Hoarseness as the first symptom in a patient with acute suppurative thyroiditis secondary to a pyriform sinus fistula: a case report.

BACKGROUND: Pyriform sinus fistulas (PSFs) are rare congenital anomalies of the third or fourth brachial pouch. Dyspnea is reportedly secondary to compression by a neck mass. However, hoarseness, as the first symptom of PSF, has not yet been reported. CASE PRESENTATION: This report describes an 11-year-old girl presenting with hoarseness as the first symptom of PSF. Hoarseness occurred 2 days prior to admission. On admission, she had fever, hoarseness, and an elastic soft mass on her left anterior neck. Contrast-enhanced computed tomography of the cervical region demonstrated an abscess partially infiltrating the thyroid gland and an air pocket near the pyriform sinus. Pharyngoscopy revealed swelling of the left arytenoid region, with purulent retention. The left vocal cord was swollen but not paralyzed. Additionally, the laboratory data indicated thyrotoxicosis. Suspecting a PSF infection, parenteral treatment with cefotaxime and dexamethasone was initiated. On the following day, the hoarseness disappeared, and the fever resolved. Four weeks after onset, the thyroid hormone levels returned to the normal range, and a barium esophagogram revealed residual contrast in the left pyriform sinus, leading to a diagnosis of PSF. CONCLUSION: PSF presenting with hoarseness as the first symptom in patients should be considered.

Hemorrhage owing to cerebral cavernous malformation: imaging, clinical, and histopathological considerations.

Cavernous malformation (CM) is the second most common cerebral vascular malformation and is often found incidentally. Their natural history is usually benign, however, patients with CM who present with symptomatic hemorrhage may later follow a serious clinical course if left untreated. The risk of hemorrhage is associated with previous hemorrhage, lesion location (infratentorial and deep), and the presence of associated developmental venous anomaly (DVA). Histopathological specimens also indicate that coexistence of DVA and other vascular malformations may be associated with hemorrhage owing to CMs. Diagnosing CMs is difficult, even in patients who initially present with symptomatic hemorrhage. Computed tomography scans typically reveal a hemorrhagic CM as a nonspecific heterogenous mass of high density, which may not be misdiagnosed as a solitary hematoma, especially when located in the infratentorial region. Magnetic resonance imaging demonstrates internal loculation with mixed-signal intensities typical for CMs, although this may be partially or completely masked by acute hemorrhage. Susceptibility-weighted imaging (SWI) reveals a significant "blooming" effect of hemosiderin deposition. Three-dimensional postcontrast T1-weighted imaging is essential to identify associated DVAs, and this is important for both diagnosis and planning of surgical treatment. Contrast-enhanced MRI should be performed to diagnose hemorrhagic CMs and differentiate them from spontaneous solitary hematoma or hemorrhagic tumors.

Gastric cancer metastatic to neck lipoma: a case report with imaging consideration.

A 71-year-old man visited our hospital for examination of a soft neck mass. Computed tomography and magnetic resonance imaging scans showed a well-circumscribed large lipomatous tumor with multiple nodules inside. Atypical lipomatous tumor or lipoma involving the lymph nodes was considered. Pathological examination of the surgical specimen suggested typical lipoma including multiple metastatic foci from gastric cancer. Subsequent endoscopy revealed a gastric tumor, which was histologically proven to be signet-ring cell carcinoma. Considering these findings, this case was diagnosed as tumor-to-tumor metastasis to lipoma. We present the first such case with imaging and clinical characteristics.

Silicone oil migrating from intraocular tamponade into the ventricles: case report with magnetic resonance image findings.

Silicone oil is an important adjunct for intraocular tamponade in treating retinal detachment. We report a case in which image findings suggested migration and intracranial accumulation of intraocular silicone. We detected silicone oil in the lateral ventricle that showed hyperdensity on computed tomography, slight hyperintensity on T1-weighted magnetic resonance images, and slight hypointensity on T2-weighted images. Applied silicone-selective imaging and proton magnetic resonance spectroscopy confirmed the diagnosis of intraventricular silicone.

How does water diffusion in human white matter change following ischemic stroke?

PURPOSE: Temporal evolution of the water apparent diffusion coefficients (ADC) parallel (ADC parallel) and perpendicular (ADC perpendicular) to the human white matter tract following ischemia has not been investigated systematically. We attempted to quantify the evolution of ADC parallel and ADC perpendicular and examine whether it can be interpreted by a model of ischemic edema. METHODS: We retrospectively selected 53 patients with ischemic lesions involving the posterior limb of the internal capsule (PLIC) and placed regions of interest in the right and left PLIC on ADC maps. We performed regression analysis of lesion-to-contralateral ratios of ADC parallel and ADC perpendicular against the time (t = 1-1600 h) from onset. We then fitted the estimated time courses of ADC parallel and ADC perpendicular obtained from the analysis to a model of nerve tissue composed of cylinders (axons) and spheres corresponding to isotropic structures, particularly focal cytoplasmic swellings of glial cells and axons seen in ischemic white matter. RESULTS: The evolution of ADC perpendicular and ADC parallel differed. The estimated time course of ADC parallel in microm(2)*ms(-1) was 0.64 + 0.88 exp (-0.24t) for 1 < t < 54 h and 0.00059t + 0.61 for t >or= 54 h (contralateral normal value, 1.52). That of ADC perpendicular was 0.19-0.063 exp (-0.24t) for 1 < t < 54 h and 0.00040t + 0.17 for t >or=54 h (normal value 0.22). The model fitted to these values showed that the volume of the cylinders decreased, that of the spheres increased, and extracellular volume changed little from one hour to approximately one day after stroke onset. CONCLUSION: In the human PLIC, ADC parallel continued to decrease from one hour to a few days after stroke onset, and ADC perpendicular tended to increase. The temporal evolution could be interpreted by progression of the focal cytoplasmic swelling of glial cells and axons previously observed in animal studies.

[Biochemical and bacteriological investigation of six cases of purple urine bag syndrome (PUBS) in a geriatric ward for dementia].

AIM: Purple urine bag syndrome is a condition in which the urinary catheter bag turns purple. A tryptophan-indigo hypothesis has been proposed as the mechanism of PUBS, in which bacterial decomposition of tryptophan in gut associated with chronic constipation, bacterial overgrowth in the urinary tract and alkaline urine causes production of indigo and discoloration. We considered that further investigation of cases was needed. METHODS: We investigated 6 cases exhibiting PUBS (3 males and 3 females). RESULTS: All cases had chronic constipation. Oral ingestion was impossible in one case. PUBS disappeared after antibiotic treatment (3 cases) or spontaneously (one case). Alkaline urine and indicanuria were not found in all cases that showed the disappearance of PUBS. In bacterial culture of urine during the exhibition of PUBS, Enterococcus faecalis was isolated together with Morganella morganii (3 cases) and Pseudomonas aeruginosa (one case). Single infections by Klebsiella pneumoniae or Citrobacter species were also found. After disappearance of PUBS, infected bacterial species changed but no cases showed sterile urine. Urine and blood alpha-amino-n-butyric acid levels reduced after the disappearance of PUBS whereas tryptophan levels did not show related changes. In one case, blood protein concentration increased after the spontaneous disappearance of PUBS. Indicanuria and alkalization of urine from urinary catheter bag were more intense than of fresh urine. CONCLUSIONS: The present results generally support the 'Tryptophan-indigo hypothesis'. Furthermore, it was suggested that additional factors associated with the occurrence of PUBS are an environment that facilitates specific bacterial growth in a hospital as well as abnormal metabolism relating to alpha-amino-n-butyric acid and reduced protein synthesis in patients.

Ipsilateral percutaneous transhepatic portal vein embolization with gelatin sponge particles and coils in preparation for extended right hepatectomy for hilar cholangiocarcinoma.

PURPOSE: To evaluate the effectiveness and safety of ipsilateral percutaneous transhepatic portal vein embolization (PTPVE) with gelatin sponge particles and coils to induce lobar hypertrophy in patients with hilar cholangiocarcinoma in preparation for extended right hepatectomy. MATERIALS AND METHODS: Between 1999 and 2004, PTPVE was performed in 22 patients with hilar cholangiocarcinoma (mean age, 67 years; range, 57-77 y; 16 men and six women). Percutaneous puncture of the right portal vein was performed under ultrasound guidance. A reverse-curve catheter was used for right portal vein embolization. Coils were used to occlude second-order branches. The future liver remnant volume was assessed by comparing computed tomographic scans before and 14-24 days after PTPVE. RESULTS: PTPVE was technically successful in all cases. The average increase in ratio of future liver remnant volume to total liver volume was 8.6%. Liver function tests after PTPVE but before surgery showed no significant changes. Nineteen patients underwent hepatic resection without liver failure. In three patients, tumors could not be removed because of detection of extrahepatic disease. One patient who underwent successful hepatic resection had an abscess in the removed right lobe. CONCLUSION: Ipsilateral PTPVE with gelatin sponge and coils appears to be effective and safe for extended right hepatectomy for hilar cholangiocarcinoma.

Edema in the retropharyngeal space associated with head and neck tumors: CT imaging characteristics.

To determine computed tomographic (CT) imaging characteristics of retropharygeal edema, we reviewed CT images in 18 patients with head and neck tumors. Retropharyngeal edema spread craniocaudally between soft palate and upper half of thyroid cartilage in all patients. No edema fluid extended above soft palate and below thyroid cartilage. Horizontally, it spread symmetrically in ten and asymmetrically in eight patients. Predominance in asymmetrical retropharyngeal edema was found on the same side as that of unilateral predominance both in lymph nodes enlargement and jugular vein stenosis/occlusion. All patients had edema also in other cervical spaces. Edema of retropharyngeal and other spaces fluctuated synchronously. In 14 patients, as primary lesion and/or cervical lymph nodes regressed, retropharyngeal edema disappeared or decreased. Retropharyngeal edema had some imaging characteristics. With knowledge of that, we could avoid diagnostic confusion when evaluating head and neck CT images.

Practical visualization of internal structure of white matter for image interpretation: staining a spin-echo T2-weighted image with three echo-planar diffusion-weighted images.

BACKGROUND AND PURPOSE: To our knowledge, no method satisfactory for clinical use has been developed to visualize white matter fiber tracts with diffusion-weighted MR imaging. The purpose of this study was to determine whether superposition of a spin-echo T2-weighted image and a color-coded image derived from three orthogonal diffusion-weighted images could show fiber tract architecture of the brain with an image quality appropriate for accurate reading with a computer monitor. METHODS: MR images from 50 consecutive cases were reviewed. Three diffusion-weighted images per section were acquired with three orthogonal motion-probing gradients. These images were registered to a corresponding spin-echo T2-weighted image. A color-coded image was synthesized from three diffusion-weighted images by assigning red, green, or blue to each diffusion-weighted image and then adding a spin-echo T2-weighted image with a weighting factor. The ability of the superposed image to delineate the white matter pathways was evaluated on the basis of the known anatomy of these pathways and qualitatively compared with that of the spin-echo T2-weighted image. RESULTS: The main white matter fiber pathways, in particular the superior longitudinal fascicle, corpus callosum, tapetum, optic radiation, and internal capsule, were more clearly and easily identified on the superposed image than on the spin-echo T2-weighted image. The time required to produce the superposed image was approximately 40 minutes. CONCLUSION: Superposition of a spin-echo T2-weighted image and a color-coded image created from three orthogonal diffusion-weighted images showed structures of the brain that were not clearly visible on the spin-echo T2-weighted image alone. Such superposition presents images that are easy to interpret correctly.

A case of angioglioma composed of astrocytoma with a papillary growth pattern: immunohistochemical and ultrastructural studies.

We report a case of a large cystic astrocytoma associated with arteriovenous malformation in the right cerebral hemisphere of a 16-year-old boy. Neuroimaging showed large abnormal vessels with flow voids and arteriovenous shunt around the cystic lesion. Histologically, the cyst wall was formed by abnormal vasculature and clusters of glial cells forming a papillary growth pattern. The abnormal vasculature consisted of dilated vein-like vessels and medium-sized arteries with incomplete media, and was diagnosed as an arteriovenous malformation. Immunohistochemically, glial fibrillary acidic protein (GFAP) decorated both the perikaryon and the processes of the glial tumor cells. They were negative for epithelial membrane antigen (EMA), cytokeratin, and S-100 protein. Ultrastructurally, the tumor cells were rich in intermediate filaments, and neither cilia, microvilli, nor ependymal rosettes were verified. Based on these morphological features and the low MIB-1 labeling index of 0.8%, the glial tumor was diagnosed as astrocytoma, Grade II, according to the World Health Organization (WHO) tumor classification. An association of glioma with various types of vascular anomalies has been designated as angioglioma. A unique feature of the present case, however, is a papillary growth pattern, which is not listed in the current WHO classification of brain tumors. The recognition of the occurrence of such cases would be important in differential diagnosis of papillary ependymoma and choroid plexus papilloma.