The significance of magnetic resonance imaging and computed tomography findings in sphenoid sinus agenesis.

Agenesis of the sphenoid sinuses is a very rarely encountered anatomic variation. Findings on magnetic resonance imaging can mislead the radiologist and clinician. Therefore, the gold standard for diagnosis is computed tomography (CT) of the paranasal sinuses. We present the case of a 28-year-old man who was admitted to our hospital with a 3-month history of headache. CT of the paranasal sinuses revealed isolated bilateral sphenoid sinus agenesis.

Is perioperative examination of frozen sections necessary in nephron-sparing surgery?

AIM: To evaluate the role of perioperative freezing in the management of surgical procedures in patients with malignant renal masses. MATERIALS AND METHODS: The study group consisted of 17 patients diagnosed with renal masses who underwent nephron-sparing surgery. The group included 5 females and 12 males aged from 44 to 68 years (mean = 54.6). The mean mass size was 5.5 cm. Mass locations were as follows: 9 were in the lower pole, 4 were in the mid-pole, and 6 were in the upper pole. Perioperative freezing was not carried out. The patients were followed-up in a period ranging from 3 months to 7 years. RESULTS: Tumor pathology was reported as renal cell carcinoma in all cases, and surgical margins were negative in all of them. One patient died after 1 year because of tumor metastasis. In another patient, the tumor reoccurred in the same kidney and a radical nephrectomy was performed. Other patients were followed without recurrence. CONCLUSION: Imaging of the renal vascular system and freezing during surgery is not necessary for nephron-sparing surgery for renal cell carcinoma; however, we should be careful in terms of capsule invasion because of tumor recurrence.

A bladder wall angiomyolipoma as a manifestation of tuberous sclerosis: first case report.

A 21-year-old female patient admitted to the emergency department complaining of left side pain. Hypovolemic shock, which was probably caused by retroperitoneal bleeding from left sided renal angiomyolipoma, was developed. Abdominal computed tomography showed multiple fat containing lesions in different, regions including right bladder wall, lower pole of left kidney, and right kidney. Some lesions compatible with tuberous sclerosis such as angiofibromas, Shagreen patches, myocardial, and brain hamartomas were also detected. Bladder wall mass showing intra- and extravesical extensions was seen at exploration. We removed the tumor completely preserving bladder trigone. Angiomyolipoma located at lower pole of left kidney was also removed. Diagnosis of bladder angiomyolipoma was confirmed by the immunohistochemical examination. Recurrent or residual mass was not detected at the three-months-follow-up. We report the first case of bladder angiomyolipoma confirmed by histopathologically as a tuberous sclerosis.

Is microsurgery necessary in grade 3 varicocele?

PURPOSE: To compare the results of microsurgical and naked eye varicocelectomy in patients with grade 3 varicocele. MATERIALS AND METHODS: This study was conducted on 84 patients with grade 3 varicocele, between 2007 and 2009. Patients were randomized into two groups, equal in number. Thereafter, microsurgical varicocelectomy was performed in the first group, while the other group underwent naked eye varicocelectomy. Groups were compared in terms of operation duration, number of ligated internal and external spermatic veins, early and late postoperative complications, and postoperative color Doppler ultrasonography findings. Parametric and nonparametric values were compared using Student's t test and Chi-Square test, respectively. RESULTS: The mean duration of surgery was 19 ± 2.3 minutes (range, 12 to 25 minutes) in the naked eye surgery group and 43 ± 3.9 minutes (range, 25 to 75 minutes) in the microsurgery group (P = .008). The number of ligated internal and external spermatic veins, the incidence of early and late postoperative complications, and color Doppler ultrasonography findings were not significantly different between the two groups (P = .12, P = .09, P = .17, and P = .22, respectively). CONCLUSION: In patients with grade 3 varicocele, microsurgery and naked eye surgical methods proved similar results in terms of success and complications. Because the operation time of the classical varicocelectomy is significantly shorter, it may be preferred in this subset of patients.

Cine phase-contrast MRI evaluation of normal aqueductal cerebrospinal fluid flow according to sex and age.

PURPOSE: The aim of this study was cerebrospinal flow quantification in the cerebral aqueduct using cine phase-contrast magnetic resonance imaging (MRI) technique in both sexes and five different age groups to provide normative data. MATERIALS AND METHODS: Sixty subjects with no cerebral pathology were included in this study. Subjects were divided into five age groups: < or =14 years, 15-24 years, 25-34 years, 35-44 years, and > or =45 years. Phase, rephase, and magnitude images were acquired by 1.5 T MR unit at the level of cerebral aqueduct with spoiled gradient echo through-plane, which is a cine phase-contrast sequence. At this level, peak flow velocity (cm/s), average flow rate (cm/ s), average flow (L/min), volumes in cranial and caudal directions (mL), and net volumes (mL) were studied. RESULTS: There was a statistically significant difference in peak flow between the age group of < or =14 years and the older age groups. There were no statistically significant differences in average velocity, cranial and caudal volume, net volume, and average flow parameters among different age groups. Statistically significant differences were not detected in flow parameters between sexes. CONCLUSION: When using cine-phase contrast MRI in the cerebral aqueduct, only the peak velocity showed a statistically significant difference between age groups; it was higher in subjects aged < or =14 years than those in older age groups. When performing age-dependent clinical studies including adolescents, this should be taken into consideration.

Evaluation of dynamic magnetic resonance imaging in assessing velopharyngeal insufficiency during phonation.

BACKGROUND: Velopharyngeal insufficiency (VPI) expresses the structural and neuromuscular disorder of soft palate and pharyngeal walls inhibiting the normal functions of velopharyngeal (VP) sphincter mechanism. In this study, efficacy of dynamic magnetic resonance imaging in the diagnosis of VPI is investigated. MATERIALS AND METHODS: A total of 32 cases, 16 controls and 16 cleft palates, were included in this study. T1 fast spin echo-weighted imaging during rest, dynamic investigations with True-fast imaging with steady-state precession sequence during /sss/ and /mmm/ phonations were performed. RESULTS: During /sss/ phonation, complete closure was observed in the control group, whereas mean VP opening was 4.11 cm2 preoperatively and 0.21 cm2 postoperatively in the cleft palate group. In the postoperative period, only 3 patients did not have complete closure. In the second operations, performed 6 months later, only muscle repair was done. All 3 had complete closure. CONCLUSIONS: In cleft palate cases with delayed diagnosis, appropriate application of muscle repair will be sufficient for anatomic repair of VPI without any extra procedures. In addition, dynamic magnetic resonance imaging is an objective, noninvasive, reliable, and effective modality that may be used in the diagnosis and treatment of VPI without any extra investigations.

Detection and quantification of the parenchymal abnormalities in emphysema using pulmo-CT.

We aimed to determine the degree and extent of parenchymal abnormalities on pulmo-CT in patients with emphysema. The study group consisted of 29 patients (18 male, 11 female; mean age 57.9+/-13). The diagnosis was based on clinical symptoms, pulmonary function tests (PFT) values, and chest CT findings. All of the patients CT scans were obtained during suspended deep inspiration from the apices to the costophrenic angles. The mean lung attenuation (MLD) and parenchymal abnormalities related to emphysema were quantitatively calculated with tables, histograms and graphics at the whole lung. The lung density measurements revealed a mean density of -898.48+/-51.37 HU in patients with emphysema and -825.1+/-25.5 HU in control group. In addition, mean percentage of subthreshold attenuation values was found as 12.03+/-15.75 and 1.07+/-0.83 in patients with emphysema and control group, respectively. Compared with control group, the patients with emphysema had a significantly lower inspiratory MLD (p<0.05). Additionally, statistically significant correlations were seen between the MLD and percentage of subthreshold values (r=0.44, p<0.05). In contrast, there was poor correlation between PFT measurements and the subthreshold values. In conclusion, pulmo-CT is a quick, simple method for quantitative confirmation of the presence of parenchymal abnormalities of lung as mosaic attenuation and should be used in combination with other radiological methods and PFT as it gives additional information to routine examinations in patients with emphysema.

Multiple brain abscesses in a child with autoimmune hemolytic anemia.

A 14-year-old female with autoimmune hemolytic anemia (AIHA) developed an acute hemolytic crisis with acute renal failure under conventional treatment with corticosteroids. Because of the life-threatening situation, we decided to start pulse dose methylprednisolone and also hemodialysis with a femoral catheter placement was performed. Fifteen days after initiating of dialysis subfebrile fever was developed, followed within 2 days with a left hemiparesis. Brain magnetic resonance imaging (MRI) revealed multiple intracerebral abscesses. The clinical picture worsened and the patient died before scheduled surgery for the abscesses.

Radiological and clinical course of pneumonia in patients with avian influenza H5N1.

INTRODUCTION: We evaluated chest X-ray and clinical findings of patients with lower respiratory tract infection due to influenza H5N1 and presented the radiological findings and clinical course of the infection. MATERIALS AND METHODS: Between December 2005 and February 2006, eight hospitalized patients (median age 10, 5-15 years) with avian-flu were evaluated in this study. All patients were evaluated with chest X-ray and four of them with CT scan. Post mortem pathological characterization were also available for three of the patients. RESULTS: A rapidly progressive pneumonia with high mortality rate was observed especially for cases with late admission. The major radiologic abnormalities were extensive pneumonic infiltration with segmental and multifocal distribution, mostly located in lower zones of the lung. No pleural effusion and hilar lymphadenopathy was noted. CONCLUSION: Avian flu may be presented as rapidly progressive pneumonia. The chest radiography has an important role in diagnosis and should be obtained daily because of rapid change of the findings that may necessitate prompt action.

Reconstruction of wide scrotal defect using superthin groin flap.

INTRODUCTION: Grafts and flaps have been widely used to reconstruct scrotal defects due to Fournier's gangrene. Controversy still exists concerning the use of grafts and flaps because of the low protection provided by the grafts and the high volume of the flaps. We describe the use of an expanded groin flap for scrotum reconstruction. TECHNICAL CONSIDERATIONS: Three patients were treated for total scrotal tissue loss using this method. An expander was installed through an incision from the inferolateral aspect of the groin, and superthin flaps obtained after 3 weeks were dissected starting from the medial side. Care was taken during dissection, because the skin was thin on the lateral side, and dissection was performed in a subfascial fashion. Finally, the defect was covered with the lateral part of the expanded flap and the donor site was primarily closed. CONCLUSIONS: To cover the testes, both the aesthetic and functional state should be taken into consideration. Therefore, a thin and durable cover is required for scrotal reconstruction. The expanded superthin groin flap possesses these features and is a good option.

Primary hydatid cyst of the brain during pregnancy.

A 26-year-old woman in the 28th week of pregnancy presented with a primary cerebral hydatid cyst manifesting as deteriorating consciousness and weakness in the left arm and leg. Cranial computed tomography revealed an intracranial hydatid cyst. The cyst was surgically removed and albendazole was administered. The patient had a spontaneous vaginal term delivery and no problem was observed in the mother or child. No primary focus was found in the lungs, liver, and other organs. Hydatid cyst is still an important disease. Intracranial hydatid cyst without primary foci in organs such as the liver and lungs is very rare. Primary cerebral hydatid cyst during pregnancy can be successfully treated by surgical and medical intervention.

Right renal stone on the trajectory of upper left ureter.

We report a 52-year-old woman with a right renal pelvic stone, mimicking a left upper ureteral stone in a kidney-ureter-bladder film. Computed tomography detected the exact anatomical location of the stone, which was not possible by intravenous urography and ultrasonography. In this study, we discuss diagnostic modalities of the urinary calculi in the light of the literature.

The importance of rigid nasal endoscopy in the diagnosis and treatment of rhinolithiasis.

OBJECTIVES: Rhinolithiasis is the presence of mineralized and calcareous formations located in the nasal cavity. They have rare occurrence and can be easily confused with infection or obstruction of upper airways. If they are undetected for a long time, they may grow large enough to cause of nasal obstruction, mimicking sinusitis. Seven cases of rhinolithiasis were presented, and their diagnosis was made by rigid endoscopic nasal examination. Also computerized tomography scan was used to describe the size and site of the rhinoliths accurately. Our purpose was to determine the role of rigid nasal endoscopy in the diagnosis and the treatment of rhinolithiasis. METHODS: In this study, seven cases of rhinolithiasis, who were diagnosed and treated by rigid nasal endoscopy were presented. RESULTS: Between January 2000 and November 2004, seven cases (four males and three females; age ranged from 8 to 45 years) with rhinolithiasis were diagnosed. The most frequent symptoms were nasal obstruction with purulent rhinorhea, nasal and oral malodor. As complementary examinations, computerized tomography and simple X-ray of paranasal sinuses were used to locate and measure the dimension of calcareous mass, and to reveal possible invasion of the adjacent structures. The removal of rhinolithiasis was done with rigid nasal endoscopy under topical anesthesia in six cases and general anesthesia in one case. CONCLUSION: Rhinolithiasis is a rare condition but must always be suspected in patients with long standing nasal obstruction, nasal and oral malodor, purulent rhinorrhea and chronic headache.

Intracranial lipomas--a clinical study.

OBJECTIVE: This study aimed to investigate the localization of the lipoma, as well as associated intracranial and extracranial lesions in 14 patients immediately following hospital admission. The pathological findings from the neurological examinations of these patients are also investigated. METHODS: Fourteen patients who were admitted to our clinic with a variety of symptoms and diagnosed with intracranial lipoma were included in the study. Problems presented upon admission, neurological findings, and other existing system abnormalities were evaluated. Localization of the lipomas and accompanying pathologies were determined by using computerised tomography and magnetic resonance imaging. RESULTS: The most frequent reasons for admission of patients with intracranial lipomas were: headache 7 (50%), trauma 3 (21.5%), epilepsy 3 (21.5%) and one with symptoms due to the local mass effect of tumor (7%). Although the pericallosal region is accepted as the region where lipomas commonly occur, this study found the most frequent occurrence in the quadrigeminal cistern. Intracranial lipoma calcification was only evident in 1 of the 14 patients. In addition, contrary to the expectations, intracranial and extracranial lesions accompanying lipomas were rare. All patients received systematic treatment. CONCLUSION: This study showed that intracranial lipomas are more frequent in the quadrigeminal region of the brain; most are asymptomatic, generally caught incidentally; and accompanying intracranial and extracranial pathologies are less common than expected.

Evaluation and treatment of antrochoanal polyps.

OBJECTIVES: Antrochoanal polyp (ACP) is a benign maxillary sinus polyp that originates from the mucosa of the maxillary sinus, passes through a sinus ostium, and extends into the choana. The common presentation of ACP is unilateral nasal obstruction. The radiographic findings and differential diagnosis of ACPs are discussed by comparing them with data in the literature. METHOD: This study included 19 (14 male, 5 female; median age 24.5 years, range 8-75 years) surgically treated patients with ACPs diagnosed by clinical examination, nasal endoscopy, and computed tomography. RESULTS: Nasal obstruction was found in all cases. Endoscopic sinus surgery was preferred for removal of the nasal part of ACPs in 13 cases. Only in one case, polypectomy combined with Caldwell-Luc operation and septoplasty was performed. The observed complications were as follows: minor hemorrhage in three cases, mild cheek swelling with pain in two patients, and infraorbital hypoesthesia in one case. Histopathologic examination of ACPs revealed loose mucoid stroma and mucous glands, which were covered by respiratory epithelium. CONCLUSION: Endoscopic sinus surgery may be indicated in patients with ACPs because the function and capacity of the maxillary antrum are preserved. The greater portion of the antral part of polyp can be removed while leaving the healthy antral mucosa intact.

Central diabetes insipidus following intracranial hemorrhage due to vitamin K deficiency in a neonate.

A previously healthy 30-day-old girl presented with seizures, irritability and inability to sleep for three days. Vitamin K was not given just after birth. She was lethargic. A multifocal clonic seizure was evident during examination. Anisocoria was diagnosed on eye examination. Brain magnetic resonance imaging showed intracerebral hemorrhage, ventricular dilatation, and hematoma in the left temporofrontal region extending to the hypothalamus. Central diabetes insipidus was diagnosed by water deprivation due to dehydration and hypernatremia, and then desmopressin was added to phenobarbital. The possible mechanism of central diabetes insipidus in our patient is damage of vasopressin pathway resulting from compression of hemorrhage. An operation of ventriculoperitoneal shunt was also performed due to hydrocephalus. While she was symptom-free except for neurological sequel during routine control examinations after discharging from hospital, the parents said that she died, most probably from bronchopneumonia, at the age of 7.5 months. In conclusion, we emphasize that prophylactic vitamin K should be administrated to all babies just after birth, and infants with intracranial hemorrhage should carefully be monitored for central diabetes insipidus.

Peroral CT enterography with lactulose solution: preliminary observations.

OBJECTIVE: The objective of our study was to evaluate lactulose solution as a new oral contrast agent with the use of peroral CT enterography to determine the adequacy of luminal distention and conspicuity of the bowel wall. CONCLUSION: Peroral CT enterography performed with lactulose solution is a simple and noninvasive method of evaluating the small bowel by obtaining good distention. It can also be used at routine abdominal examinations as a negative contrast agent instead of iodinated oral contrast medium, especially for CT angiography.

Deep intracranial extension of squamous cell carcinoma of the scalp.

We report a case of recurrent squamous cell carcinoma (SCC) of the scalp with deep cerebral invasion in a 15-year-old girl. Plain films and CT showed extensive, full thickness, and skull destruction at the vertex. Gadolinium-enhanced MRI revealed neoplastic invasion of the meninges and both cerebral hemispheres down to the lateral ventricle. This case represents an example of (SCC) imitating a primary brain tumor by exhibiting intracranial extension.