Pleomorphic adenoma of the buccal salivary gland: magnetic resonance imaging findings with differential diagnoses

The majority of minor salivary gland tumors are malignant. Of the benign tumors, pleomorphic adenomas are most common. The cheeks, lips, and gingiva are rarely sites of occurrence. A case of pleomorphic adenoma of the buccal salivary gland is presented here with a discussion of the importance of magnetic resonance imaging in demonstrating the extent of the lesion and establishing a differential diagnoses.     

Post-subarachnoid Hemorrhage Vasospasm in Patients with Primary Headache Disorders

Background

Altered cerebral vasomotor reactivity leading to vasospasm can be seen both in patients with primary headache disorders (PHD) and in patients with subarachnoid hemorrhage (SAH). The pathogenesis of vasospasm in post-SAH patients and in headache disorder sufferers may be related. To address this hypothesis, we analyzed a large cohort of SAH patients to determine whether a diagnosis of PHD predisposes to vasospasm, delayed cerebral ischemia, or worsened clinical outcome.

Methods

Prospectively collected data from patients enrolled in the SAH Outcomes Project between 1996 and 2006 were analyzed. Patients were segregated based on whether they had a diagnosis of PHD or not and were subsequently compared for differences in clinical and radiographic outcome.

Results

A total of 921 SAH patients were analyzed, 265 of which had a diagnosis of PHD. In total, symptomatic vasospasm was seen in 17 %, while angiographic vasospasm was seen in 28 %. Vasospasm rates were similar among patients with a PHD and in those without a PHD (p > 0.05). However, on multivariate analysis new ischemic infarcts were more common in patients with a PHD as compared to patients without a PHD (p = 0.015). Functional outcomes at 3 months were similar among PHD and non-PHD patients (p > 0.05).

Conclusion

A history of PHD is associated with an increased rate of ischemic infarcts during admission for SAH. Increased rates of vasospasm within small cerebral blood vessels may be implicated. Further studies are warranted to more closely link the mechanisms of vasospasm in PHD and SAH patients.     

Withdrawal of Technological Life Support Following Subarachnoid Hemorrhage

Background

Prognostication of mortality or severe disability often prompts withdrawal of technological life support in patients following aneurysmal subarachnoid hemorrhage (aSAH). We assessed admission factors impacting decisions to withdraw treatment after aSAH.

Methods

Prospectively collected data of aSAH patients admitted to our institution between 1991 and 2009 were reviewed. Patients given comfort care measures were identified, including early withdrawal of treatment (<72 h after admission). Independent predictors of treatment withdrawal were assessed with multivariable analysis.

Results

The study included 1,134 patients, of whom 72 % were female, 58 % white, and 38 % black or African-American. Mean age was 52.5 ± 14.0 years. In-hospital mortality was 18.3 %. Of the 207 patients who died, treatment was withdrawn in 72 (35 %) and comfort measures instituted early in 31 (15 %). Among patients who died, WOLST was associated with older age (63.6 ± 14.2 years, WOLST vs. 55.6 ± 13.7 years, no WOLST, p < 0.001); GCS score <8 (62 % of WOLST vs. 44 % with no WOLST, p = 0.010); HH >3 (72 % of WOLST vs. 53 % with no WOLST, p = 0.008); and hydrocephalus (81 % of WOLST vs. 63 % with no WOLST, p = 0.009). Independent predictors of WOLST were poorer Hunt and Hess grade (AOR 1.520, 95 % CI 1.160–1.992, p = 0.002) and older age (AOR 1.045, 95 % CI 1.022–1.068, p < 0.001) with the latter also impacting early WOLST decisions.

Conclusions

Older age and poor clinical grade on presentation predicted WOLST, and age predicted decisions to withdraw treatment earlier following aSAH. While based on prognosis, and in some cases patient wishes, this may also constitute a self-fulfilling prophecy in others.     

Modern management of acute pancreatitis

There is a rising incidence of acute pancreatitis in the United States. Numerous clinical prognostic scoring systems have been developed, including the BISAP score. Vigorous fluid resuscitation remains a cornerstone of early management of acute pancreatitis. Cross-sectional imaging in the early phase of evaluation has not been associated with improvement of outcomes. There is no role for prophylactic antibiotics in early management. However, there is growing emphasis on the identification and treatment of extrapancreatic infections. Enteral nutrition in severe acute pancreatitis has reduced mortality, systemic infection, and multiorgan dysfunction compared to parenteral nutrition. Conservative management consisting of percutaneous drainage and delayed surgical intervention is now favored for local complications, such as infected necrosis. These developments have contributed to improved outcomes for patients with acute pancreatitis.     

Acute Renal Failure during Pregnancy Secondary to Spontaneous Perirenal Hematoma

A 32-year-old pregnant female presented with right flank pain, hematuria, and ARF at 25 weeks of gestation. Imaging studies demonstrated right perinephric hematoma, which compressed the inferior vena cava. ARF improved with expectant care as the hematoma gradually resolved.