Coexistence of trifid and bifid median nerve in a patient with bilateral carpal tunnel syndrome.

Carpal tunnel syndrome is the most common upper extremity neuropathy in the wrist that may be associated with anatomic variations of median nerve. Trifurcation of the median nerve has been very rarely reported in the literature. We report coexistence of bilateral median nerve variation in the wrist and its radiological features. Ultrasonography and magnetic resonance imaging was performed to the patient after Tinel and Phalen tests. There was bifurcation and trifurcation of the median nerve in right and left wrists respectively. Bilateral carpal tunnel syndrome was caused by bilateral median nerve variation in the present case. When a median nerve variation is detected in one wrist, a possible variation at the other side should be kept in mind and hence should be evaluated. A thorough knowledge of the variations of the median nerve is essential in order to avoid surgical complications and to ensure optimal patient outcome. US is an easy and cheap radiological method for diagnosis and it should be the first chosen radiological technique to evaluate median nerve variations in idiopathic CTS patients.

Reasons for using swelling ratio in sonographic diagnosis of carpal tunnel syndrome and a reliable method for its calculation.

INTRODUCTION: The aim of this study was to investigate factors affecting median nerve cross-sectional area (CSA) and determine a dependable swelling ratio (SR) calculation method. METHODS: Using ultrasonography, median nerve CSAs were measured at the tunnel inlet, midtunnel, and outlet, and at 4 cm and 12 cm proximal to the wrist. We used CSAmax as the largest of the tunnel measurements and calculated swelling ratios (SRs) by using the CSAmax. Sonographic measurements were correlated with electrophysiologic findings. We evaluated the effects of gender, weight, and height on median nerve thickness. RESULTS: We studied 95 wrists of 55 CTS patients and 48 wrists of 27 volunteers. Gender, weight, and height had effects on certain median nerve CSA measurements. CSAmax, SRmax4, and SRmax12 had superior correlations with electrophysiologic findings. The correlation between 4-cm and 12-cm median nerve CSAs was statistically significant (r = 0.879 and P < 0,001). CONCLUSION: We have developed a reliable SR method considering factors affecting median nerve CSA.

Assessment of dental caries risk in children based on color Doppler US and the changes in blood perfusion in the salivary glands during salivary stimulation.

PURPOSE: To investigate in otherwise healthy children the association between the caries index, the stimulated salivary flow rate (SFR), and the spectral Doppler findings of the changes in blood perfusion in the salivary glands during the secretion of saliva. MATERIALS AND METHODS: The study group consisted of 38 children with a mean age of 9.47 ± 1.89 years. The caries index was calculated by determining the number of decayed, missing, and filled teeth. Groups A, B, and C represented subjects with low, moderate, and normal SFRs, respectively, calculated by obtaining chewing-stimulated whole saliva. All subjects were examined by color Doppler ultrasonography (CDUS) before and during secretory stimulation with lemon, by which maximum systolic velocity (MSV), pulsatility index (PI), resistive index (RI), and flow volume (FV) were calculated at the external carotid and facial arteries. RESULTS: The differences for spectral indices obtained before and after stimulation were significantly different among Groups A, B, and C at the external carotid artery (P = 0.006 for delta MSV, P = 0.014 for delta PI, P < 0.001 for delta RI, and P = 0.022 for delta FV) and at the facial artery (P = 0.001 for delta MSV, P = 0.004 for delta PI, P < 0.001 for delta RI, and P < 0.001 for delta FV). In addition, significant correlations were calculated between the SFR and the aforementioned delta values. CONCLUSION: CDUS enabled the evaluation of changes in blood perfusion in the salivary glands during salivary stimulation and may be a promising tool for the assessment of caries risk in children.

Carotid stenosis evaluation by 64-slice CTA: comparison of NASCET, ECST and CC grading methods.

Purpose is to evaluate the intraobserver and interobserver variability of the North American Symptomatic Carotid Endarterectomy Trial (NASCET), European Carotid Surgery Trial (ECST) and Common Carotid (CC) methods, which are used to measure the degree of ICA stenosis, using 64-slice CT angiography and to compare the measurements made by these three methods. 88 cases (111 carotid arteries) were included in the study. Carotid CTA was performed by a 64 slice scanner (Toshiba, Aqullion 64).Two radiologists measured the degree of carotid stenosis by using NASCET, ECST and CC methods. Intraobserver and interobserver variability of each method was determined by intraclass correlation coefficient (ICC), Bland-Altman plots and kappa and linear weighted kappa statistics. The relation between the measurements was assessed by correlation coefficient (with linear and quadratic methods). Correlation coefficients showed that there is linear correlation between the measurements made by the three methods. The degree of stenosis measured with the NASCET method had the lowest value, while the corresponding values measured with the ECST and CC methods were close to each other. ICC and Bland-Altman plots showed high intra and inter observer agreement for NASCET, ECST and CC methods whereas kappa statistics showed moderate to substantial agreement. CC method had slightly higher agreement when compared with the other two methods. Intra and interobserver agreement is high for NASCET, ECST and CC methods however CC method has a slightly higher reproducibility. There is linear correlation between the measurements made by the three methods.

Time-resolved MR angiography of the intracranial venous system: an alternative MR venography technique.

OBJECTIVES: To compare time-resolved imaging of contrast kinetics (TRICKS) magnetic resonance angiography (MRA) with two-dimensional time-of-flight (TOF) magnetic resonance venography (MRV), and three-dimensional contrast-enhanced (CE) MRV in the visualisation of normal cerebral veins and dural venous sinuses. METHODS: This prospective study consisted of 35 consecutive patients. All patients were examined with TOF MRV, TRICKS MRA and CE MRV; a single dose of intravenous contrast material was administered for the last two sequences. The image quality of these techniques was assessed and compared qualitatively (by a semiquantitative scoring system) and quantitatively (by calculating signal-to-noise ratios [SNRs] and contrast-to-noise ratios [CNRs]). RESULTS: Left transverse sinus, left sigmoid sinus, bilateral thalamostriate veins and Trolard veins were better visualised by TRICKS MRA and CE MRV compared with TOF MRV (P < 0.05). For left thalamostriate vein visualisation, TRICKS MRA was inferior to CE MRV (P < 0.05). With quantitative analysis the SNRs and CNRs were highest at TRICKS MRA, which was followed by CE MRV and TOF MRV (P < 0.05). CONCLUSIONS: Despite its limited spatial resolution, TRICKS MRA is comparable to static CE MRV and better than TOF MRV in the visualisation of normal dural sinuses and cerebral veins. KEY POINTS: • Time resolved magnetic resonance angiography can image the intracranial venous system dynamically • It seems comparable to contrast-enhanced MRV techniques in venous visualisation • The optimal phase for venous structures can be chosen from the dynamic data set • The diagnostic performance in venous thrombosis requires further research.

Recurrent atretic parietal cephalocele in adult and radiological findings.

Atretic parietal cephaloceles are an extremely rare and occult form of congenital herniations that involve the meninges, remnants of glial cells or central nervous system structures. They are detected as subscalp lesions that are covered by skin. In the literature, atretic parietal cephaloceles have been reported in children in 59 cases and in two cases in adults. We present here a case of a recurrent atretic parietal cephalocele that we recently observed in an adult. This case indicates that an atretic parietal cephalocele should always be considered in the differential diagnosis of subscalp lesions. Radiologic diagnosis is a lifesaving measure that can be undertaken before an operation. Additionally, regular follow-up magnetic resonance imaging is recommended for each case with remnant lesions due to the slow growth of these masses.

Developmental dysplasia in male infants: risk factors, instability and ultrasound screening.

OBJECTIVE: To evaluate the relationship between risk factors and presence of developmental dysplasia of the hip (DDH) in male infants, and to compare the efficiency of different ultrasound (US) screening protocols. MATERIALS AND METHODS: 1321 male infants were included in the study. Ultrasound examinations were performed by combining Graf's static method and Harcke's dynamic method. The relationship between the risk factors and DDH and the effect of risk factors on sonographic worsening in type 2a hips were assessed by the chi-square test and Fisher`s exact test. RESULTS: The incidence of DDH was 1.4%. 13% of the cases had type 2a morphology, among whom in 3.1% sonographic deterioration occurred. The treatment rate was 1.8%. The rate of follow-up US was 17.5%. No risk factor was found to have a statistically significant influence on DDH (= type 2b morphology). Among the 32 cases with DDH, 23(72%) had a risk factor or positive clinical finding while 9(28%) did not (p:0.006). CONCLUSION: Risk factors do not have a statistically significant relationship with DDH in male cases. In our study 28% of the cases with DDH would be missed by a selective US screening protocol. We recommend assessment of all male infants with hip US.

Follow-up sonographic results for Graf type 2A hips: association with risk factors for developmental dysplasia of the hip and instability.

OBJECTIVES: The purpose of the study was to evaluate the association of sonographic worsening in type 2a hips with risk factors of developmental dysplasia of the hip, stability of the hip, and initial sonographic findings. METHODS: Among infants who were referred for hip sonography between 2007 and 2009, 3450 were included in this study. Sonographic examinations were performed by combining the static Graf technique and the dynamic Harcke technique. The rate of sonographic worsening in type 2a hips and the relationship between sonographic worsening and risk factors for developmental dysplasia, instability of the hip, lateralization (right or left) of immaturity, and the presence of unilateral and bilateral immature hips were evaluated. RESULTS: Type 2a hips were observed in 529 infants (15.3%; 780 hips [11.3%]). Of these, in 36 cases (6.8%; 44 hips [5.6%]), the sonographic results worsened. Twenty-five of these 36 cases (32 of 44 hips) were diagnosed as type 2 b; in others, the dysplasia worsened, and 6 cases (7 hips) were classified as type 2 c, 3 cases (3 hips) as type D, and 2 cases (2 hips) as type 3. Instability, unilateral type 2a hips, and associated central nervous system anomalies were found to be independent predictors of sonographic worsening in type 2a hips. CONCLUSIONS: Type 2a hips may worsen sonographically at a rate of 5.6%; hence, sonographic follow-up is needed. Instability, central nervous system anomalies, and unilateral type 2a hips were found to be independent predictors of sonographic worsening. Our study shows that cases with these risk factors should be followed more carefully.

Can renal dimensions and the main renal artery diameter indicate the presence of an accessory renal artery? A 64-slice CT study.

PURPOSE: To evaluate whether renal dimensions and the main renal artery (mRA) diameter can provide indirect evidence of the presence or absence of accessory renal arteries (aRA). MATERIALS AND METHODS: The study group consisted of 167 patients (83 women, 84 men; mean age, 52.4±13.1 years) who presented to our radiology department for abdominal CT examinations with various indications. CT examination was performed on a 64-slice CT scanner in the arterial phase. The kidney diameters were recorded. The number of renal arteries supplying each kidney was evaluated, and their diameters were measured. We attempted to determine a formula that could be used to predict the presence or absence of aRAs. RESULTS: One or multiple aRAs were found in 76 (22.8%) of the 334 kidneys. The mRA diameter was 5.51±0.96 mm. The mRA diameter was smaller in kidneys with aRAs than in those without (P < 0.001). A cut-off value of 4.15 mm for the diameter of mRA to predict the presence of aRAs led to negative and positive predictive values of 80% and 90%, respectively. A formula that can predict that an aRA is absent with 97% accuracy given the values of the mRA diameter and the kidney length was determined using logistic regression. CONCLUSION: The mRA diameter (4.15 mm) alone and the results of the formula developed herein employing the mRA diameter and kidney length can respectively predict the presence or absence of an aRA with high accuracy.

Prevalence and extent of coronary artery disease determined by 64-slice CTA in patients with zero coronary calcium score.

The purpose of the study was to assess the presence and extent of atherosclerosis determined by 64-slice CTA in patients with 0 coronary calcium score (CACS) and to evaluate the affect of demographic features and risk factors on the atheroma burden of these patients. 883 cases (378 (42.8%) male, 505 (57.2%) female, mean age 51.28) with zero CACS were included in the study. Cases underwent CTA because of carrying risk factors or having chest pain or atypical symptoms. A non-enhanced CT scan was obtained for calcium scoring immediately before CTA in all cases. CT examinations were performed by 64-slice scanner (Toshiba, Aquillon 64, Toshiba Medical Systems, Otowara, Japan). Coronary artery disease (CAD) was graded according to CTA findings and five groups were defined. In 703 cases (79.6%) CTA was normal while 180 (20.4%) cases had positive CTA findings and 43 cases (4.9%) had CTA obstructive lesion. Cases with positive CTA findings were significantly older than those with normal CTA Diabetes was a significant risk factor of CAD in both male and female cases. Dyslipidemia was associated with CAD in males and family history of CAD was a significant risk factor for females with positive CTA findings. This study demonstrated that considerable amount of patients with zero CAC score have positive CTA findings. Age and diabetes are the risk factors, which were associated with positive CTA findings in both sexes. Dyslipidemia was a significant risk factor in males and family history of CAD in females. Especially in patients with risk factors CTA is better than CAC scoring in determining the atheroma burden.

Diagnosis and follow-up in constipated children: should we use ultrasound?

PURPOSE: We investigated the efficacy of ultrasound in determining megarectum and fecal load and the response to treatment in constipation and tried to specify objective criteria in this study. METHODS: A total of 66 cases were queried and divided into 2 groups as constipated (n = 35; mean age, 6.8 ± 2.9 years) and control (n = 31; mean age, 8.4 ± 3.8 years) according to Rome III criteria. After the clinical evaluation, pelvic ultrasonography (US) was performed by 2 separate radiologists. The bladder capacity and the transverse rectal diameter were measured with a full bladder. Then the rectal diameter and rectal anterior wall thickness were measured, and the presence of fecal load in the rectum and sigmoid colon was recorded with an empty bladder. The examination and ultrasound were repeated after treatment for a month in these patients. RESULTS: Comparison of the US measurements of the 2 radiologists performing the US tests did not show any interobserver difference (r = 0.981; P < .001). We therefore believe our results are objective and reproducible. We found a positive correlation between the rectal diameters and the age, height, weight, and bladder capacity. The posturination mean rectal diameter was thicker in the constipated group (3.02 ± 1.04 cm) than in the control group (1.98 ± 0.64 cm) (P < .001). The cutoff point of rectal diameter for a diagnosis of constipation was determined as 2.44 cm (71% sensitive; 76% specific; area under curve, 0.825; P < .001). The rectal anterior wall thickness and fecal load were higher in the constipated patients (P < .001). There was a significant decrease in the constipation score and fecal load after treatment for a month (P < .001), but the rectal diameter had not reached normal limits yet despite the decrease (2.71 ± 0.77 cm) (P > .05). CONCLUSION: The use of US helps in making a correct diagnosis and in the follow-up with objective criteria and also convinces the patient and the family that the treatment needs to be continued.

The stylohyoid chain: CT imaging.

We aimed in this report to discuss the embryology, anatomy, theories of ossification and symptoms, clinical presentation, and diagnosis of the stylohyoid chain (SHC) variations, together with the role of radiographs, computed tomography (CT) and three-dimensional (3D)-CT in showing these variations. Because CT/3D-CT additionally facilitates visualization of the entire SHC with different axes, it is the most valuable method for establishing the relationship between the SHC and the surrounding tissue. SHC variation can be discovered during CT performed for indications other than ossified SHC. It is important to diagnose whether or not the SHC is ossified, since one of the treatment procedures in ossified SHC is total excision. If the clinician and radiologist are aware of these variations observed in the SHC, patients with vague symptoms may be spared unnecessary investigations and may be properly diagnosed earlier.

Optimisation of contrast medium volume and injection-related factors in CT pulmonary angiography: 64-slice CT study.

OBJECTIVE: To compare the image quality of computed tomography pulmonary angiography (CTPA) obtained with the injection of various low doses of contrast medium (CM) with different injection-related factors. METHODS: A total of 90 patients (42 females, 48 males; 54.3 +/- 18.6 years) undergoing CTPA were included. Three CM protocols, each containing 30 patients, were created. Protocols 1, 2 and 3 consisted of a CM of 60 ml, 55 ml and 50 ml, and a bolus trigger level of 120 HU, 90 HU and 75 HU, respectively. Injection was uniphasic for protocols 1 and 2 (flow rate 5 ml/s), and biphasic for protocol 3 (flow rates 5 and 4 ml/s); with saline flushing afterwards. Enhancement was measured in three central and six peripheral pulmonary arteries. RESULTS: The mean attenuation value for pulmonary arteries was over 250 HU for all protocols. There was no difference between the attenuation levels with the protocols (p > 0.05). The percentage of pulmonary arteries exceeding optimal attenuation (> or =250 HU) showed that protocols 2 and 3 were 90-100% successful (p < 0.05). CONCLUSION: The use of proper injection-related factors during CTPA, such as a low trigger level and a high flow rate with saline injection following a decreased CM volume (55 ml or 50 ml), will enable adequate pulmonary artery contrast enhancement.

Assessment of vascularity with color Doppler ultrasound in gynecomastia.

PURPOSE: The aim of this study was to analyze the presence and type of vascularity with color Doppler ultrasound (CDUS) in gynecomastia, to describe gray-scale ultrasound (US) and CDUS features in different stages of gynecomastia, and to compare these findings with the characteristic US appearances of Tanner stages. MATERIALS AND METHODS: A total of 108 breasts of 54 males aged 11-27 years with complaint of gynecomastia and US verification of gynecomastia were evaluated. Each breast was then classified according to Tanner stages. The retroareolar thickness was measured. The breast was divided into three regions (medial, lateral, and retroareolar) and the arterial flow was scored according to the number of regions in which arterial flow was observed. Venous blood flow was scored according to the number of vessels in each breast. RESULTS: Gynecomastia was present in 78 breasts with a retroareolar thickness of 5-31 mm and symptom duration of 1-300 weeks. Fifteen breasts with gynecomastia had no arterial or venous flow. Tanner stages were found to be strongly associated with arterial and venous flow scores, duration of symptoms, and retroareolar thickness (P < 0.001). CONCLUSION: This study shows that vascular structures should be accepted as a component of gynecomastia. Vascularity in gynecomastia corresponds to progression of breast development, and as the process advances vascularity becomes more prominent.

Sex determination from measurements of the sternum and fourth rib using multislice computed tomography of the chest.

INTRODUCTION: One of the most important data that can be obtained from bones is sex determination for which the recommended method is taking metric measurements. Metric measurements can be performed directly on dried bones obtained from the cadaver or indirectly from their radiographs. AIM: We assessed the accuracy of sex determination and the applicability of previously defined rules using the sternum and 4th rib measurement data from chest multislice computed tomography (MSCT) imaging of 340 patients and developed a model/formula that would provide the best way to determine sex. METHODS: We analyzed the chest MSCT of 340 patients (143 females, 197 males; mean age: 57.6+/-15.2 years) and created a coronal image parallel to the sternal long axis and a coronal image at the level of sternal ending of the 4th rib. The 5 sternal measurements [length of the manubrium and sternal body, combined length of the manubrium and sternal body (CL), manubrium width and corpus sterni width] and 4th rib width (FRW) described in the literature were obtained. Sternal index (SI) and sternal area (SA) were calculated from these measurements. RESULTS: The left FRW values were used for sex determination as the left FRW was found to be more significant than the right FRW. An accuracy of over 80% was achieved for sex determination when the "142 rule" was used for CL only, a cut-off value of 5600 mm(2) for SA only and a cut-off value of 16 mm for FRW only. We found that Hyrtl's law and SI did not provide adequate accuracy for sex determination in our patients. The model with the highest accuracy (88.2%) for sex determination used SA and FRW together. We also believe that the best predictors for sex determination using the sternum and 4th rib are SA and FRW, similar to the Torwalt and Hoppa report. CONCLUSION: Radiological methods such as MSCT are useful in making reliable measurements to be used in various anthropological and forensic investigations and determining their accuracy.

Anatomic variations and anomalies of the coronary arteries: 64-slice CT angiographic appearance.

PURPOSE: To retrospectively review the 64-slice computed tomography (CT) appearance of coronary artery anatomic variants and anomalies and determine their incidence in 700 patients. MATERIALS AND METHODS: CT data of 700 patients who underwent 64-slice CT angiography (CTA) because of known or suspected coronary artery disease were retrospectively reviewed by two radiologists experienced in cardiovascular radiology. In each study, anatomic variants and anomalies were investigated. RESULTS: The coronary artery system was right dominant in 76%, left dominant in 9.1% and co-dominant in 14.8% of the cases. Ramus intermedius was present in 31%. Conus artery with a separate ostium in the right sinus Valsalva was observed in 22%, and in 0.2% two conus arteries originating with separate ostia were visualized. The sinus node artery (SNA) originated from the right coronary artery (RCA) in 79%, from the circumflex artery (Cx) in 20%, and from the left main coronary artery (LMCA) in 0.4%. In 0.4% of the cases SNA originating from the right sinus Valsalva with a separate ostium was seen. LMCA was absent in 0.4%. Cx was absent in 0.1%, and diagonals were absent in 0.1%. High takeoff of LMCA and RCA were observed in 0.7% and 0.1%, respectively. Myocardial bridging was observed in 37%. Anomalous origin of the coronary artery from the opposite sinus was observed in 1% of the cases. CONCLUSION: Complex anatomy of the coronary artery system can accurately be depicted by 64-slice CTA. This modality is useful in detecting coronary artery variants and anomalies and is a valid alternative to conventional coronary angiography in their diagnosis.

Comparison of morphologic and dynamic US methods in examination of the newborn hip.

PURPOSE: Comparison of morphologic and dynamic methods of hip ultrasonography (US) to differentiate normal from abnormal findings in the diagnosis of developmental dysplasia of the hip (DDH). MATERIALS AND METHODS: A total of 6,800 hips in 3,400 infants were examined with US, using the morphological method of Graf, and the dynamic method of Harcke. RESULTS: According to the Graf classification 81.47% of infants had Type 1 (normal hip), 10% Type 2a (physiologic immaturity), 2.44% Type 2b (acetabular dysplasia), 1.05% Type 2c (critical zone hip), 2.89% Type 3 (mildly dislocated), and 2.10% had Type 4 (dislocated) hips. Study in the transverse/neutral plane showed a normal relationship between the femoral head and the acetabulum in the 6,460 hips that were classified as Type 1-2c, that the hip was subluxated in 197 hips of Type 3, and was luxated in 143 hips of Type 4. Dynamic study with stress maneuver of the Type 1-2a hips showed that while 91.48% of the Type 1 hips (n = 5540) were stable and 8.52% were unstable, 92.37% of the Type 2a hips (n = 682) were stable and 7.63% were unstable. Dynamic study was not performed in cases that were diagnosed as Type 2b or worse. Follow-up US showed progression from Type 2a to Type 2b in 2.63% of Type 2a cases. Of the cases, 1.7% that were morphologically normal (Type 1) but unstable in their initial US examination, were revealed to be Type 3 later in the repeat US examination. CONCLUSION: We believe that overtreatment and delayed treatment rates of DDH will be minimized by the use of both morphological and dynamic US methods in the evaluation of the newborn hip.

Proliferative myositis presenting with a checkerboard-like pattern on CT.

Proliferative myositis is a rare pseudosarcomatous inflammatory process. Radiological diagnosis of self-limiting proliferative myositis helps direct appropriate clinical management and avoiding unnecessary surgical excision. We present the ultrasonography, computed tomography, and magnetic resonance imaging findings in a case of proliferative myositis. In this case, malignancy was suspected, and complete excision was performed. A checkerboard-like pattern, a characteristic sonographic and pathological finding of proliferative myositis, was demonstrated by computed tomography in our patient; to the best of our knowledge, this is the first such case in the literature.

The effects of copper contraceptive intrauterine device on the uterine blood flow: A prospective transvaginal Doppler study.

PURPOSE: To evaluate the hemodynamic changes by transvaginal color Doppler sonography (CDS) in the uterine vascular bed after the insertion of a contraceptive intrauterine device (CIUD) and to investigate whether those CDS findings could predict potential side effects, such as dysmenorrhea and abnormal bleeding. METHOD: Pulsatility index (PI), resistance index, and systole/diastole ratio (S/D) were measured in the uterine artery and its myometrial branches on 28 patients before and after the insertion of copper IUD, and a correlation with dysmenorrhea and abnormal bleeding was investigated. RESULT: PI and S/D values in the uterine artery increased significantly after the insertion of the CIUD (p < 0.05). Patients with increased bleeding scores after insertion of CIUD had significantly lower uterine artery PI compared with those without increased bleeding scores (p < 0.05). No statistically significant difference was detected in the Doppler flow parameters regarding dysmenorrhea scores. CONCLUSION: Low uterine artery PI values recorded in the early phase of the menstrual cycle in patients with a CIUD were associated with an increased bleeding risk.