Evaluation of hydroxyapatite cement for frontal sinus obliteration after mucocele resection

OBJECTIVES: To retrospectively evaluate our experience with frontal sinus obliteration using hydroxyapatite cement (BoneSource; Stryker Biotech Europe, Montreux, Switzerland) and compare it with fat obliteration over the approximate same period. Frontal sinus obliteration with hydroxyapatite cement represents a new technique for obliteration of the frontal sinus after mucocele resection. METHODS: Exploration of the frontal sinus was performed using bicoronal, osteoplastic flaps, with mucosal removal and duct obliteration with tissue glue and muscle or fascia. Flaps were elevated over the periorbita, and Silastic sheeting was used to protect the BoneSource material from exposure as it dried. The frontal table was replaced when appropriate. RESULTS: Sixteen patients underwent frontal sinus obliteration with fat (fat obliteration group), and 38 patients underwent obliteration with BoneSource (BoneSource group). Fat obliteration failed in 2 patients, who underwent subsequent BoneSource obliteration, and none of the patients in the BoneSource group has required removal of material because of recurrent complications. Frontobasal trauma (26 patients [68%] in the BoneSource group and 9 patients [56%] in the fat obliteration group) was the most common history of mucocele formation in both groups. Major complications in the BoneSource group included 1 patient with skin fistula, which was managed conservatively, and 1 patient with recurrent ethmoiditis, which was managed surgically. Both complications were not directly attributed to the use of BoneSource. Contour deficit of the frontal bone occurred in 1 patient in the fat obliteration group and in none in the BoneSource group. Two patients in the fat obliteration group had donor site complications (hematoma and infection). Thirteen patients in the BoneSource group had at least 1 prior attempt at mucocele drainage, and no statistical relation existed between recurrent surgery and preservation of the anterior table. CONCLUSION: Hydroxyapatite is a safe, effective material to obliterate frontal sinuses infected with mucoceles, with minimal morbidity and excellent postoperative contour.

Postmortem noninvasive virtual autopsy: extrapleural hemorrhage after blunt thoracic trauma

A 19-year-old man speeding recklessly along a highway caused a left-frontal crash with another car. After his vehicle came to a standstill, he climbed out of the wreck and crawled across the tarmac to the other side of the road, where he died several minutes after the accident and before the arrival of an ambulance. Postmortem multislice computed tomography (MSCT) demonstrated fractures of the first, second, and third ribs and scapula on the left, an extrapleural hemorrhage in the apical region of the left thorax, as well as a large amount of blood in the left thoracic cavity. These radiologic findings were indicative of a delayed rupture of a traumatic extrapleural hematoma into the pleural space. A traditional autopsy confirmed the very rare diagnosis of a traumatic extrapleural hemorrhage with a delayed rupture.

[Rumenocentesis: a suitable technique for analysis of rumen juice pH in cattle?]

In the United States, rumenocentesis has been recommended especially for early diagnosis of subacute rumen acidosis (SARA). The objective of the current study was to evaluate health risks due to the technique ofrumenocentesis and to measure pH in ruminal juice using a commercial indicator paper (Pehanon) and a pH electrode (reference method). After 11 dairy cows underwent rumenocentesis, the clinical status of those animals was evaluated daily, and cows were slaughtered as well as pathologically--anatomically examined on day 7. During the observation period, the following pathological clinical signs were evident: forced inspiration (3 cows), transient episode of hyperthermia (2 cows), increased tension of the abdominal wall (8 cows) and positive foreign body tests (3 cows). One cow had to be culled on day 7 because of severe generalised septic peritonitis spreading from the site of rumenocentesis. At slaughter, hematoma formation in the area of the puncture site was found in 9 out of 10 cows. It was concluded that the severe complications encountered with this technique do not legitimate rumenocentesis as a routine procedure for collection of rumen juice samples in cows under Swiss conditions. The correlation between the pH reference method and the commercial indicator paper was the high (r = 0.926).

Ultrasound diagnosis of spontaneous carotid dissection with isolated Horner syndrome

BACKGROUND AND PURPOSE: Isolated Horner syndrome without associated cranial nerve palsies or ischemic symptoms is an important presentation of spontaneous internal carotid artery dissection (sICAD). Ultrasound is often used as a screening method in these patients because cervical MRI is not always available on an emergency basis. Current knowledge on ultrasound findings in patients with sICAD presenting with isolated Horner syndrome is limited. METHODS: Patients were recruited from prospective cervical artery dissection databases of 3 tertiary care centers. Diagnosis of sICAD was confirmed by cervical MRI and MR angiography or digital subtraction angiography in all patients. Data on Doppler sonography and color duplex sonography examinations performed within 30 days of symptom onset were analyzed. RESULTS: We identified 88 patients with Horner syndrome as the only sign of sICAD. Initial ultrasound examination was performed in 72 patients after a mean time interval from symptom onset to examination of 11 (SD 8) days. The overall frequency of false-negative ultrasound findings was 31% (22 of 72 patients). It showed stenosis >or=80% or occlusion in 34 (47%) patients, and stenosis hematoma in 7 patients and intimal flap in one. Patients with normal ultrasound were less frequently smokers (9% versus 28%, P=0.034), and had less frequently migraine without aura (9% versus 43%, P=0.012) or neck pain (18% versus 62%, P=0.003) than those with pathological ultrasound findings. CONCLUSIONS: Nearly one third of patients with Horner syndrome as the only sign of sICAD presented with normal ultrasound findings. These results indicate that ultrasound is not a reliable method to diagnose sICAD in patients with isolated Horner syndrome.

International registry on factor XIII deficiency: a basis formed mostly on European data

FXIII deficiency is known as one of the rarest blood coagulation disorders. In this study, the phenotypic and in part genotypic data of 104 FXIII-deficient patients recorded from 1993 - 2005 are presented. The most common bleeding symptoms were subcutaneous bleeding (57%) followed by delayed umbilical cord bleeding (56%), muscle hematoma (49%), hemorrhage after surgery (40%), hemarthrosis (36%), and intracerebral bleeding (34%). Prophylactic treatment was initiated in about 70% of all patients. FXIII-B subunit-deficient patients had a milder phenotype than patients with FXIII-A subunit deficiency. The most frequent mutation affecting the F13A gene was a splice site mutation in intron 5 (IVS5-1G>A). This mutation was found in eight (17%) of 46 analyzed families. The haplotype analysis of patients carrying the IVS5-1A allele was consistent with a founder effect. The international registry (http://www.f13-database.de) will provide clinicians and scientists working on FXIII deficiency with a helpful tool to improve patient care and direct future studies towards better understanding and treatment of the disease.

[Cosmetic results after breast conserving carcinoma treatment in patients with intramammarian seromas]

INTRODUCTION: There were 373 patients irradiated after breast conserving carcinoma treatment. A planning computed tomography revealed in 97 of these patients seromas and tissue defects exceeding 2cm in diameter. The cosmetic results in those patients and the impact of seromas herein had to be evaluated. PATIENTS AND METHODS: Mean age was 59 years. A quadrant resection was performed in 17.5 percent of the patients, a segmental resection in 27.8 percent and a tumour excision in 54.6 percent. Radiation therapy was applied with the Linear accelerator and 6 MeV photons up to a total dose in the residual breast of 50 Gy followed by a boost dose to the former tumour bed of 10 Gy. A distinct evaluation and documentation of therapy related side effects and the resulting cosmesis was done in 51 patients. RESULTS: In all the examined seroma patients there were moderate acute skin reactions grade 1 to 3. As late effects in 82.3 percent scar indurations were noticed. At the skin 51 percent showed enhanced pigmentation, 68.6 percent atrophia and only 11 percent teleangiectasia. Subcutaneous fibrosis occurred in 56,9 percent of the patients, 78.4 percent of the women had breast asymmetries. In 41.2 percent there were a lymphedema subcutaneously, in 72.5 percent impaired sensibility. The overall cosmetic result documented with a 5 point score was "very good" (score 1) in 19.6 percent and "good" (score 2) in 33.3 percent, 37.3 percent were "satisfactory" (score 3) and 9.8 percent "bad" (score 4) respectively. No "very bad" results (score 5) were seen. CONCLUSIONS: The cosmetic results in the examined group of seroma and hematoma patients were inferior to those reported in the literature. We conclude that postoperative seroma and hematoma have an adverse effect on the resulting cosmesis and that their frequency and extent have to be reduced in future by the responsible surgeons.

Long-term pallidal deep brain stimulation in patients with advanced Parkinson disease: 1-year follow-up study

OBJECT: The goal of this study was to investigate the efficacy of long-term deep brain stimulation (DBS) of the posteroventral lateral globus pallidus internus (GPi) accomplished using a single-contact monopolar electrode in patients with advanced Parkinson disease (PD). METHODS: Sixteen patients suffering from severe PD and levodopa-induced side effects such as dyskinesias and on-off fluctuations were enrolled in a prospective study protocol. There were six women and 10 men and their mean age at surgery was 65 years. All patients underwent implantation of a monopolar electrode in the posteroventral lateral GPi. Initially, nine patients received unilateral stimulation. Three of these patients underwent contralateral surgery at a later time. Ten patients received bilateral stimulation (contemporaneous bilateral surgery was performed in seven patients and staged bilateral surgery in the three patients who had received unilateral stimulation initially). Formal assessments were performed during both off-medication and on-medication (levodopa) periods preoperatively, and at 3 and 12 months postoperatively. There were no serious complications related to surgery or to DBS. Two transient adverse events occurred: in one patient a small pallidal hematoma developed, resulting in a prolonged micropallidotomy effect, and in another patient a subcutaneous hemorrhage occurred at the site of the pacemaker. In patients who received unilateral DBS, the Unified Parkinson's Disease Rating Scale activities of daily living (ADL) score during the off-levodopa period decreased from 30.8 at baseline to 20.4 at 3 months (34% improvement) and 20.6 at 12 months (33% improvement) postoperatively. The motor score during the off period improved from 57.2 at baseline to 35.2 at 3 months (38% improvement) and 35.3 at 12 months (38% improvement) postoperatively. Bilateral DBS resulted in a reduction in the ADL score during the off period from 34.9 at baseline to 22.3 at 3 months (36% improvement) and 22.9 at 12 months (34% improvement). The motor score for the off period changed from 63.4 at baseline to 40.3 at 3 months (36% improvement) and 37.5 at 12 months (41% improvement). In addition, there were significant improvements in patients' symptoms during the on period and in on-off motor fluctuations. CONCLUSIONS: Pallidal DBS accomplished using a monopolar electrode is a safe and effective procedure for treatment of advanced PD. Compared with pallidotomy, the advantages of pallidal DBS lie in its reversibility and the option to perform bilateral surgery in one session. Comparative studies in which DBS is applied to other targets are needed.

Acute lower gastrointestinal hemorrhage: minimally invasive management with microcatheter embolization

PURPOSE: To evaluate the efficacy of superselective embolization therapy in the management of acute lower gastrointestinal (LGI) hemorrhage, including any bleeding distal to the ligament of Treitz. MATERIALS AND METHODS: Between June and August 2007, 20 patients with acute LGI bleeding underwent superselective transcatheter arterial embolization (TAE) at the authors' institution. The bleeding had different causes. All patients were treated with use of microcatheters. The following embolic agents were used: microcoils (n = 16), polyvinyl alcohol (PVA) particles (n = 2), and a combination of microcoils and PVA particles (n = 2). Outcome measures included technical success (complete cessation of bleeding as documented at completion angiography), clinical success (resolution of signs or symptoms of LGI bleeding within 30 days after TAE), and the rate of major and minor complications. RESULTS: The identified bleeding sources were as follows: jejunal branch, branch of middle colic artery, branch of ileocolic artery, ileal branch, branch of left colic artery, branch of sigmoid artery, branch of the superior rectal artery, and branch of the middle rectal artery. Technical success with effective control of active bleeding was achieved in all patients (100%). Clinical success attributed to TAE was documented in 18 of the 20 patients (90%). Major complications included death due to pulmonary embolism, heart infarction, and multiorgan failure in the 3rd week after TAE; a procedure-related colonic infarction occurred in one patient. A minor complication occurred in one patient who developed a groin hematoma. CONCLUSIONS: Superselective embolization may be used for effective, minimally invasive control of acute LGI bleeding.

Thrombolysis in patients with acute stroke caused by cervical artery dissection: analysis of 9 patients and review of the literature

BACKGROUND: Results of recently published studies suggest that intravenous thrombolysis (IVT) and local intra-arterial thrombolysis (LIT) are feasible procedures in acute stroke after cervical artery dissection (CAD). OBJECTIVES: To describe 9 patients with acute stroke caused by CAD who were treated by LIT (n = 7) or IVT (n = 2) and to review the literature. METHODS: Retrospective analysis of clinical and neuroradiological findings; literature review from 1980 to present. MAIN OUTCOME MEASURE: Modified Rankin Scale (mRS) score. RESULTS: Of 7 patients treated with LIT, 3 had good outcomes (mRS score of 0-2) and 4 had bad outcomes (mRS score of 3-6) at 3 months. The 2 patients who had received IVT recovered to mRS scores of 0 and 3. Twenty-one patients were identified in the literature. Overall (N = 30), in the IVT group (n = 19), the outcome was good in 8 patients (42%) and bad in 11 (58%); in the LIT group (n = 11), 6 patients (55%) had a good outcome and 5 (45%) had a bad outcome. Overall, 47% (14/30) of the patients (IVT and LIT groups) had a good outcome. Total mortality was 13% (4/30). There were no secondary complications due to extension of wall hematoma or angiography. One symptomatic hemorrhage occurred. CONCLUSIONS: Thrombolysis is feasible in acute stroke caused by CAD. Local complications from extension of wall hematoma did not occur. Further prospective studies are needed to determine the safety and efficacy of thrombolysis in the special circumstance of acute stroke caused by CAD.

Atraumatic splenic rupture in amyloidosis

BACKGROUND: Splenic involvement in amyloidosis is rather frequent (5-10%). An atraumatic rupture of the affected spleen is however an extremely rare event. We report on a patient with undiagnosed amyloidosis who underwent emergency splenectomy for atraumatic splenic rupture. METHODS: Review of the literature and identification of 31 patients, including our own case report, with atraumatic splenic rupture in amyloidosis. Analysis of the clinical presentation, the surgical management, the nomenclature and definition of predisposing factors of splenic rupture. RESULTS: We identified 15 women and 16 men (mean age 53.3 +/- 12.4 years; median 52, range: 27-82 years) with an atraumatic splenic rupture. Easy skin bruisability and factor X deficiency were detected in four (13%) and five patients (16%), respectively. The diagnosis of splenic rupture was made either by computed tomography (n = 12), ultrasound (n = 5), exploratory laparotomy (n = 9) or autopsy (n = 4). All patients underwent surgery (n = 27) or autopsy (n = 4). Amyloidosis was previously diagnosed in nine patients (29%). In the remaining 22 patients (71%), the atraumatic splenic rupture represented the initial manifestation of amyloidosis. Twenty-five patients (81%) suffered from primary (AL) and four patients (13%) from secondary amyloidosis (AA). In two patients, the type of amyloidosis was not specified. A moderate splenomegaly was a common feature (68%) and the characteristic intraoperative finding was an extended subcapsular hematoma with a limited parenchymal laceration (65%). In five patients with known amyloidosis, the atraumatic splenic rupture was closely associated with autologous stem-cell transplantation (ASCT) (16%). Three patients were suffering from multiple myeloma (10%). A biopsy-proven amyloidotic liver involvement was present in 14 patients (45%), which lead to atraumatic liver rupture in two patients. The splenic rupture related 30-day mortality was 26% (8/31). CONCLUSIONS: Atraumatic splenic rupture in amyloidosis is associated with a high 30-day mortality. It occurs predominantly in patients with previously undiagnosed amyloidosis. A moderate splenomegaly, coagulation abnormalities (easy skin bruisability, factor X deficiency) and treatment of amyloidosis with ASCT are considered predisposing factors for an atraumatic splenic rupture.

Decompressive craniectomy in subarachnoid hemorrhage

OBJECT: The aim of this study was to analyze decompressive craniectomy (DC) in the setting of subarachnoid hemorrhage (SAH) with bleeding, infarction, or brain swelling as the underlying pathology in a large cohort of consecutive patients. METHODS: Decompressive craniectomy was performed in 79 of 939 patients with SAH. Patients were stratified according to the indication for DC: 1) primary brain swelling without or 2) with additional intracerebral hematoma, 3) secondary brain swelling without rebleeding or infarcts, and 4) secondary brain swelling with infarcts or 5) with rebleeding. Outcome was assessed according to the modified Rankin Scale (mRS) at 6 months (mRS Score 0-3 favorable vs 4-6 unfavorable). RESULTS: Overall, 61 (77.2%) of 79 patients who did and 292 (34%) of the 860 patients who did not undergo DC had a poor clinical grade on admission (World Federation of Neurosurgical Societies Grade IV-V, p < 0.0001). A favorable outcome was attained in 21 (26.6%) of 79 patients who had undergone DC. In a comparison of favorable outcomes in patients with primary (28.0%) or secondary DC (25.5%), no difference could be found (p = 0.8). Subgroup analysis with respect to the underlying indication for DC (brain swelling vs bleeding vs infarction) revealed no difference in the rate of favorable outcomes. On multivariate analysis, acute hydrocephalus (p = 0.009) and clinical signs of herniation (p = 0.02) were significantly associated with an unfavorable outcome. CONCLUSIONS: Based on the data in this study the authors concluded that primary as well as secondary craniectomy might be warranted, regardless of the underlying etiology (hemorrhage, infarction, or brain swelling) and admission clinical grade of the patient. The time from the onset of intractable intracranial pressure to DC seems to be crucial for a favorable outcome, even when a DC is performed late in the disease course after SAH.

Ultrasound of the axillary arch muscle in children

Purpose: Unilateral or bilateral axillary masses in children are often of clinical concern for malignancies. Our review illustrates a normal variant of the axilla mimicking clinically an axillary mass. Methods and Materials: Systematic review of our PACS and RIS with the keyword “axilla” and the modality “ultrasound” in children under 16 years of age from 1.12.2009 until 30.11.2012. 19 axillary ultrasound examinations in 16 patients (7m/9f, age 3 months to 15 years) were included. One patient was examined 2 and one patient 3 times. In 6 patients a prominent muscle was noted overlying the humeral head in an abducted position. The muscle diameter was measured in cm and compared with the contralateral side. In one patient photographs of the axilla were available. Results: In 16 examinations a lymphadenopathy (n=5), abscess formation (n=5), seroma or hematoma (n=1) or lymphangioma (n=1) and no diagnosis (n=1) was found. In 4 patients (25%) a unilateral muscle variant and in 2 patients a bilateral muscle variant (axillary arch muscle) was noted. In one patient a duplication of the muscle was found. In 4 patients the muscle was larger than the contralateral side. Conclusion: An axillary mass in children without other clinical complaints may be related to a normal variant, the axillary arch muscle. Ultrasound is the first modality of choice if imaging is required. Radiologists should be aware of this normal variant since no other workup is necessary in asymptomatic children.

Spinal cerebrospinal fluid leak as the cause of chronic subdural hematomas in nongeriatric patients

OBJECT The etiology of chronic subdural hematoma (CSDH) in nongeriatric patients (≤ 60 years old) often remains unclear. The primary objective of this study was to identify spinal CSF leaks in young patients, after formulating the hypothesis that spinal CSF leaks are causally related to CSDH. METHODS All consecutive patients 60 years of age or younger who underwent operations for CSDH between September 2009 and April 2011 at Bern University Hospital were included in this prospective cohort study. The patient workup included an extended search for a spinal CSF leak using a systematic algorithm: MRI of the spinal axis with or without intrathecal contrast application, myelography/fluoroscopy, and postmyelography CT. Spinal pathologies were classified according to direct proof of CSF outflow from the intrathecal to the extrathecal space, presence of extrathecal fluid accumulation, presence of spinal meningeal cysts, or no pathological findings. The primary outcome was proof of a CSF leak. RESULTS Twenty-seven patients, with a mean age of 49.6 ± 9.2 years, underwent operations for CSDH. Hematomas were unilateral in 20 patients and bilateral in 7 patients. In 7 (25.9%) of 27 patients, spinal CSF leakage was proven, in 9 patients (33.3%) spinal meningeal cysts in the cervicothoracic region were found, and 3 patients (11.1%) had spinal cysts in the sacral region. The remaining 8 patients (29.6%) showed no pathological findings. CONCLUSIONS The direct proof of spinal CSF leakage in 25.9% of patients suggests that spinal CSF leaks may be a frequent cause of nongeriatric CSDH.

Additional surgical procedure is a risk factor for surgical site infections after laparoscopic cholecystectomy

PURPOSE: Surgical site infections (SSI) are associated with increased costs and length of hospital stay, readmission rates, and mortality. The aim of this study was to identify risk factors for SSI in patients undergoing laparoscopic cholecystectomy. METHODS: Analysis of 35,432 laparoscopic cholecystectomies of a prospective multicenter database was performed. Risk factors for SSI were identified among demographic data, preoperative patients' history, and operative data using multivariate analysis. RESULTS: SSIs after laparoscopic cholecystectomy were seen in 0.8 % (n = 291) of the patients. Multivariate analysis identified the following parameters as risk factors for SSI: additional surgical procedure (odds ratio [OR] 4.0, 95 % confidence interval [CI] 2.2-7.5), age over 55 years (OR 2.4 [1.8-3.2]), conversion to open procedure (OR 2.6 [1.9-3.6]), postoperative hematoma (OR 1.9 [1.2-3.1]), duration of operation >60 min (OR 2.5 [1.7-3.6], cystic stump insufficiency (OR 12.5 [4.2-37.2]), gallbladder perforation (OR 6.2 [2.4-16.1]), gallbladder empyema (OR 1.7 [1.1-2.7]), and surgical revision (OR 15.7 [10.4-23.7]. SSIs were associated with a significantly prolonged hospital stay (p < 0.001), higher postoperative mortality (p < 0.001), and increased rate of surgical revision (p < 0.001). CONCLUSIONS: Additional surgical procedure was identified as a strong risk factor for SSI after laparoscopic cholecystectomy. Furthermore, operation time >60 min, age >55 years, conversion to open procedure, cystic stump insufficiency, postoperative hematoma, gallbladder perforation, gallbladder empyema, or surgical revision were identified as specific risk factors for SSI after laparoscopic cholecystectomy.

Magnetic resonance imaging features of sinonasal disorders in horses.

Diseases of paranasal sinuses and nasal passages in horses can be a diagnostic challenge because of the complex anatomy of the head and limitations of many diagnostic modalities. Our hypothesis was that magnetic resonance (MR) imaging would provide excellent anatomical detail and soft tissue resolution, and would be accurate in the diagnosis of diseases of the paranasal sinuses and nasal passages in horses. Fourteen horses were imaged. Inclusion criteria were lesions located to the sinuses or nasal passages that underwent MR imaging and subsequent surgical intervention and/or histopathologic examination. A low field, 0.3 tesla open magnet was used. Sequences in the standard protocol were fast spin echo T2 sagittal and transverse, spin echo T1 transverse, short-tau inversion recovery (STIR) dorsal, gradient echo 3D T1 MPR dorsal (plain and contrast enhanced), spin echo T1 fatsat (contrast enhanced). Mean scan time to complete the examination was 53 min (range 39-99 min). Lesions identified were primary or secondary sinusitis (six horses), paranasal sinus cyst (four horses), progressive ethmoid hematoma (two horses), and neoplasia (two horses). The most useful sequences were fast spin echo T2 transverse and sagittal, STIR dorsal and FE3D MPR (survey and contrast enhanced). Fluid accumulation, mucosal thickening, presence of encapsulated contents, bone deformation, and thickening were common findings observed in MR imaging. In selected horses, magnetic resonance imaging is a useful tool in diagnosing lesions of the paranasal sinuses and nasal passages.