How to avoid and manage iatrogenic femoral arteriovenous fistulae?

Iatrogenic femoral arteriovenous fistula [AVF] is one of the most frequent complications of percutaneous vascular intervention. We report 3 cases of iatrogenic AVF; one followed coronary angiography and stent implantation and the other two followed permcath insertion for hemodialysis. A review of these cases and of the relevant literature showed that most of these iatrogenic AVF originated below the bifurcation of the common female artery [CFA], which indicates that an excessively distal puncture site is a possible anatomic explanation for the formation of iatrogenic AVF. All the cases were managed successfully by open surgery

Unusual case of left iliac vein compression secondary to May-Thurner syndrome and crossed fused renal ectopia

External compression of the left iliac vein against the fifth lumbar vertebra by the right iliac artery [May and Thurner syndrome] is a well-known anatomic variant. We identified a rare case of May-Thurner syndrome associated with crossed fused renal ectopia on the left side. The patient presented with complete thrombosis of the left common iliac vein down to the popliteal vein. He was treated with catheter directed thrombolysis followed by anticoagulant therapy

Pleuropulmonary blastema. a rare childhood malignancy

Pleuropulmonary blastema [PPB] is an extremely rare, intrathoracic neoplasm of early childhood with unfavorable outcome. We present a case of a 4-year-old boy with progressive dyspnea due to tension pneumothorax. After chest tube insertion, the CT scan showed large multilocular cystic lesions containing air and solid areas involving the right lower lobe, and its related pleura. Thoracotomy was carried out, and the cyst was removed with the pleural solid areas. Histopathological examination confirmed the diagnosis of PPB type II. Postoperatively, the patient was scheduled to start chemotherapy in a specvalvxed pediatric oncology center to complete the treatment

Gray matter heterotopia: value of MRI

Gray matter heterotopia is defined as abnormally positioned but otherwise normal neurons. These cells are found anywhere along their normal migration path along radial glial fibers from ependyma to cortex. Gray matter heterotopia has been divided into three groups based on clinical and imaging characteristics; subependymal, subcortical, and band heterotopia. The Purpose of this study is to evaluate MRI features of different types of gray matter heterotopia. A prospective study was conducted between June 2004 and December 2006, Department of Radiology, King Faisal University, Dammam, KSA. The medical records and MRI studies of patients with gray matter heterotopia were reviewed. The MRI morphologic findings of the heterotopia were recorded along with presence and type of associated cranial malformations. Available clinical and electrophysiological data were recorded as well. Twenty patients were included in the study. Their ages ranged from 9 months to 39 years with a mean age of 15 years. All patients suffered from epileptic seizures. According to the location of heterotopia, patients were classified into three groups; subependymal [12], subcortical [5] and band [3]. MRI was found to be accurate in diagnosis and differentiation between various types of gray matter heterotopia. Severity of clinical manifestations of heterotopia was related to the location and pattern of heterotopia. Determination of the heterotopia type and its extent is useful to direct the management plan and predict the prognosis

High frequency sonographic assessment of dequervain's disease and US-guided therapeutic steroid injection

DeQuervain's disease is a stenosing tenosynovitis. There is inflammation of the cellular lining membrane of the fibrous tube through which the tendons of abductor pollicis Iongus [APL] and extensor pollicis brevis [EPB] move, at the radial styloid process. There is pain and weakness of hand grip. It may occur in association, with rheumatoid arthritis, other inflammatory synovitis, direct trauma, and pregnancy. The purpose of this study was to investigate the value of ultrasound [US] in diagnosis of DeQuervain's disease, to describe US-guided injection technique and demonstration of changes in tendon sheath following US-guided local steroid injection. A cohort of thirty patients with clinical diagnosis of DeQuen,ain's disease and 10 normal subjects were studied prospectively. US examination was performed using HDI 3000 from ATL-USA and linear array transducer 11MHz. The affected tendon sheath was in filtrated with 15 mg triamcinolone diacetate, 2 ml saline and 2 ml of 2% lidociane. The injection was delivered under direct sonographic guidance. US examination was performed following clinical evaluation and repeated at 1 and 12 weeks later. The marginal appearance of tendon sheathes was measured. We used VAS [visual analog scale] 0-10 and hand's grip strength to measure pain. The normal tendons show normal fibrillar hyperechogenicity with no tears or hematoma. The affected tendons of APL and EPB show diffuse circumferential hypoechogenicity around the tendons, distension in the tendon sheath and a surrounding fluid film at the radial styloid process. The US; recognized 3 patients with a different diagnosis of tenosynovitis of the flexor carpiradialis tendon that results in pain at the base of the thenar muscles eminence. The tendons of APL and EPB became inflamed and thickened. US measurements of tendon sheathes showed a significant increase in thickness [range 1.8-2.6 mean 2.4 +/- 0.2 mm], compared with normal subjects [range 0.7-1.2 mean 0.9 +/- 0.3 mm], [P<0.00 1]. In all of our patients, a significant decrease in the thickness of the affected tendon sheath was observed one week after US-guided local steroid injection, [range 1.1-1.5 mean 1.2 +/- 0.2 mm]. Complete relief of symptoms and signs was further observed at 12 weeks. The VAS 0-10 scale and hand's grip strength were significantly improved [P<0.001]. US examination of tendon sheathes is simple, sensitive, easy, safe and quick to perform and reproducible. The US-guided local corticosteroid injection will avoid inappropriate direct injury into the tendon. It was proved to be safe and effective in treatment of DeQuervain's. Therefore. US procedure should be considered early in diagnosis and management of DeQuervain's disease

Neuroradiological correlative study of pateints with transient ischemic attacks [TIAs] with special emphasis on the role of MRA

Accurate evaluation of the intracerebral vasculature is essential for proper diagnosis and treatment of many neurological disorders including TIAs. Vascular anatomy of brain can be assessed by many modalities including: Direct angiography, MRA, CT angiography and transcranial sonography. This study aimed to compare the validity and clinical matching of the different radiological and para-radiological modalities of examination in the evaluation of the cause of TlAs, with special interest to evaluate MRA and relation of TIAs to congenital vascular anomalies. 28 patients presented recently with TIAs were the subject of this study. Conventional CT of the brain, MRI brain, MRA brain and neck were performed to all patients while Duplex Doppler study of neck vessels was performed in 20/28 patients. MRA Brain showed positive findings in 20/28 patients while MRA neck showed positive results in 8 patients and both were negative in 2 patients [either one or both were positive in 26 patients] and they match clinical presentation in 20/28 of the patients and mismatch the clinical diagnosis in 8/28 of patients. combined MRA and MRI studies for the patients increase the diagnostic accuracy to 79% . .MRA neck showed 100% matching with D. Doppler examination of the neck vessels. MRI diagnosed 12/28 patients while CT diagnosed only 6/28 patients. Congenital anomalies of brain vessels occurred in 13/28 patients. The most common anomaly was absent Al segment in 28% of patients followed by absent P1 segment in 11% of patients. MRA missed the diagnosis in 2/28 patients while MRI proved it. Vertigo was a deceiving symptom, with the least accuracy and matching with all modalities of examination. MRA is the technique of choice to evaluate brain vascularity [accurate, safe, no contrast medium and no Ionizing radiation] with high accuracy and matching with clinical presentation. There is direct relation between the incidence of TIAs and congenital anomalies of the brain. MRI examination is very helpful in few patients while conventional CT can be replaced by MRI as it adds nothing and miss the diagnosis in many patients. Duplex Doppler study of neck vessels can replace MRA neck. We recommend the following scheme for evaluation of patients with TIAs :1. MRI brain, 2. MRA brain, 3. D.Doppler neck vessels

Study of pulmonary mainfestations in systemic sclerosis

Pulmonary involvement is frequent in systemic sclerosis, which leads to reduction in lung volumes and gas transfer across the alveolocapillary barrier and alteration of the pulmonary functions. The aim of this work was to study the pulmonary [functional and structural] changes in patients with systemic sclerosis. Thirty subjects comprised the material of this study, twenty of them had systemic sclerosis and ten were normal healthy volunteers as a control group. They were subjected to thorough history taking, complete clinical examination, PFT, BAL, CXR, 2D Echocardiography and HRCT. It was found that the mean values of FVC and DLCO were significantly lower in sysiemic sclerosis patients than those in normal control group. Also the lymphocytes, granulocytes, IgG and albumin in BAL fluid of patients with systemic scterosis were significantly higher than that in the normal control. HRCT scores were significantly higher in systemic sclerosis patients than normal control and also were higher in patients with abnormal BAL than those with normal BAL. It was concluded that: 1. Patients with systemic sclerosis have an inflammatory aiveolitis with hypercellularity and increased percentage of granulocytes recovered from the lower respiratory tract by BAL. 2. The significant correlalion between the degree of alveolitis and the degree of decline in PFT in such patients, increases the value oi BAL in identification of high risk group. 3. HRCT is an excellent radiodiagnostic tool for quantification of lurig lesions in systemic sclerosis and also for predication of sequale of these lesions on pulmonary functions