Anal sphincter tears in patients with rectal prolapse and faecal incontinence.

OBJECTIVE: Faecal incontinence often persists after surgery for rectal prolapse. Multiple mechanisms have been proposed as responsible, however, anal sphincter integrity has only been studied in a handful of cases. This study assesses the incidence of ultrasound detected anal sphincter tears in patients with rectal prolapse and faecal incontinence. METHODS: Retrospective search of medical records at Flinders Medical Centre over a 7-year period to identify patients with full thickness rectal prolapse and faecal incontinence who had undergone endosonographical imaging of the anal sphincter complex. Anal manometry and pudendal nerve terminal motor latency studies were also included. RESULTS: Twenty-one patients were identified (1 male, 20 female) of median age 67.5 years. Fifteen (71%) subjects had an abnormality in the anal sphincter complex on endoanal ultrasound. Of these, the defects in 4 (19%) patients were isolated to the internal sphincter, 3 (14%) to the external sphincter and in the remaining 8 (38%) subjects, defects were found in both internal and external sphincters. The degree of sphincteric defect was variable but at least 6 (29%) of the study group had full-length external sphincter tears. In the 19 patients studied, anal manometry revealed reduced basal and squeeze pressures in the majority. Delayed pudendal nerve terminal motor latency was evident in 9 of 18 patients studied. CONCLUSION: Anal sphincter tears are common in patients presenting with rectal prolapse and faecal incontinence. The faecal incontinence associated with prolapse appears to be multifactorial in aetiology. Anal sphincter defects are likely to contribute to persistent faecal incontinence or recurrence following rectal prolapse. Endoanal ultrasound derived knowledge of anal sphincter injury may guide surgical management in problematic cases.

Meningioangiomatosis.

The imaging findings of a case of meningioangiomatosis with pathologic correlation are presented.

Incisional hernia and small bowel obstruction following laparoscopic surgery: computed tomography diagnosis.

Incisional hernias are a relatively uncommon complication of laparoscopic surgery. Early CT diagnosis of small bowel obstruction due to incarceration in an incisional hernia after laparoscopic cholecystectomy enabled early surgery to be carried out, thereby preventing gut ischaemia and resection.

Biopsy diagnosis of malignant versus benign liver "nodules": new helpful markers. An update.

Improved imaging techniques have led to an increased detection of suspicious "nodules" in the cirrhotic and noncirrhotic liver. Although the histologic diagnosis of clearly benign or clearly malignant lesions is usually straightforward, problems arise in the differential diagnosis of benign "nodules" and dysplastic lesions or well-differentiated hepatocellular carcinomas. This is especially so in limited diagnostic material, such as cytologic preparations from fine-needle aspirates and needle-core tissue biopsies. Recently, additional helpful markers have been described that may help to establish a conclusive diagnosis even on such material. Two of these, the reticulin stain and immunohistochemical staining for CD34, have been found to be useful also in cytologic cellblock material. Telomerase, a complex enzyme that is active in most malignant tumors, has also been found to show strong activity in most hepatocellular carcinomas. Mention is made of an immunohistochemical marker (MOC-31), reported to be useful in the differentiation between metastatic adenocarcinoma and hepatocellular carcinoma.

Rhombencephalosynapsis.

A case report of rhombencephalosynapsis in a 34-year-old female is presented and the clinical features and possible pathogenesis of this disorder are reviewed.

Delayed pudendal nerve conduction and endosonographic appearance of the anal sphincter complex.

PURPOSE: The aim of this study was to test the hypothesis that a delay in pudendal nerve conduction as measured by pudendal nerve terminal motor latency should be associated with atrophy of the external anal sphincter as measured using endoanal ultrasound. METHODS: Sixty-two adult females (median age, 58.9 (range, 22-88) years) presenting for evaluation of fecal incontinence with no evidence of an external anal sphincter tear on ultrasound were recruited. Ultrasound was performed with a 7.5-MHz radial rotating axial endoprobe in the left lateral position. Four measurements were made in the transverse plane--the external anal sphincter thickness in the midanal canal at the 6 o'clock and 9 o'clock positions, the internal sphincter at the 9 o'clock position, and the external anal sphincter in the low canal at the 9 o'clock position. Pudendal nerve terminal motor latency was measured using a transrectal nerve stimulation technique with measurement of the evoked muscle response. RESULTS: Although there was a trend toward thinner external sphincter muscles in those with bilateral prolonged pudendal nerve terminal motor latency, independent sample t-tests and Pearson correlation coefficients showed no statistically significant relationship (right pudendal nerve terminal motor latency: P = 0.083, 0.184, 0.128, 0.910; r = 0.228, 0.175, -0.201, -0.015; left pudendal nerve terminal motor latency: P = 0.946, 0.276, 0.510, 0.123; r = -0.009, -0.143, -0.087, -0.201). CONCLUSIONS: No statistically significant relationship between ultrasound-measured anal sphincter muscle thickness and pudendal nerve terminal motor latency was identified. Although a trend was suggested that could be further evaluated by a study with a larger sample size and a control group with asymptomatic patients, the small differences in muscle thickness involved and the difficulties in measurement suggest that the establishment of clinically useful ultrasound criteria for the detection of the neuropathic anal sphincter complex is unlikely.

An unusual cause of hemifacial spasm.

Hemifacial spasm (HFS) is a movement disorder characterized by involuntary paroxysmal chronic contractions of the facial musculature. The usual cause is vascular compression of the seventh cranial nerve, at its exit zone from the brain stem. We report a case of left hemifacial spasm, in a 66-year-old woman, in which the neuroradiological investigation with magnetic resonance imaging showed a hypervascular soft tissue mass arising from the left skull base, in the jugular foramen. This lesion was thought highly likely to be a glomus jugulare tumour. While the usual occurrence of tumour compression causing HFS has been previously recognized, the association of glomus jugulare tumours presenting with HFS has not. The importance of this association is discussed. Copyright 1999 Harcourt Publishers Ltd.

Anterior sacral meningocele as a pelvic complication of Marfan syndrome.

Anterior sacral meningocele (ASM) is well recognized in Marfan syndrome as a consequence of dural ectasia. Two cases presenting as nongynaecological pelvic masses are described highlighting the clinical difficulty in diagnosis and the classical radiological findings. The classification of ASM and associated anomalies of the sacrum are reviewed.

MRI of car occupants with whiplash injury.

Our purpose was to document and investigate the prognostic significance of features seen on MRI of patients with whiplash injury following relatively minor road traffic crashes. MRI was obtained shortly and at 6 months after the crash using a 0.5 T imager. The images were assessed independently by two radiologists for evidence of fracture or other injury; loss of lordosis and spondylosis were also recorded. Clinical examinations were used to assess the status of patients initially and at 6 months. The results of the independent MRI and clinical investigations were then examined for association using statistical tests. Initial MRI was performed on 29 patients, of whom 19 had repeat studies at 6 months; 48 examinations were thus examined. Apart from spondylosis and loss of lordosis, only one abnormality was detected: an intramedullary lesion consistent with a small cyst or syrinx. There were no statistically significant associations between the outcome of injury and spondylosis or loss of lordosis. No significant changes were found when comparing the initial and follow-up MRI. It appears that MRI of patients with relatively less severe whiplash symptoms reveals a low frequency of abnormalities, apart from spondylosis and loss of lordosis, which have little short-term prognostic value. Routine investigation of such patients with MRI is not justified in view of the infrequency of abnormalities detected, the lack of prognostic value and the high cost of the procedure.

Sudden onset of subarachnoid block after subdural catheterization: a case of arachnoid rupture?

We describe a patient who received an apparently uneventful extradural block in labour but developed rapid extension of neural block within minutes of receiving her first incremental dose 2 h later. Computed contrast tomography revealed radio-opaque dye within both the subdural and subarachnoid spaces, but none within the extradural space. This case report demonstrates that subdural spread of low-dose local anaesthetics is not always clinically distinguishable from extradural analgesia and that the arachnoid membrane may subsequently perforate with potentially serious consequences.

The hypoglossal canal: normal MR enhancement pattern.

PURPOSE: To review the anatomy of the hypoglossal canal and present the normal precontrast and postcontrast MR appearance of axial posterior fossa images. METHODS: Thirty-one axial MR examinations of the normal posterior fossa were retrospectively reviewed. RESULTS: The hypoglossal canals are well seen on 3-mm-thick axial MR images of the posterior fossa (28 [90%] of 31 patients). Symmetric intense intracanalicular enhancement after intravenous administration of gadopentetate dimeglumine is routine, typically with minor anterior extension into the nasopharyngeal region (28 [100%] of 28). A linear filling defect traversing the enhanced canal often is seen (21 [75%] of 28) and may represent hypoglossal nerve rootlets. Circumferential enhancement of the meninges at the level of the foramen magnum was a common finding (19 [64%] of 28). CONCLUSION: Enhancement within the hypoglossal canal with anterior extension beneath the skull base is a normal finding. This pattern is characteristic enough on MR imaging to aid interpretation of skull base lesions and to exclude the possibility of a mass within the hypoglossal canal.

Intracerebral ganglioglioma.

A case of a rare intracerebral tumour, namely a ganglioglioma, is reported to illustrate the CT and MRI features. The finding of focal thinning of the inner skull vault in association with an adjacent intracerebral mass lesion can aid in the diagnosis of intracerebral ganglioglioma.

Lymphomatoid granulomatosis.

A case of lymphomatoid granulomatosis is presented demonstrating the most common chest radiograph findings as well as some infrequent but recognized associations. The clinical presentation and pathogenesis are discussed. The difficulty in radiological diagnosis is highlighted.

Percutaneous retrieval of a partially expanded iliac artery stent: case report.

A partially expanded, intraluminal, balloon-expandable Palmaz vascular stent was retrieved percutaneously in a 48-year-old woman after attempted placement across a common iliac artery stenosis. A pinhole in the balloon prevented expansion, and the stent could not be stabilized to allow balloon exchange. The stent was snared by a 5Fr 4 mm balloon catheter replaced coaxially through the stent and then withdrawn into a 14Fr Amplatz sheath which had been percutaneously placed in the external iliac artery. Open surgical removal of the stent was thus avoided.