Cerebral X-linked Adrenoleukodystrophy Presenting As Enlarging Cavum Vergae Cyst: A Case Report.

The cavum vergae cyst (CVC) is an uncommon brain malformation. Most patients with CVC are asymptomatic and do not require neurosurgical intervention. Separately, cerebral X-linked adrenoleukodystrophy (X-ALD) is one of the phenotypes of a genetic peroxisomal disorder that is seldom managed by neurosurgeons. We report an unusual case of cerebral X-ALD presenting as an enlarging CVC in a child, and discuss its nuances in corroboration with the literature. A previously well six-year-old male presented with confusion and fever. Urgent neuroimaging demonstrated a large CVC with resultant hydrocephalus. Of note, there were symmetrical areas of signal changes in the periventricular white matter bilaterally involving the corpus callosum, thalami, cerebral peduncles, midbrain, and pons in his MRI. Further investigations performed as part of his medical workup reported high plasma concentrations of very long-chain fatty acids (VLCFA). Put together, a diagnosis of cerebral X-ALD was confirmed. Initially, an external ventricular drain was inserted directly into the CVC under stereotaxy to decompress it. Subsequently, endoscopic fenestration of the CVC was performed as the definitive treatment. He recovered uneventfully from the neurosurgical interventions and proceeded for the treatment of his cerebral X-ALD. To our knowledge, this is the first report of cerebral X-ALD presenting as a CVC in a patient. This case adds to the limited literature for both rare conditions and highlights the importance of a multidisciplinary approach to management.

Renal impairment and time to fracture healing following surgical fixation of distal radius fracture.

INTRODUCTION: Despite the prevalence of renal impairments, the existing literature examining fracture healing in the upper limb in patients with renal impairment is sparse. This study hence aims to investigate the effect of renal impairment on time to fracture healing after distal radius fracture fixation surgery. MATERIALS AND METHODS: Patients above 50 years old who underwent distal radius fracture fixation via volar plating were included. Time to fracture healing was defined as duration between day of surgery and presence of radiographic union as evidence by bridging of callus or osseous bone. To assess for renal impairment, estimated glomerular filtration rate (eGFR) was calculated based on the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Pre-existing comorbidities were also collected and analysed. RESULTS: Ninety-nine consecutive patients took mean 65.5 ± 8.0 days to fracture healing post-operatively. Patients with renal impairment had longer time to fracture healing than patients without (67.1 ± 50.4 days versus 50.4 ± 31.8 days, p = 0.044). Patients ≥ 65 years also had a longer duration to fracture healing compared to patients < 65 years (mean 63.7 ± 53.0 days versus 50.2 ± 27.2 days, p = 0.033). Similarly, patients with ASA Class I had a shorter mean time to fracture healing than patients with ASA Class II and above (mean 42.5 ± 22.8 days versus 62.8 ± 47.6 days, p = 0.028). CONCLUSIONS: Time to fracture healing post-distal radius fracture fixation was significantly related to renal impairment, age and ASA classification.

Clinical outcomes and management of contrast hypersensitivity in patients requiring repeated computed tomography imaging.

Introduction: In collaboration with the Department of Rheumatology, Allergy and Immunology, our study aims to review the outcomes of and propose an improved workflow for the management of patients with prior hypersensitivity reactions to iodinated contrast media (ICM). Method: Outpatients coming for contrast-enhanced computed tomography (CECT) were stratified into 3 categories (definite, unconfirmed and inaccurate) based on likelihood of their contrast hypersensitivity label. Patients could be offered a different ICM, receive the same ICM, or be referred to an allergist for further evaluation. There were 4 outcomes: (1) alternative ICM tolerated; (2) same ICM tolerated again; (3) patient developed a hypersensitivity reaction to either alternative or original ICM; and (4) CECT was deferred until assessment by an allergist. Comparison was made pre- and post-intervention to see if patient outcomes were improved. Results: There were 132 patients who made a total of 154 visits (90.3% had documented contrast hypersensitivity). Post-intervention, the number of visits postponed for premedication decreased (81.0% to 34.7%). There was a reduction in hypersensitivity reactions (from 42.9% to 14.3%). Of the 12 patients assessed by the allergist, 6 could continue using the same or alternative ICM, 4 were advised to abstain from further contrast administration and 2 were pending testing with a third agent. Conclusion: Active intervention by the radiologist can decrease the number of postponed, converted or cancelled CECT studies as well as reduce the number of adverse allergic-like events. Direct collaboration between radiologist and allergist for specific cases may be helpful in patients who will likely need future/repeated CECTs.

The Effect of Hand Dominance, Age, Gender, Fracture Comminution and ASA Status on Time to Fracture Healing Following Surgical Fixation of Distal Radius Fractures.

Background: There is recent renewed interest in the effect of hand dominance on distal radius fractures. Current studies focus on functional or patient-reported outcomes, with lack of studies pertaining to radiological outcomes. The primary aim of this study is to examine the effect of hand dominance on time to fracture healing following surgical fixation of distal radius fracture. We also looked at the effect of age, gender, fracture comminution and American Society of Anaesthesiologists (ASA) status on time to fracture healing. Methods: Patients who underwent distal radius fracture fixation surgery in our department from 1 January 2015 to 31 December 2015 were included. Time to fracture healing was taken from the day of surgery to when radiographic union was present as evidence by bridging callus or osseous bone. We looked at the effect of hand dominance, age, gender, fracture comminution and ASA status on time to fracture healing. Results: One hundred and forty-five consecutive patients (80 females and 65 males) had a mean period of 56.2 ± 41.8 days to fracture healing post-operatively. Patients with dominant hand injury had a shorter duration to fracture healing than patients with non-dominant hand injury (mean 47.3 ± 31.1 days versus 62.1 ± 46.8 days, p = 0.023). Patients ≥ 65 years and with pre-existing medical conditions (ASA Class II and above) had a longer duration to fracture healing (mean 63.7 ± 53.0 days versus 51.9 ± 33.4 days, p = 0.036 and mean 47.9 ± 30.0 days versus 62.0 ± 47.7 days, p = 0.016, respectively). In addition, patients with comminuted fractures took longer to heal than patients with non-comminuted fractures (mean 57.6 ± 33.4 days versus 48.3 ± 20.8 days, p = 0.038). Conclusion: Time to fracture healing post distal radius fracture fixation surgery was significantly related to hand dominance, as well as age, ASA classification and fracture configuration. Dominant wrist injuries had shorter time to fracture healing. Level of Evidence: Level IV (Therapeutic).

Imaging mimickers of cholangiocarcinoma: a pictorial review.

Cholangiocarcinoma (CCA) is the second most common primary hepatobiliary malignancy and presents as three separate morphological subtypes; namely mass-forming, periductal-infiltrating, and intraductal-growing patterns. Each of these subtypes have distinct imaging characteristics, as well as a variety of benign and malignant mimics, making accurate diagnosis of CCA on imaging challenging. Whilst histopathological examination is required to arrive at a definitive diagnosis, it is still important for radiologists to be cognizant of these entities and provide reasonable differential diagnoses, as these potentially have a large impact on patient management. This pictorial essay illustrates the three morphological subtypes of CCA, as well as some important mimics for each subtype, that are encountered in clinical practice.