[False negative diffusion in acute ischemic stroke]. / Difusión falsamente negativa en el ictus vertebrobasilar agudo.

INTRODUCTION: The new techniques of magnetic resonance imaging have produced a important advance in the early diagnosis of acute ischemic stroke. The diffusion weighted imaging (DWI) has a high sensitivity and specificity in the acute ischemia. CASE REPORT: 70 years old woman with previous history of hypertension and dyslipemia. The patient presented sudden vertigo with cervical neck pain and gaze problems. The physical exploration revealed right miosis, nistagmus, IX and X cranial nerve affection and ataxia. The clinical diagnosis was Wallenberg s syndrome and a medulla lateral infarction. However DWI was normal (10 hours). The neurological deficit was persistent and a repeated study disclosed a lateral infarction of the medulla. CONCLUSIONS: The sensitivity of DWI is reduced during the first 24 hours. There are false negative diagnosis mainly in small infarctions of posterior territory.

Difusión falsamente negativa en el ictus vertebrobasilar agudo / False negative diffusion in acute ischemic stroke

Introducción. Las nuevas técnicas de resonancia magnética representan un gran avance en el diagnóstico precoz del ictus isquémico agudo. La difusión por resonancia magnética (DRM) es una técnica muy sensible y específica en la isquemia aguda. Caso clínico. Mujer de 70 años, con antecedentes patológicos de hipertensión arterial y dislipemia bien controlados. Consultó por un cuadro clínico brusco de vértigo, con dolor cervical derecho, dificultad en la deambulación y lateralización de la marcha hacia la derecha. En la exploración física destacaba miosis derecha, nistagmo en resorte a la derecha, afectación de IX y X pares craneales derechos y una marcha atáxica. El cuadro clínico era compatible con un síndrome de Wallenberg y sugería la existencia de un infarto bulbar lateral derecho. Sin embargo, el estudio de DRM realizado a las 10 horas de evolución era normal y no demostraba lesiones encefálicas. El cuadro clínico persistió en los días posteriores, por lo que se realizó una nueva DRM de control al quinto día, que demostró la presencia de un infarto laterobulbar derecho. Conclusiones. La sensibilidad de la DRM se reduce en las primeras 24 horas del infarto, con posible existencia de falsos negativos, que fundamentalmente ocurren en pequeños infartos de territorio vertebrobasilar (AU)

Value of sonography in the assessment of space-occupying lesions of the anterior nasal fossa.

PURPOSE: This study was conducted to define the gray-scale, color, and power Doppler sonographic appearances and spectral analysis patterns of anterior nasal masses. METHODS: Eight patients with anteriorly located nasal masses were referred to our hospital for CT of the paranasal sinuses. Subsequently, they were examined with a high-frequency linear-array ultrasound transducer. We performed gray-scale sonography and color and power Doppler imaging. RESULTS: Five masses were nasal hemangiomas. The three remaining masses were a submucosal glandular cyst, a nasolabial cyst, and tuberculum septi hypertrophy. Three of the hemangiomas were histopathologically confirmed. Sonography identified the anatomic origin of all 8 lesions. On color and power Doppler imaging, the 5 hemangiomas exhibited intense vascularity that decreased with compression. Spectral analysis demonstrated arterial and venous flow within the hemangiomas, with resistance indices of 0.60-0.66 and peak systolic velocities of 6.4-18.4 cm/second. The other 3 lesions were avascular or had vascularity only at the periphery. CONCLUSIONS: Anterior nasal fossa tumors can frequently be diagnosed by clinical examination, but specific sonographic and Doppler patterns can help to establish the anatomic origin, the local extension, and the correct diagnosis in indeterminate cases, obviating other diagnostic imaging or surgical procedures.

Antrochoanal autopolypectomy: CT findings.

Antrochoanal polyp (Killian polyp) is an infrequent, benign lesion of maxillary origin. We describe the basic characteristics of this lesion and a rare case of autopolypectomy. Coronal and axial CT images are presented before and after autoexpulsion of an antrochoanal polyp in a patient with long-standing nasal obstruction. The initial CT examination revealed a typical left antrochoanal polyp filling all the maxillary sinus and passing through the ethmoid infundibulum until the choana. The CT after autopolypectomy showed the secondary mass effect at surrounding structures and residual inflammatory changes.

Congenital intrahepatic portosystemic venous shunt: sonographic and magnetic resonance imaging.

We report an intrahepatic portosystemic venous shunt (IPVS) detected by ultrasound in an asymptomatic newborn. The lesion, which was further documented using color Doppler ultrasound and magnetic resonance imaging (MRI), had almost totally disappeared 6 months later without any treatment. Intrahepatic portosystemic venous shunts (IPVS) are uncommon and their etiology is controversial. Some cases of IPVS have been reported in the literature, most of them in adult patients with portal hypertension and cirrhosis of the liver. However, only scattered reports describe IPVS in the absence of liver pathology. A revision of the proposed etiologies of IPVS is made and the usefulness of gray-scale and color Doppler sonography and MRI in diagnosing IPVS is discussed.

Nonoperative management of splenic injuries.

The traditional management of splenic trauma has undergone major revision in recent years. Given the physiological importance of the spleen, certain controversy has arisen regarding the most appropriate method of managing this type of trauma. Nonoperative therapy in children has proven to be successful not only in the case of kidney lesions but also for splenic lesions. Nonoperative management carried out in the authors' hospital on a group of 56 patients (49 adults and seven children over the age of 7 years) has proved successful in 37 cases. The success of this technique requires a well-formulated protocol, diagnostic methods (ultrasound and computed tomography), rigorous patient control in the emergency room during the initial phase (first 48 hours), the availability of a medical team if surgical intervention becomes necessary (persistent or recurrent hemorrhage), and complementary measures which facilitate the cicatrization of the splenic injury (bed rest, antibiotic therapy).

[Abdominal tuberculosis in patients with acquired immunodeficiency syndrome]. / Tuberculosis abdominal en los pacientes con síndrome de inmunodeficiencia adquirida.

BACKGROUND: In individuals with HIV infection, extrapulmonary forms of tuberculosis are considered as opportunistic infections and are included in the diagnosis of AIDS. They often have atypical clinical features. Abdominal participation is uncommon and its diagnosis may be difficult. METHODS: The clinical, radiological and pathological features of patients with a diagnosis of AIDS with abdominal tuberculosis in a series of 254 AIDS cases in a general hospital from 1984 to October 1990 were reviewed. RESULTS: Tuberculosis developed in 104 (41%) of AIDS patients. In 25 (24%) the disease was exclusively pleuropulmonary and in 79 (76%) extrapulmonary tuberculosis was present, either alone or in association. Extrapulmonary tuberculosis was the first opportunistic infection in 66 AIDS cases (26%). The abdominal participation was demonstrated in 19 patients, with the following localizations: lymph nodes (9), liver (8), spleen (5), ileum (1) and peritoneum (1). Four patients with splenic tuberculosis also had multifocal nodular lesions. CONCLUSIONS: Abdominal participation was found in 19 of the 104 AIDS patients with tuberculosis (18%). Lymph node involvement was the most common type. Hepatosplenic tuberculosis had a miliary form or showed multifocal images in echography or computed tomography.

[Kaposi's sarcoma with primary pulmonary involvement in a parenteral drug addict with acquired immunodeficiency syndrome]. / Sarcoma de Kaposi con afección primaria pulmonar en un adicto a drogas por vía parenteral con síndrome de inmunodeficiencia adquirida.

Pulmonary Kaposi's sarcoma (KS) was diagnosed by pulmonary biopsy in a heterosexual parenteral drug abuser (PDA). The patient had previously been diagnosed of Pneumocystis carinii pneumonia and pulmonary tuberculosis. Thoracic computed tomography (CT) showed bilateral nodular lesions which were less apparent in conventional radiological study and which increased in size in spite of correct therapy. As cutaneous lesions suggesting KS subsequently appeared, the possibility of pulmonary KS was considered and confirmed by open biopsy. The rarity of a primarily pulmonary presentation of KS in a PDA, the difficulty in diagnosis owing to concomitant infective diseases and the diagnostic value of thoracic CT for the diagnosis of pulmonary KS are discussed.

Occult cancer in patients with deep venous thrombosis. A systematic approach.

The authors prospectively studied 113 consecutive patients with deep venous thrombosis of the lower extremities to determine the most appropriate workup study for searching for a hidden cancer. After a careful physical examination, the following routine tests were performed: erythrocyte sedimentation rate (ESR), whole blood counts, biochemistry, carcinoembryonic antigen (CEA) levels, chest radiograph, upper gastrointestinal endoscopy, abdominal ultrasound and computed tomography (CT) scan. If a malignant lesion was suspected, further appropriate studies were performed. After discharge, periodic follow-up was performed on all patients in the outpatient clinic. A malignant neoplasm was detected in 12 patients. Of these 12 patients, six were asymptomatic with the exception of experiencing thrombophlebitis. Cancer was found more commonly in patients with idiopathic deep vein thrombosis (DVT) (7 of 31 versus 5 of 82 patients with secondary DVT; P = 0.012), and in those patients with abnormal lactic dehydrogenase (LDH) levels (6 of 23 versus 6 of 90; P = 0.007). Abnormal CEA levels allowed diagnosis of two cases of colonic cancer (on colonoscopy). Both ultrasound and CT scan of the abdomen showed two cases of urinary bladder carcinoma at a very early stage. Furthermore, two cases of adenomatous polyps in colon were found, a condition considered by most authors to be a colorectal cancer precursor. In addition, there were five patients with large benign pelvic tumors, and two patients with absent inferior vena cava. The most striking finding was that some cases of cancer were at a very early stage. It was concluded that blood cell counts, LDH, CEA, chest radiograph, and abdominal ultrasonography (or CT scan) should be routinely performed on all patients with deep venous thrombosis (particularly those with idiopathic DVT). Malignancy would not have been recognized in some patients if these tests had not been performed.

[Multilocular cystic nephroma. A diagnostic problem]. / Nefroma quístico multilocular. Un problema diagnóstico.

A multilocular cystic nephroma is described in a female patient diagnosed as having a mucinous cystadenocarcinoma of the left ovary, treated by surgery. It is presented as a mixed mass in the left kidney; image findings were specified with the new image diagnostic methods currently available, ultrasonography and computerized tomography. In the ultrasonographic study the mass is presented as an heterogenous image, with multiple anecogenic areas, separated by more ecogenic bands, situated mainly in the lower pole affecting all the cortical area and occasionally invading renal sinus. In the computerized tomography study a cystic mass is observed, with cysts of a different size that, after administering intravenous iodine, show a density increase in intercystical fibrous tracts. In cases with more complex image presentations, fine needle puncture is recommended, preferably in different areas in the mass in order to rule out the presence of malignant cells.

[Correlation of etiology and severity in a series of 506 cases of acute pancreatitis]. / Correlación etiología-gravedad en una serie de 506 pancreatitis agudas.

We present a retrospective study on 506 patients with acute pancreatitis (AP), admitted in our hospital in the last five years (1984-1988). The goal of the paper is to establish a possible correlation between the severity and the etiology of the AP. Depending on the severity of the acute attack, and according to the Ranson's prognostic signs and the findings of the abdominal CAT, we have classified AP in three grades: mild, moderate and severe. 52% of AP were of biliary etiology, 25.7% alcoholic, and in 17.0% of the cases the responsible agent was not demonstrated. In relation with severity, the distribution was as follows: mild, 184 (36.4%), moderate, 254 (50.2%) and severe, 68 (13.4%). Among the cases of biliary and alcoholic etiology, 14.7% and 9.2%, respectively, were severe. Postoperative AP were severe in 71.4% of the cases. Systemic complications were more frequent in the severe forms, particularly of biliary etiology. Pancreatic abscesses and fistulas were also more frequent in biliary pancreatitis; on the other hand, pseudocysts and ascites were more common in alcoholic pancreatitis. Overall mortality was 2.8% (14 patients). Mortality was 19.1% in the severe forms. In relation to etiology the mortality was as follows: 3.7% in biliary AP; 0.8% in alcoholic AP; 14.3% in postoperative AP; and 2.3% in the idiopathic AP.

[Biliary peritonitis after hepatic biopsy: favorable course with conservative medical treatment]. / Peritonitis biliar postbiopsia hepática: evolución favorable con tratamiento médico conservador.

In a 53-year-old woman a percutaneous liver biopsy was performed with tru-cut to study persistent hypertransaminasemia. The patient did not present extrahepatic cholestasis. Immediately after biopsy the patient had a picture of biliary peritonitis that evolved favorably with conservative medical treatment, including hemodynamic resuscitation, antibiotic therapy, analgesic treatment and monitoring by the resuscitation service. A review is made of the literature on this complication of liver biopsy and treatment is discussed.

CT findings in metastatic ovarian tumors from gastrointestinal tract neoplasms (Krukenberg tumors).

The computed tomographic (CT) findings are reviewed in 7 patients with metastatic ovarian tumors from gastrointestinal tract neoplasms (Krukenberg tumors). All patients presented mixed ovarian masses. In 6 cases the masses were mainly cystic, with internal septa and focal or uniform enlargement of the cyst wall. In the seventh patient the ovarian mass appeared on the CT as mainly solid. The size of the neoplasm varied between 5 and 46 cm. Ascites was only seen in 1 case and in another the existence of a primary tumor in the sigmoid colon was demonstrated. In our cases the CT signs of ovarian metastasis were indistinguishable from primary tumors of the ovary.

CT findings in a case of polypoid-like metastasis in the ileum from extraosseous osteosarcoma.

We describe a case of ileal metastasis from an extraosseous osteosarcoma which has not been previously reported in the English radiological literature. The metastasis had a polypoid-like appearance. The CT scan disclosed an intraluminal mass surrounded by contrast material and mesenteric fat inside the pseudopedicle.

CT features of mesenteric panniculitis.

Mesenteric panniculitis (MP) is an inflammatory process of the mesenteric fat associated with a variable amount of fibrosis. We present the CT findings in four patients with MP. In three patients CT showed a fatty mass in the root of the mesentery and surrounding the mesenteric vessels without distorting them. The fourth patient presented an unusual form of MP with radiologically visible calcifications. Diagnosis was suggested preoperatively in two cases.

CT findings in circumscribed upper abdominal idiopathic retroperitoneal fibrosis.

Idiopathic retroperitoneal fibrosis (IRF) is a rare condition of unknown etiology. An unusual case of IRF exclusively located at the peripancreatic area without extension below the lower renal poles is reported.