our knowledge, this is the first case where transjugular intrahepatic portosystemic shunt placement is applied for nonbleeding, congestive anorectal varices

Polyp measurement and size categorisation by CT colonography: effect of observer experience in a multi-centre setting.

The extent measurement error on CT colonography influences polyp categorisation according to established management guidelines is studied using twenty-eight observers of varying experience to classify polyps seen at CT colonography as either 'medium' (maximal diameter 6-9 mm) or 'large' (maximal diameter 10 mm or larger). Comparison was then made with the reference diameter obtained in each patient via colonoscopy. The Bland-Altman method was used to assess agreement between observer measurements and colonoscopy, and differences in measurement and categorisation was assessed using Kruskal-Wallis and Chi-squared test statistics respectively. Observer measurements on average underestimated the diameter of polyps when compared to the reference value, by approximately 2-3 mm, irrespective of observer experience. Ninety-five percent limits of agreement were relatively wide for all observer groups, and had sufficient span to encompass different size categories for polyps. There were 167 polyp observations and 135 (81%) were correctly categorised. Of the 32 observations that were miscategorised, 5 (16%) were overestimations and 27 (84%) were underestimations (i.e. large polyps misclassified as medium). Caution should be exercised for polyps whose colonographic diameter is below but close to the 1-cm boundary threshold in order to avoid potential miscategorisation of advanced adenomas