The preliminary results of a new CT-guided periradicular cervical steroid injection technique: safety and feasibility of the lateral peri-isthmic approach in 28 patients.

BACKGROUND: Computed tomography (CT)-guided cervical nerve injections are broadly being used in the treatment of cervical radiculopathy; however, catastrophic complications have been reported. Herein, we aimed to evaluate the efficacy, feasibility, and safety of a novel CT-guided cervical injection technique. MATERIALS AND METHODS: We prospectively performed cervical injections in 28 patients with cervical radiculopathies using a novel CT-guided cervical transforaminal injection technique; lateral peri-isthmic approach in which the tip of the needle advanced to the lateral cortex of the isthmus instead of the foraminal area. Patients' pain reduction rates were evaluated using visual analog scores (VAS) at pre-treatment, immediately after treatment, at 3 weeks and 6 months after the treatment. Intra-vascular contrast medium injections and distribution of the contrast material into the foraminal, epidural or extraforaminal area during the procedure were noted. RESULTS: Pre-treatment pain scores were reduced by 4.2 ± 1.4 (p < 0.001), 3.9 ± 1.37 (p < 0.001) and 3.25 ± 1.53 (p < 0.001) immediately after the treatment, 3 weeks and 6 months after the treatment respectively. The number of patients with >50% pain relief as measured by VAS were 21 (75%) immediately after the procedure, 19 (67.8%) at 3 weeks and 17 (60%) at 6 months after the procedure. The injected contrast material was dispersed into the neural foramen in 9 cases (32.1%), the foraminal and epidural area in 14 cases (50%) and the extraforaminal area in 5 cases (17.9%). CONCLUSION: The CT-guided lateral peri-isthmic approach seems to be a secure and feasible method for cervical injections with satisfactory pain reduction.

[Assessment of coronary artery calcium scoring]. / Kalsiyum skorunun koroner arterlerdeki segmenter dagilimi

OBJECTIVES: Calcium accumulation in the coronary arteries is a known indicator of atherosclerosis. The purpose of this study was to demonstrate the effect of patients' demographic characteristics on calcium scoring and the topographic accumulation of calcium in the coronary arteries. STUDY DESIGN: Two-hundred ninety-nine patients were included in the study (192 male, 107 female; mean age 59.08±10.7; range 19 to 84 years). All patients with total calcium scores of 1 Hounsfield unit or more underwent 16-slice multi-detector computed tomography with calcium scoring evaluation. Their coronary trees were divided into 14 different segments, and the number of lesions in each segment was calculated separately. RESULTS: When the coronary arteries were examined for calcium accumulation by segment, the proximal segment of the LAD (left anterior descending coronary artery) had the most calcium accumulation. Total calcium scores were higher in patients with high total and LDL cholesterol values than in normolipidemic patients. Total calcium scores were higher for patients with hypertension than for patients without hypertension. Calcium scores of smokers and non-smokers were not significantly different. Diabetic patients had higher calcium scores than patients without diabetes. No significant difference was identified between patients with and without a positive family history of coronary artery disease. Total calcium scores were higher for older patients and for patients with hyperlipidemia. CONCLUSION: Segmental analysis of calcium scoring demonstrates that calcium accumulation is mostly seen in the proximal LAD. Coronary artery calcification is increased by hypertension, age and hyperlipidemia.

The role of DTI in early detection of cervical spondylotic myelopathy: a preliminary study with 3-T MRI.

INTRODUCTION: The radiological diagnosis of cervical spondylotic myelopathy (CSM) has to be made as soon as possible, since surgery performed in earlier stages during the course of CSM was reported to be more successful when compared with later stages. We hypothesized that diffusion tensor imaging (DTI) may detect CSM in earlier stages, before the appearance of signal increase in T2-weighted sequences. METHODS: A total of 16 patients with neurological signs and symptoms of CSM but without hyperintensity in spinal cord on T2-weighted sequences enrolled in the study. The magnetic resonance (MR) examinations were performed on a 3-T MR imaging system. Apparent diffusion coefficient (ADC) and fractional anisotropy (FA) maps were generated on axial plane. The ADC and FA measurements in each individual were made at the level of most severe cervical canal stenosis and at a nonstenotic level. Student's t test was used to compare FA and ADC values of the spinal cord in stenotic and nonstenotic segments. We also investigated if there was a correlation between DTI parametrics and duration of clinical symptoms by using Pearson correlation analysis. RESULTS: All patients showed changes in DTI parametrics at stenotic segments. While FA values of the spinal cord at the stenotic level showed a statistically significant reduction, there was a statistically significant increase in the measured ADC values (p < 0.001). There was no statistical correlation between the duration of symptoms and DTI parametrics. CONCLUSION: Our preliminary findings indicate that DTI may show abnormalities in the spinal cord before the development of T2 hyperintensity on conventional sequences in patients with CSM.

OptEase and TrapEase vena cava filters: a single-center experience in 258 patients.

We aimed to evaluate the efficacy and safety of the OptEase and TrapEase (both from Cordis, Roden, Netherlands) vena cava filters in the prevention of pulmonary embolism (PE). Between May 2004 and December 2008, OptEase (permanent/retrievable; n = 228) or TrapEase (permanent; n = 30) vena cava filters were placed in 258 patients (160 female and 98 male; mean age 62 years [range 22 to 97]). Indications were as follows: prophylaxis for PE (n = 239), contraindication for anticoagulation in the presence of PE or DVT (n = 10), and development of PE or DVT despite anticoagulation (n = 9). Medical records were retrospectively reviewed for indications, clinical results, and procedure-related complications during placement and retrieval. Clinical PE did not develop in any of the patients. However, radiologic signs of segmental PE were seen in 6 of 66 patients with follow-up imaging data. Migration or fracture of the filter or cava perforation was not seen in any of the patients. Except for a single case of asymptomatic total cava thrombosis, no thrombotic occlusion was observed. One hundred forty-one patients were scheduled to undergo filter removal; however, 17 of them were not suitable for such based on venography evaluation. Removal was attempted in 124 patients and was successful in 115 of these (mean duration of retention 11 days [range 4 to 23]). Nine filters could not be removed. Permanent/retrievable vena cava filters are safe and effective devices for PE prophylaxis and for the management of venous thromboembolism by providing the option to be left in place.

MR spectroscopy findings in Lafora disease.

PURPOSE: Our aim was to investigate the [(1)H] MR spectroscopy (MRS) findings of Lafora Disease (LD), which is a disabling form of progressive myoclonic epilepsy. METHODS: Twelve patients diagnosed with LD and 12 control subjects underwent MRS studies with single-voxels of 8 cc obtained in the frontal lobe, pons, and cerebellum. The metabolites and NAA/Cr, NAA/Cho, Cho/Cr, mI/Cr ratios were calculated. Subgroup analysis was also done between 5 patients with EPM2B and 6 patients with EPM2A mutations. Two investigators scored neurological symptom severity. RESULTS: We found a statistically significant difference of NAA/Cho ratio in LD patients compared with normal controls in cerebellum (P= 0.04). In addition, both myoclonus and ataxia scores showed significant correlation with NAA/Cho ratios in the pons (P= 0.03, P= 0.04) and in the cerebellum (P= 0.04, P= 0.01), respectively. CONCLUSION: We conclude that the cerebellum is the mostly affected structure in LD and there are significant correlations of MRS findings with some clinical parameters. The differences in the group may be related to different genetic mutations besides disease duration and other clinical variables. MRS studies could provide insights about the severity of the involvement of LD.

Pseudomeningocele in communication with the facet joint: demonstration by computerized tomography-arthrography.

Pseudomeningocele is an uncommon but well-known complication of lumbar spine operations. Although it is mostly asymptomatic and managed conservatively in most cases, it is claimed as a causative factor of failed back surgery syndrome and requires surgery in some cases. Usually, its diagnosis is confidently done with imaging modalities such as magnetic resonance imaging, computed tomography and myelography. In this report, we describe a case of pseudomeningocele that communicated with a facet joint. The diagnostic approach for this unusual lesion and its probable causes are discussed.

Osteochondritis dissecans of the tarsal navicular.

A 27-year-old male athlete presented with chronic right dorsal midfoot pain and limitation in midfoot movements. Computed tomography and magnetic resonance imaging demonstrated an nondisplaced osteochondral fragment within the proximal articular surface of the tarsal navicular. Imaging findings of this disease are presented and discussed.

Degenerative lumbar spinal stenosis: correlation with Oswestry Disability Index and MR imaging.

Because neither the degree of constriction of the spinal canal considered to be symptomatic for lumbar spinal stenosis nor the relationship between the clinical appearance and the degree of a radiologically verified constriction is clear, a correlation of patient's disability level and radiographic constriction of the lumbar spinal canal is of interest. The aim of this study was to establish a relationship between the degree of radiologically established anatomical stenosis and the severity of self-assessed Oswestry Disability Index in patients undergoing surgery for degenerative lumbar spinal stenosis. Sixty-three consecutive patients with degenerative lumbar spinal stenosis who were scheduled for elective surgery were enrolled in the study. All patients underwent preoperative magnetic resonance imaging and completed a self-assessment Oswestry Disability Index questionnaire. Quantitative image evaluation for lumbar spinal stenosis included the dural sac cross-sectional area, and qualitative evaluation of the lateral recess and foraminal stenosis were also performed. Every patient subsequently answered the national translation of the Oswestry Disability Index questionnaire and the percentage disability was calculated. Statistical analysis of the data was performed to seek a relationship between radiological stenosis and percentage disability recorded by the Oswestry Disability Index. Upon radiological assessment, 27 of the 63 patients evaluated had severe and 33 patients had moderate central dural sac stenosis; 11 had grade 3 and 27 had grade 2 nerve root compromise in the lateral recess; 22 had grade 3 and 37 had grade 2 foraminal stenosis. On the basis of the percentage disability score, of the 63 patients, 10 patients demonstrated mild disability, 13 patients moderate disability, 25 patients severe disability, 12 patients were crippled and three patients were bedridden. Radiologically, eight patients with severe central stenosis and nine patients with moderate lateral stenosis demonstrated only minimal disability on percentage Oswestry Disability Index scores. Statistical evaluation of central and lateral radiological stenosis versus Oswestry Disability Index percentage scores showed no significant correlation. In conclusion, lumbar spinal stenosis remains a clinico-radiological syndrome, and both the clinical picture and the magnetic resonance imaging findings are important when evaluating and discussing surgery with patients having this diagnosis. MR imaging has to be used to determine the levels to be decompressed.

CT and MR characteristics of hibernoma: six cases.

PURPOSE: The purpose of this study was to describe the computed tomography (CT) and magnetic resonance (MR) imaging findings of hibernoma. MATERIALS AND METHODS: We retrospectively evaluated imaging findings of CT and MR examinations of six patients (three men and three woman, aged 27-48 years) with histopathological diagnosis of hibernoma. RESULTS: On CT examination, the lesions were slightly hyperdense, and on T1- and T2-weighted MR images, they were isointense or slightly hypointense compared to the subcutaneous fat. All of these lesions showed contrast enhancement and one out of the six lesions had internal linear septations. CONCLUSION: Hibernoma has a wide spectrum of CT and MR imaging findings, which should be considered in differential diagnosis, especially with other lipomatous lesions.

An investigation of the association between coronary artery dominance and coronary artery variations with coronary arterial disease by multidetector computed tomographic coronary angiography.

PURPOSE: Depending on the perfusing interventricular septum of the arteries, there are 3 types of circulation dominance: right, left, and balanced. In this study, coronary artery branches supplying the ventricular septum were investigated in vivo in a large group of patients by multidetector computed tomography (MDCT) coronary angiography. In addition, the association of coronary artery variations with coronary arterial disease was investigated. MATERIALS AND METHODS: The study included 325 consecutive patients (214 men and 108 women, with a mean age of 59 +/- 14 years) who underwent MDCT coronary angiography. Multidetector computed tomography was performed with a 16-detector-row computed tomographic scanner. The type of dominance, coronary arterial diseases, and coronary artery variations were recorded. RESULTS: In our study, the types of coronary circulation were right, left, and balanced in 227 (70%), 40 (12.5%), and 58 (17.5%) patients, respectively. Dominance of right circulation was detected in 150 of 217 (69%) of men and in 77 of 108 (71%) of women; dominance of left circulation was found in 26 of 217(12%) of men and in 14 of 108 (13%) of women; balanced/codominance circulation was found in 41 of 217 (19%) of men and in 17 of 108 (16%) of women. However, no significant differences were detected between the sexes for the type of coronary circulation. Coronary artery disease was determined in 68 patients (20.9%) by MDCT, and coronary artery variations were also determined in 34 patients (10.4%). Both the number and the rate of coronary artery variations were significantly higher among the patients with left artery dominance. CONCLUSIONS: Knowledge of coronary artery variations and pathologies is important in planning the treatment and in interpretation of findings of cardiovascular diseases. Our study indicated that, although right dominance circulation is more common in general population, both the coronary diseases and coronary artery variations are more common in individuals with left dominance circulation.

Femoral nerve palsy due to iliacus hematoma occurred after primary total hip arthroplasty.

The perforation of the medial acetabular wall during total hip arthroplasty due to drilling is not uncommon. But, it has rarely been associated with serious adverse events. Here, we present a case report describing an iliacus hematoma with subsequent femoral nerve palsy after primary total hip arthroplasty in a 67-year-old woman who underwent primary total hip arthroplasty due to painful hip osteoarthritis. The diagnosis was made by pelvic magnetic resonance imaging. Conservative treatment was employed and the symptoms were resolved within 3 months. It should be borne in mind that femoral nerve palsy may occur after total hip arthroplasty. It may be due to a treatable cause, such as iliacus hematoma. So, pelvic MRI is recommended in such a condition, rather than just observation.

The value of magnetic resonance cholangiography in the preoperative assessment of living liver donors.

OBJECTIVE: The purpose of this study was to investigate the ability of magnetic resonance cholangiography (MRC) in the depiction of biliary anatomy of living liver donors by using intraoperative cholangiography (IOC) as a gold standard. MATERIALS AND METHODS: Between 2004 and 2006, 86 potential adult-to-adult living donor liver transplantation donors had preoperative MRC at our institution. Of these, 24 potential donors were excluded due to various clinical factors. A total of 62 of these individuals were selected for liver donation and included in the study. MRC was performed on a 1.5-T scanner with breath-hold, rapid acquisition with relaxation enhancement (RARE) sequence with half-Fourier acquisition (HASTE; Siemens) and free-breathing, three-dimensional turbo spin-echo sequence with respiratory triggering. Thin- and thick-slab imaging techniques were employed with half-Fourier RARE MRC. IOC was performed in all 63 cases. The images of IOC and MRC were classified according to a modified Huang classification, independently. The results of the MRC were then compared with the IOC results. RESULTS: IOC was used as the reference standard; a total of 43 (69.3%) liver donors were considered to have normal biliary anatomy, whereas 19 (30.7%) were considered to have variants of biliary anatomy. Compared with IOC, MRC correctly revealed biliary anatomy in 59 of 62 (95.1%) donors. The sensitivity, specificity, positive predictive value and negative predictive value of MRC in distinguishing normal and any type of variant biliary anatomy were 84.2%, 100%, 100%, and 93.4%, respectively. CONCLUSION: MRC is an effective imaging technique for the preoperative evaluation of the biliary anatomy in living liver donors. However, MRC and IOC should be considered complementary to one another in order to avoid complications.