Spinal subarachnoid hemorrhage progressing to spinal cord compression in a patient on a direct oral anticoagulant: a case report.

Background: Spontaneous spinal subarachnoid hemorrhage (SSH) is an infrequent yet critical condition, accounting for less than 1% of all spinal hemorrhages and presenting substantial diagnostic difficulties. It predominantly arises due to factors such as tumors, trauma, arteriovenous malformations (AVM), and certain medications including anticoagulants. The complexity of its presentation necessitates vigilance from healthcare providers to avert irreversible neurological impairments. Case Description: This study delineates the unusual case of an 82-year-old woman undergoing direct oral anticoagulant (DOAC) therapy who reported sudden, severe chest and back pain, rapidly escalating to lower limb motor and sensory deficits, coupled with urinary and fecal incontinence. An initial cranial computed tomography (CT) indicated a peri-mesencephalic subarachnoid hemorrhage (SAH). Subsequent spinal CT angiography (CTA) and magnetic resonance imaging (MRI) affirmed the diagnosis of a spontaneous SSH, displaying significant cord compression, particularly in the thoracic regions between the T6 and T9 vertebrae. Emergency laminectomy was done to evacuate the subarachnoid hematoma that was causing cord compression. Postoperatively, the patient recovered partial neurological function. Conclusions: SSH, though rare, embodies a significant diagnostic hurdle and potential for lasting neurological deficits if not identified and treated promptly. Particularly in patients on anticoagulant therapy presenting with acute onset back pain and neurological dysfunction, SSH ought to be a crucial consideration. It is imperative to integrate prompt and advanced neuroimaging techniques and consider spinal angiography as a golden standard for a comprehensive diagnosis. Treatment strategies depend largely on the presence of neurological deficits, emphasizing the necessity of quick identification and emergency intervention in severe cases. This study elucidates the critical role of timely intervention in optimizing recovery outcomes, highlighting the necessity of including anticoagulant-induced spinal hemorrhage in differential diagnoses for patients manifesting signs of acute spinal cord compression.

Fetal MRI-Based Body and Adiposity Quantification for Small for Gestational Age Perinatal Risk Stratification.

BACKGROUND: Small for gestational age (SGA) fetuses are at risk for perinatal adverse outcomes. Fetal body composition reflects the fetal nutrition status and hold promise as potential prognostic indicator. MRI quantification of fetal anthropometrics may enhance SGA risk stratification. HYPOTHESIS: Smaller, leaner fetuses are malnourished and will experience unfavorable outcomes. STUDY TYPE: Prospective. POPULATION: 40 SGA fetuses, 26 (61.9%) females: 10/40 (25%) had obstetric interventions due to non-reassuring fetal status (NRFS), and 17/40 (42.5%) experienced adverse neonatal events (CANO). Participants underwent MRI between gestational ages 30 + 2 and 37 + 2. FIELD STRENGTH/SEQUENCE: 3-T, True Fast Imaging with Steady State Free Precession (TruFISP) and T1 -weighted two-point Dixon (T1 W Dixon) sequences. ASSESSMENT: Total body volume (TBV), fat signal fraction (FSF), and the fat-to-body volumes ratio (FBVR) were extracted from TruFISP and T1 W Dixon images, and computed from automatic fetal body and subcutaneous fat segmentations by deep learning. Subjects were followed until hospital discharge, and obstetric interventions and neonatal adverse events were recorded. STATISTICAL TESTS: Univariate and multivariate logistic regressions for the association between TBV, FBVR, and FSF and interventions for NRFS and CANO. Fisher's exact test was used to measure the association between sonographic FGR criteria and perinatal outcomes. Sensitivity, specificity, positive and negative predictive values, and accuracy were calculated. A P-value <0.05 was considered statistically significant. RESULTS: FBVR (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.2-0.76) and FSF (OR 0.95, CI 0.91-0.99) were linked with NRFS interventions. Furthermore, TBV (OR 0.69, CI 0.56-0.86) and FSF (OR 0.96, CI 0.93-0.99) were linked to CANO. The FBVR sensitivity/specificity for obstetric interventions was 85.7%/87.5%, and the TBV sensitivity/specificity for CANO was 82.35%/86.4%. The sonographic criteria sensitivity/specificity for obstetric interventions was 100%/33.3% and insignificant for CANO (P = 0.145). DATA CONCLUSION: Reduced TBV and FBVR may be associated with higher rates of obstetric interventions for NRFS and CANO. EVIDENCE LEVEL: 2 TECHNICAL EFFICACY: Stage 5.

Adverse Histological Features of Differentiated Thyroid Cancer Are Commonly Found in Autopsy Studies: Implications for Treatment Guidelines.

Background: While the popularity of lobectomy for differentiated thyroid cancer (DTC) has increased since the 2015 ATA (American Thyroid Association) guidelines, recent studies reported that adverse histological features (minimal extrathyroidal extension [mETE], multifocality, vascular invasion, and lymph node [LN] metastases) may be found in 30-60% of lobectomy specimens, questioning the validity of this approach. Aim: To assess the prevalence adverse histological features in occult DTC detected in autopsy studies. Methods: Meta-analysis of autopsy studies of the thyroid in subjects without known history of thyroid cancer. Results: Twenty-nine studies including 8750 subjects fulfilled the inclusion criteria, with incidentally discovered DTC in 740 autopsies (8.5%). Age was reported in 17 studies, with a median age of 61 years (range 41-68 years). Multifocality was reported in 27 studies with a calculated event rate of 28.2% ([CI 23.1-33.8], I2 = 46.3%), with bilateral involvement in 18% [CI 12.6-25.1]. mETE was reported in 5 studies, with an event rate of 24.5% ([CI 9.3-50.7], I2 = 88.5%), and the presence of LN metastases were reported in 13 studies with an event rate of 11% ([CI 6.1-19.1], I2 = 69.5%). Vascular invasion was reported in seven studies with an event rate of 16% ([CI 4-47], I2 = 86.8%). Of 25 studies with whole body autopsies (722 subjects), 3 cases of distant metastases were reported, of which 2 had fatal metastatic disease (where thyroid origin was not diagnosed before death), and 1 had occult disease. Conclusions: Adverse histological features including mETE, LN metastases, multifocality, and vascular invasion are common in occult DTC. When minimal in size, these adverse histological features do not seem to be markers of aggressive disease and may not be an indication for completion thyroidectomy or radioiodine therapy.

Central Precocious Puberty as a Presenting Sign of Nonclassical Congenital Adrenal Hyperplasia: Clinical Characteristics.

CONTEXT: Central precocious puberty (CPP) may be the first presentation of nonclassical congenital adrenal hyperplasia (NCCAH) in girls. Data on the prevalence and the clinical phenotype of CPP associated with NCCAH are sparse. OBJECTIVES: To study the clinical and laboratory characteristics that could differentiate idiopathic CPP from CPP associated with NCCAH and to determine the prevalence of NCCAH among girls with CPP. DESIGN: Case-control study. SETTING: Tertiary pediatric endocrinology institute. PARTICIPANTS AND METHODS: From 2008 to 2017, 147 girls who had undergone stimulation tests with gonadotropin-releasing hormone and ACTH were diagnosed with CPP; of these, seven (4.8%) were eventually diagnosed with NCCAH. These seven patients together with 30 girls who presented with CPP during 1984 to 2008 and were later diagnosed with NCCAH comprised the NCCAH group. Demographic, anthropometric, clinical, and laboratory data were compared between the NCCAH group and the 140 girls with idiopathic CPP (ICPP group). RESULTS: No between-group differences were found in height, weight, body mass index, bone age, and Tanner stage. Mean basal levels of androstenedione, dehydroepiandrosterone-sulphate, and 17-hydroxyprogesterone were significantly higher in the NCCAH group, although ranges overlapped between the groups, and stimulated cortisol level was higher in the ICPP group. CONCLUSION: NCCAH was found in 4.8% of girls presenting with true CPP over 10 years, and no single parameter could differentiate between the diagnoses. Thus, in girls with true CPP from populations in which NCCAH is prevalent, assessment of adrenal androgens is required, and ACTH test should be considered.