Dynamic contrast-enhanced MRI as a valuable non-invasive tool to evaluate tissue perfusion of free flaps: Preliminary results

Early detection of a compromised circulation of free flaps and an immediate revision may lead to higher rates of flap salvage. The aim of this study was to evaluate the perfusion of the entire flap using dynamic contrast-enhanced (DCE) magnetic resonance imaging (MRI). DCE was performed in 11 patients after flap transplantation using an optimized 3D gradient echo sequence to cover the whole flap. The percentage increase of signal intensity over time was evaluated for the free flap as well as for a reference tissue. Furthermore, normalized signal increase was calculated as the ratio of signal increase within the flaps to the signal increase in the reference tissue. Signal increase in free flaps and reference tissue was compared using the Wilcoxon-test (p < 0.05), normalized signal increase in normally perfused (n = 9) and in flaps with compromised perfusion (n = 2) using Mann-Whitney-test (p < 0.05). Signal increase within normally perfused flaps was similar to the reference tissue. In flaps with compromised perfusion the increase was significantly lower than in reference tissue. Normalized signal increase in adequately perfused flaps and flaps with compromised perfusion also showed a significant difference. DCE MRI may be a valuable non-invasive tool to evaluate tissue perfusion of the complete free flap.     

Refractory Progression of Coronary Aneurysms,a Case of Delayed Onset Kawasaki Disease as Depicted by Cardiac Computed Tomography Angiography

Background. Kawasaki disease (KD) is an immune-mediated vasculitis of unknown etiology with self-limited clinical course that was first described in 1967 by Dr. Tomisaku Kawasaki. It is a disease of early childhood and rare past late adulthood but one that can have detrimental consequences when there is a delay in diagnosis and treatment. Cardiovascular complications causing increased morbidity and mortality may include coronary artery aneurysms, myocardial infarction, heart failure, arrhythmias, and peripheral artery occlusion. Case Presentation. Here, we present an atypical case of delayed onset KD in a young teenager. DS had visited three different emergency departments during the course of 2 weeks for unrelenting fevers. Despite multiple treatment protocols including immunoglobulin, steroids, and tumor necrosis factor-alpha antagonists, he continued to have progression of cardiovascular complications. While echocardiographic findings were suspicious for cardiac complications, a cardiac computed tomography (CT) angiography was able to clearly distinguish giant coronary aneurysms. Conclusion. Without prompt therapy, fever and manifestations of acute inflammation can last for several weeks to months with increased risk toward complications. The incidence of coronary artery aneurysms has been noted to be 25% in untreated patients with a mortality rate of up to 2%. Using low-dose protocols along with high spatial and temporal resolution of cardiac CT angiography may provide a useful and complimentary imaging modality in accurate diagnosis and follow-up of patients with KD.     

Lumbar pannus presenting as cauda equina syndrome in a patient with longstanding rheumatoid arthritis

Relatively little attention has been paid to lumbar spine involvement in rheumatoid arthritis (RA), and indeed it is generally considered to be an uncommon and usually clinically minor manifestation of the disease. We describe a case of acute right lower extremity weakness secondary to compression of multiple lumbar nerve roots by a large interforaminal rheumatoid pannus, and review the literature on this complication and other lumbar spine involvement in RA.     

Cerebral MRI as a valuable diagnostic tool in Zellweger spectrum patients

Summary Patients with defects in the biogenesis of peroxisomes include those with Zellweger syndrome spectrum (ZSS), a developmental and progressive metabolic disease with a distinct dysmorphic phenotype and varying severity. The diagnosis of ZSS relies on the clinical presentation and the biochemical evaluation of peroxisomal metabolites. Mutation detection in one out of twelve genes coding for proteins involved in the biogenesis of peroxisomes confirms the diagnosis. In the absence of pronounced clinical features of ZSS, neuroradiological findings may lead the way to the diagnosis. Cerebral magnetic resonance imaging (cMRI) pathology in ZSS consists of abnormal gyration pattern including polymicrogyria and pachygyria, leukencephalopathy, germinolytic cysts and heterotopias as reported by previous systematic studies including cMRI of a total of 34 ZSS patients, only five of whom had a severe phenotype. The present study evaluated the cMRI results of additional 18 patients, 6 with a severe and 12 with a milder ZSS phenotype. It confirms and extends knowledge of the characteristic cMRI pattern in ZSS patients. Besides an abnormal gyration pattern and delayed myelination or leukencephalopathy, brain atrophy was a common finding. Polymicrogyria and pachygyria were more common in patients with severe ZSS, while leukencephalopathy increases with age in patients with longer survival. Nevertheless, an abnormal gyration pattern might be more frequent in patients with a mild ZSS than deduced from previous studies. In addition, we discuss the differential diagnosis of the ZSS cMRI pattern and review investigations on the pathogenesis of the ZSS cerebral phenotype in mouse models of the disease. Competing interests: None declared References to electronic databases: Peroxisome biogenesis disorder: OMIM #601539. Zellweger syndrome: OMIM #214100. Neonatal adrenoleukodystrophy: OMIM #202370. Infantile Refsum disease: OMIM #266510 Presented at the Annual Symposium of the SSIEM, Hamburg, 4–7 September 2007.     

Normal Values of High-Resolution Manometry in Supine and Upright Positions in a Thai Population

Digestive Diseases and Sciences - Although cut-off values used in high-resolution manometry (HRM) to diagnose esophageal motility disorders are based on representative samples of the US population...     

The Structure of Psychological Defense Mechanisms in Women as a Function of Alcohol Intoxication

The present experiment tested whether moderate alcohol intoxication influences the relative strength of different psychoanalytic defense mechanisms and whether the overall level of defense activity is changed. Thirty-six women were randomly assigned to either an alcohol, a placebo, or a control group. The alcohol dose was 1.0 ml of 100% alcohol/kg body weight. Subjects were tested with the Defense Mechanism Test (DMT), which gives a valid measure of both elaborate or late and primitive or early defense mechanisms. Results indicated no significant effects of alcohol intoxication on any aspect of the defense system. This was taken as supportive of the psychoanalytic notion in respect of the stability of the defense system. Possible complications were discussed.     

Lumbar pain as a clinical manifestation of the intrabdominal desmoplastic small round cell tumor

"The desmoplastic small round cell tumor is infrequent.That mainly affects male youngsters and is normally located at the abdomino-pelvic cavity, being its clinic unspecific. The diagnosis is confirmed by the presence of a specific chromosomal translocation: t (11; 22), (p13; q12). As to its treatment, it is mostly recommended to follow a multimodal aggressive one. We present the case of a man, whose atypicality is due to his advanced age (63 years old) and the symptoms he presents (lumbar ache)."     

MRI misinterpretation of spontaneous echo-contrast as a large left atrial thrombus

A magnetic resonance imaging of the heart was obtained in a patient with history of mitral valve replacement, in whom cor triatriatum dexter was suspected. Dense left atrial echo-contrast, visualized during a previous trans-esophageal echocardiography, was incorrectly interpreted as a large thrombus extending into the pulmonary veins and the patient was referred for cardiac surgical evaluation.     

Intraoperative Computed Tomography Navigation for Transpedicular Screw Fixation to Treat Unstable Thoracic and Lumbar Spine Fractures: Clinical Analysis of a Case Series (CARE-Compliant)

Transpedicular screw (TPS) fixation in unstable thoracic and lumbar (TL) spine fractures remains technically difficult because of destroyed anatomical landmarks, unstable gross segments, and discrepancies in anatomic orientation using conventional anatomic landmarks, fluoroscopic guidance, or computed tomography (CT)-based navigation. In this study, we evaluated the safety and accuracy of TPS placement under intraoperative computed tomography (iCT) navigation in managing unstable TL spine fractures.From 2010 to 2013, we retrospectively reviewed the Spine Operation Registry records of patients who underwent posterior instrumented fusion to treat unstable TL spine fractures via the iCT navigation system. An unstable spine fracture was identified as AO/Magerl classification type B or type C.In all, 316 screws in 37 patients with unstable TL spine fractures were evaluated and involved 7 thoracic, 23 thoracolumbar junctional, and 7 lumbar fractures. The accuracy of TPS positioning in the pedicle without breach was 98% (310/316). The average number of iCT scans per patient was 2.1 (range 2–3). The average total radiation dose to patients was 15.8 mSv; the dose per single level exposure was 2.7 mSv. The TPS intraoperative revision rate was 0.6% (2/316) and no neurovascular sequela was observed. TPS fixation using the iCT navigation system obtained a 98% accuracy in stabilizing unstable TL spine fractures. A malplaced TPS could be revised during real-time confirmation of the TPS position, and no secondary operation was required to revise malplaced screws.The iCT navigation system provides accurate and safe management of unstable TL spine fractures. In addition, operating room personnel, including surgeons and nurses, did not need to wear heavy lead aprons as they were not exposed to radiation.     

Dynamic cardiomyoplasty as a biomechanic bridge to heart transplantation

We report a heart transplantation that was done 4 years after a dynamic cardiomyoplasty operation. The patient was a 42-year-old man. Radionucleide ventriculography with technetium 99 m revealed an ejection fraction of 18%. In July 1997 he had undergone a dynamic cardiomyoplasty operation. At the first postoperative month the left ventricular ejection fraction was 35%. In September 2000 he presented with heart failure symptoms. In May 2001 he had undergone heart transplantation. Postoperative course was uneventful. The failure of cardiomyoplasty was probably caused by degeneration of the latissimus dorsi muscle. In this case we have learned that muscle viability is lost within 4 years after dynamic cardiomyoplasty and heart transplantation is still an option for those patients.