Cerebellar haemorrhage and tension pneumocephalus after resection of a Pancoast tumour

Summary We present an unusual case of cerebellar haemorrhage followed by tension pneumocephalus several days after thoracotomy for resection of a Pancoast tumour. The postoperative course of the 32-year-old patient was complicated by a cerebellar haemorrhage and hydrocephalus caused by compression of the fourth ventricle. Immediate surgical evacuation of the haemorrhage and placement of an external ventricular drain was performed. Respirator ventilation maintaining a continuous positive airway pressure was required. Following weaning and extubation the patient rapidly deteriorated and became comatose. A cranial CT scan revealed a dilated ventricular system filled with air, and air in the subarachnoid space. Recovery of consciousness was observed after aspiration of intracranial air through the ventricular drainage. Recurrent deterioration of consciousness after repeated air aspiration indicated rapid refilling of the ventricles with air.The patient underwent emergency surgical re-exploration of the thoracic resection cavity: dural lacerations of the cervico-thoracic nerve roots C8 and Th1 were identified. Subarachnoid-pleural fistula, cerebellar haemorrhage and tension pneumocephalus after discontinuation of continuous positive airway pressure respiration are unusual complications of thoracic surgery. We discuss the putative pathomechanisms and present a brief review of the literature.     

Pitfalls in the diagnosis of pheochromocytoma

Two patients were diagnosed as having pheochromocytoma based upon clinical findings, abnormal biochemical assays, and the presence of an adrenal mass. However, adrenalectomy in both cases revealed nonfunctioning cortical adenomas. Although both patients had some evidence of catecholamine excess, the early finding of an adrenal mass in each case appeared to confirm the diagnosis. In addition, selective venous assays resulted in false positive results in these patients. Interestingly, the selected venous assays falsely localized the catecholamine excess to the same side as the lesions found on CT. These cases demonstrate that localization studies should not be obtained prior to documentation of an unequivocal biochemical diagnosis of pheochromocytoma. If this principle is violated, an incidental cortical adenoma found on CT may be mistaken for a pheochromocytoma. Since there are multiple sources of error during selective venous sampling, it should not be used routinely in the initial evaluation of patients with pheochromocytoma.     

Pitfalls in the diagnosis of abdominal aortic aneurysm

The lethal progression of expanding aneurysms may present as a confusing clinical picture. Four cases are reported in which the diagnosis was masked and treatment delayed by symptoms thought to be related mainly to inguinal hernias. It is concluded that there is a subset of patients with aneurysmal progression in whom symptoms are related mainly to the groin. Exhaustive diagnostic methods will detect this condition when the aneurysm is not palpable. The ability to recognize these unique symptoms and signs in elderly men presenting with enlarging inguinal hernias and neuropathy is essential. Biologic and biochemical relations between inguinal hernias and aneurysms may exist.     

Pitfalls in the computed tomographic diagnosis of toruloma

A case of multiple intracerebral mass lesions is presented in which significant "improvement" in the computed tomographic appearance was noted following steroid and radiation therapies. Nonetheless, the patient's clinical course was one of rapid deterioration, and an autopsy revealed multiple torulomas. It seems that the computed tomographic appearance of torulomas can mimic those of other intracranial mass lesions and can be greatly altered by steroid and radiation therapies, either singly or in combination.     

Pitfalls in the diagnosis of Osgood-Schlatter disease.

One patient with osteomyelitis of the anterior tibial tubercle and a second patient with arteriovenous malformation of the anterior tibial tubercle were originally misdiagnosed as having Osgood-Schlatter disease. These patients demonstrate pitfalls in the diagnosis of Osgood-Schlatter disease.     

Pitfalls in the diagnosis of acute abdominal conditions

Sixteen cases of intraspinal tumors in patients ranging from 10 weeks to 11 years and three months are presented. The two youngest patients in this series are younger than any previously recorded. It is suggested that it is possible to make an early diagnosis of spinal cord pressure in infants and young children. Complete neurologic examination and study of the cerebrospinal fluid are essential. Sensory examination is of great value in even the youngest patient if the examiner is sufficiently persistent. Injection of iodized oil should be necessary in rare instances only, but where needed it is invaluable.     

Radionuclide imaging in the diagnosis and management of orthopaedic disease

Nuclear medicine imaging is often used in the diagnosis and management of several orthopaedic conditions. Bone scintigraphy measures gamma ray emission to detect the distribution of an injected radiolabeled tracer on multiple image projections. In general, this imaging modality has relatively high sensitivity but low specificity in the diagnosis of occult fractures, bone tumors, metabolic bone disease, and infection. Positron emission tomography measures tissue metabolism and perfusion by detecting short half-life positron ray emission of an injected radiopharmaceutical tracer. Historically, positron emission tomography has been used only to monitor bone metastasis and aid in the diagnosis of osteomyelitis; however, this technology has recently been applied to other orthopaedic conditions for which current imaging modalities are insufficient.     

Pitfalls in diagnosis of exophytic renal tumors

Five cases of exophytic renal tumors are presented. In 2 cases selective renal angiography was nondiagnostic. In 3 cases, excretory urography demonstrated only minimal or misleading findings. In all cases cross-sectional imaging either by computed tomography or ultrasound helped establish the correct diagnosis. The potential sources of error in the evaluation of this uncommon type of renal tumor are stressed.     

Nuclear medicine techniques in the diagnosis of orthopaedic diseases

Nuclear medicine techniques show metabolic processes, allowing the diagnoses of many bone and joint disorders. For most orthopaedic indications three-phase bone scintigraphy is used, showing inflammatory bone and joint diseases, traumatic and post-operative disorders as well as necrotic or malignant changes. In addition to bone scintigraphy, there are radiopharmaceuticals to depict inflammatory processes. Finally, positron emission tomography is a modern imaging technique used mainly for tumor diagnostics, but also for detection of inflammation.