Hemorrhagic Component Research Articles

Re-evaluation of abusive head trauma in Norway appears flawed.

A review by Wester et al in Acta Paediatrica presented 17 adjudicated cases of Norwegian infants with abusive head trauma (AHT).(1) Their interpretation of the medical findings identified alternative diagnoses for 16 of the 17 children and suggested that the injuries were not inflicted and may have been the result of spontaneously occurring events. The authors stated that eight children had clinical and radiological characteristics consistent with external hydrocephalus, complicated by chronic subdural haematoma, and that six had findings compatible with hypoxic-ischaemic insults. Fractures were attributed to prematurity and sequelae from birth trauma. If their interpretations are correct, this study calls for a thorough review of how the medical community, forensic experts and the courts manage AHT cases. However, there are several elements of concern in the Wester et al study that we believe need clarification before a conclusion can be reached.

Acute Pancreatitis as an Initial Presentation of Primary Hyperparathyroidism

Background: Acute pancreatitis secondary to hypercalcemia is may be the initial presentation of a patient with primary hyperparathyroidism. However, because of its infrequency as a cause of pancreatitis, it can be easily missed during clinical management. Clinical Case: A 56-year old woman initially presented with epigastric pain with radiation to the back. She had no previous comorbidities, did not drink alcohol, and had no previous history of cholelithiasis, nephrolithiasis nor pathologic fractures. The diagnosis was confirmed by an elevated serum lipase level (59117 U/L, reference interval (RI): 73–393 U/L) and contrast-enhanced MRI findings suggestive of acute pancreatitis with hemorrhagic component in the pancreatic body and tail. Hypercalcemia was documented on two separate occasions during her confinement with a serum total calcium level of 10.5 mg/dL (RI: 8.5–10.1 mg/dL) and an ionized calcium level of 1.45 mmol/L (RI: 1.09–130 mmol/L), however, no further workup was done at that time. She was managed conservatively and was sent home with plans to do an ERCP and possible laparoscopic cholecystectomy once her condition had stabilized. However, she had recurrence of the epigastric pain about one month after her initial episode. Her serum lipase showed an interval increase from her last result (1426 U/L from 933 U/L) and contrast-MRI now showed the development of areas of walled-off necrosis in the body and tail of the pancreas. Serum ionized calcium was again elevated (2.17 mmol/L); she also had an elevated intact PTH level (780.6 pg/ml, RI: 18.5–88.0 pg/ml). Parathyroid SPECT-CT showed a sestamibi-avid lesion inferoposterior to the right thyroid lobe, indicating a probable parathyroid adenoma. She was given 1 dose of Denusomab 120 mg subcutaneously and started on Calcitonin nasal spray 200 IU twice a day. She underwent ultrasound-guided drainage of the pancreatic necrosis and was subsequently discharged. Due to difficulty in procurement of the Calcitonin nasal spray, she was maintained on Cinacalcet 30 mg/tablet, 1 tablet once a day upon discharge with plans to undergo parathyroidectomy once she was had fully recovered from her pancreatitis. Conclusion: Primary hyperparathyroidism should always be considered when hypercalcemia is noted during the clinical management of acute pancreatitis. Reference: Misgar RA, Bhat MH, Rather TA, Masoodi SR, Wani AI, Bashir MI, Wani MA, Malik AA. Primary hyperparathyroidism and pancreatitis. J Endocrinol Invest. 2020 Oct;43(10):1493–1498.

A Challenging Case of Pituitary Macroprolactinoma During Pregnancy

Introduction: Prolactinoma is the most common secreting pituitary adenoma diagnosed in women of reproductive age. The mainstay of treatment is pharmacotherapy with dopamine agonists. Management during pregnancy poses a considerable challenge to physicians. We describe a case of a patient who developed significant symptoms of pituitary enlargement following cessation of Cabergoline in pregnancy. Case Description: A 28-year-old female presented at age 16 with galactorrhea and oligomenorrhea. She was treated with Cabergoline for 12 years. Her peak prolactin was 191ng/ml (normal range, non-pregnant: 2.8-29.2ng/ml, pregnant: 9.7- 208.5ng/ml). On MRI, she had a 1cm tumor that was stable from 2016 to 2019. Prior to recent pregnancy, she remained compliant with Cabergoline 1.5mg twice weekly with prolactin levels that ranged between 30-44 ng/ml. After becoming pregnant in August 2019, Cabergoline was discontinued. During pregnancy, she did not initially schedule follow up with endocrinology. She developed blurred vision at 12 weeks gestation but did not seek medical care until 24 weeks gestation, at which time she was found by Ophthalmology to have bitemporal field cuts. MRI pituitary at 26 weeks showed marked enlargement and evidence of a left sided pituitary macroadenoma measuring 2cm with hemorrhagic component, suprasellar extension compressing the optic chiasm and subtle extension into the left cavernous sinus. She was recommenced on Cabergoline 1.5mg twice weekly but had no improvement in visual changes or MRI findings after two weeks. Her prolactin level at 30 weeks gestation was 170ng/ml. Neurosurgical evaluation resulted in urgent endoscopic transsphenoidal surgery at 30 weeks and pathology was consistent with prolactinoma. Post-operative outcomes were favorable with no evidence of pituitary hormonal deficiencies. Her visual abnormalities resolved, and she underwent delivery via C-section at 38 weeks gestation. She had intermittent breast milk production and her baby is in good health. She remains off Cabergoline with a prolactin level of 2.38ng/ml and no residual disease on MRI done 6 months postop. Conclusion: Tumor growth causing significant symptoms requiring intervention has been reported in 2.4% of microadenomas and 21% of macroadenomas. It is essential to periodically assess visual fields during pregnancy particularly in patients with macroadenomas. Dopamine agonists are discontinued during pregnancy unless symptomatic enlargement of prolactinoma occurs. In such cases, reinstitution of dopamine agonists usually results in positive outcomes and delivery can be considered if appropriate for gestational age. Further deterioration or lack of improvement necessitates urgent neurosurgical intervention in cases such as our patient.

Woman with Epigastric Pain

A 67-year-old woman presented to the emergency department with several hours of epigastric pain. She had a history of pancreatitis complicated by a pseudocyst 5 years before. On physical examination, she was afebrile, with a blood pressure of 205/110 mm Hg and pulse rate of 83 beats/min. She had marked tenderness without muscle guarding over the epigastric area. Laboratory investigations revealed a normal hemoglobin level and an elevated lipase level (111 IU/L). Although pancreatitis was suspected, the emergency physician performed point-of-care ultrasonography (Figure 1) and confirmed the diagnosis with a computed tomographic (CT) scan (Figure 2).Figure 2CT image of the abdomen showing a cystic mass (arrowhead) in the pancreatic tail with a hemorrhagic component and contrast extravasation (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Pancreatic pseudocyst with intracystic hemorrhage. Emergency transarterial embolization of the posterior pancreatic artery was performed, and she was discharged uneventfully from the hospital. Pancreatic pseudocyst is a common complication of pancreatitis, but intracystic hemorrhage is a rare and potentially life-threatening condition with a mortality rate ranging from 15% to 50%.1Chiang K.C. Chen T.H. Hsu J.T. Management of chronic pancreatitis complicated with a bleeding pseudoaneurysm.World J Gastroenterol. 2014; 20: 16132-16137Crossref PubMed Scopus (28) Google Scholar Clinical manifestations include abdominal pain, anemia, and melena.2Chiu H.H. Chen C.M. Wang K.C. et al.Pancreatic pseudocyst bleeding associated with massive intraperitoneal hemorrhage.Am J Surg. 2006; 192: 87-88Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Delayed diagnosis may lead to complications such as rupture of the hemorrhagic pseudocyst, which can cause hemoperitoneum and shock. Angiographic embolization of the culprit artery is the mainstay of management,3Gambiez L.P. Ernst O.J. Merlier O.A. et al.Arterial embolization for bleeding pseudocysts complicating chronic pancreatitis.Arch Surg. 1997; 132: 1016-1021Crossref PubMed Scopus (115) Google Scholar with surgical intervention reserved for refractory cases.

Systemic Thrombolysis and Post-stroke Epilepsy

Systemic thrombolysis is a highly effective treatment for ischemic stroke. The effect of thrombolysis on the development of post-stroke epilepsy (PSE) remains a subject of scientific debate. The aim of this study was to clarify the clinical and neuroimaging features of PSE in patients with ischemic stroke, who underwent systemic thrombolysis. . A total of 46 patients after ischemic stroke were examined, including 33 men and 13 women aged 28 to 80 years. Group I consisted of 9 patients with PSE after systemic thrombolysis with rtPA (alteplase) at a dose of 0.9 mg/kg. Group II included 8 patients without PSE after systemic thrombolysis. Group III consisted of 29 patients with PSE, who received standard drug therapy. Comparative group analysis took into account the medical history, clinical and neuroimaging data. . Patients with PSE were characterized by the absence of clinical effect after systemic thrombolysis (p = 0.026); infarcts extending to the frontal and insular lobes (p = 0.038), insular lobe and basal nuclei (p = 0.026); development of a hemorrhagic component in the cerebral cortex (p = 0.005), as well as in the territory of the deep and terminal branches of the middle cerebral artery (MCA) (p = 0.006). Development of PSE is associated with ineffective systemic thrombolysis and the appearance of extensive and large cerebral infarcts with a hemorrhagic component.

INNV-04. CONGENITAL SPINAL GLIOBLASTOMA WITH SUSTAINED RESPONSE TO TROPOMYOSIN RECEPTOR KINASE (TRK) INHIBITION: A CASE REPORT

Abstract Large scale genomic efforts have shown that a significant percentage of infant high-grade gliomas (HGG) carry targetable gene fusions. Given the rarity of congenital spinal HGGs, little is known about the molecular features of these tumors and their response to treatment. We describe a case of a patient with congenital spinal glioblastoma. A full-term female infant with symmetric IUGR was noted to have weakness with little movement of her upper extremities. MRI of the spine showed an infiltrative and hemorrhagic intraspinal cervicothoracic neoplasm with a large hemorrhagic intramedullary component. A biopsy was done and revealed a high-grade glial neoplasm with pan-TRK expression. Next generation sequencing (NGS) confirmed a MEF2D-NTRK1 gene fusion. Prior to the result of her molecular testing, the patient clinically deteriorated with decreased movement and increased apneic episodes despite steroid treatment. She was then started on treatment with carboplatin and etoposide per Macy et al 1. After one cycle of chemotherapy and given the results of NGS, targeted therapy with larotrectinib was added to her treatment. The patient showed a response (clinical and imaging) following cycle 1 with chemotherapy, and a marked response following cycle 2 with both chemotherapy and targeted TRK inhibition. The patient completed six cycles of chemotherapy and has continued on daily oral larotrectinib. She continues to tolerate the targeted therapy well and currently is 8 months old, growing and developing well. She has regained much of her movement and is eating and growing with apparent normal development. This case provides an example of a patient with congenital glioblastoma with TRK gene fusion that showed an impressive response to targeted therapy combined with more conventional chemotherapy. 1Macy M, et al. Clinical and molecular characteristics of congenital glioblastoma. Neuro Oncol. Jul;14 (7) 931–941, 2012).

S1448 Solid Pseudopapillary Neoplasm of Pancreas: A Rare Pancreatic Malignancy

INTRODUCTION: Solid pseudopapillary neoplasm of pancreas (SPN) is one of the rarest types of pancreatic tumors, <2% of all pancreatic malignancies, also known as a Hamoudi or Frantz tumor. SPNs usually presents asymptomatically in females in the third decade of life and found incidentally on radiological imaging. CASE DESCRIPTION/METHODS: Here, we present three proven SPN cases by histology. Case 1: A 42-year-old Hispanic female with no past medical history who presented with 1-day history of cough, incidentally found to have a 3 cm hypodense lesion in the pancreatic body on CT scan. Endoscopic ultrasound (EUS) with biopsy was performed and immunohistochemical (IHC) studies found tumor cells to be positive for B-catenin, progesterone receptor and neuron specific enolase, consistent with a diagnosis of SPN. Case 2: A 48-year-old African American female with a past medical history of GERD presented with intermittent right upper quadrant abdominal pain. CT demonstrated a large solid, periportal hepatic mass (19 × 17 × 19 cm) as well as a multi-cystic mass (14 × 7 × 10 cm) arising from the distal pancreatic tail. Exploratory laparotomy was performed and pathology showed a uniform population of small cells with pseudopapillary structures with IHC profile supporting the diagnosis of metastatic SPN. Case 3: A 31-year-old Hispanic female with no significant past medical history presented with 2 months history of post-prandial epigastric abdominal pain found to have a hypodense mass (4 × 4 cm) in the distal pancreatic tail. Surgical resection was performed. Pathology findings of neoplastic tumor cells with occasional groves, collections of histiocytes, and hyaline globules with positive IHC staining for vimentin, B-catenin and progesterone receptor, consistent with diagnosis of SPN. DISCUSSION: On imaging, SPN tumors typically appear as a well-defined mass, with a thick, enhancing capsule, often with peripheral or central calcification. Although most often solid, they can demonstrate variable internal hemorrhagic or cystic components. EUS is the modality of choice for further imaging and definitive diagnosis, as biopsy can be performed. Here, we describe three cases including a unique and rare case of metastatic SPN. Clinicians should be aware of this relatively rare pancreatic lesion as its presentation may be insidious and early imaging is key. Once diagnosed, physicians should pursue multidisciplinary discussions with early surgical management even in metastatic disease, as outcomes are excellent with a favorable prognosis.Figure 1.: MR Imaging - SPN.Figure 2.: Endoscopic US - SPN.Figure 3.: Histopathology - SPN.

CARDIAC TAMPONADE FROM RAPID UREMIC PERICARDITIS IN PATIENT WITH WARFARIN OVER-ANTICOAGULATION

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Cardiac tamponade constitutes a medical emergency, which requires prompt recognition, diagnosis and treatment that is geared towards preventing cardiovascular collapse and cardiac arrest. CASE PRESENTATION: 81-year-old male patient with end stage renal disease on hemodialysis, paroxysmal atrial fibrillation on warfarin anticoagulation, diabetes mellitus type II, and morbid obesity, who was evaluated for history of 24-hour progression of general malaise, orthopnea, dyspnea on exertion, and dizziness after missing two sessions of hemodialysis. Physical exam was remarkable for borderline low blood pressure, +3 leg edema, distended jugular veins, bibasilar crackles, distant heart sounds, absence of cardiac murmurs or heart sounds. ECG showed pulsus alternans and low voltage criteria. Limited bedside echocardiogram was remarkable for a moderate pericardial effusion with minimal ventricular and atrial compression abnormalities. Patient was provided hemodialysis for volume overload without hemodynamic decompensation and was monitored with telemetry and bedside hemodynamics. Shortly after hemodialysis, patient developed worsening shortness of breath and became hypotensive. Patient was started on norepinephrine vasopressor therapy. A bedside limited echocardiogram showed diastolic right ventricular and right atrial collapse, non-collapsibility of the inferior vena cava and severe pericardial effusion that duplicated in size. Bedside emergent subxiphoid echocardiography-guided pericardiocentesis with instillation of agitated saline was performed with removal of about 400cc of serosanguineous fluid with resolution of hypotension and electric alternans. Labs reflected marked uremia, elevated ESR and C-reactive protein and warfarin overanticoagulation with INR of 4.5. Pericardial fluid resulted with a culture-negative exudative effusion composed of bloody material and inflammatory cells. Chest non-contrast computed tomography showed nonspecific mild mediastinal adenopathy. Positron emission tomography–computed tomography showed no significant F-18 Fluorodeoxyglucose avid lesions that were identified. Patient was provided ultrafiltration for 5 days, and started on colchicine and indomethacin with weekly follow-up of inflammatory markers and echocardiography, with marked improvement of pericardial effusion size and return of normal hemodynamics. DISCUSSION: Uremic pericarditis was identified in setting of acute pericarditis in a patient with over-anticoagulation. The hemorrhagic component resulted in rapid fluid accumulation and tamponade. The instillation of agitated saline can help assess for inadvertent chamber puncture during procedure. CONCLUSIONS: Uremic pericarditis is now an uncommon cause of pericarditis, but it can be exacerbated in the setting of inflammatory pericarditis and over-anticoagulation, leading to rapid accumulation of bloody pericardial fluid and cardiac tamponade. Reference #1: Maggiolini S, Gentile G, Farina A, et al. Safety, efficacy, and complications of pericardiocentesis by real-time echo-monitored procedure. Am J Cardiol 2016;117:1369-74. Reference #2: Sadjadi SA, Mashahdian A. Uremic pericarditis: a report of 30 cases and review of the literature. Am J Case Rep. 2015;16:169-173. Reference #3: Osuch JR, Khandekar JD, Fry WA. Emergency subxiphoid pericardial decompression for malignant pericardial effusion. Am Surg. 1985;51(6):298-300. DISCLOSURES: No relevant relationships by VICTOR MOLINA-LOPEZ, source=Web Response No relevant relationships by Hector Santiago, source=Web Response No relevant relationships by Francisco Tirado-Polo, source=Web Response

Magnetic Resonance Imaging of Recurrent Adult Granulosa Cell Tumor of the Ovary: A Retrospective Analysis of 11 Cases.

ObjectiveThe aim of the study was to characterize magnetic resonance imaging findings in patients with recurrent ovarian adult granulosa cell tumors (AGCTs).MethodsClinical and magnetic resonance imaging manifestations of recurrent AGCTs were evaluated in 11 patients.ResultsInitial recurrences of AGCT were diagnosed between 13 months and 30 years (mean, 11.3 years). Recurrent tumors were located in the pelvic peritoneum, the abdominal peritoneum, the retroperitoneum, and bone. The number of recurrent tumors varied from 1 to 5. Tumors varied in morphology and all margins were well circumscribed. The internal structures noted were as follows: multilocular cystic and solid and cystic. Furthermore, internal hemorrhage and sponge-like multicystic components were identified.ConclusionsOvarian AGCTs recurred in the pelvic peritoneum, abdominal peritoneum, and the retroperitoneal lymph nodes. Large recurrent AGCTs were commonly well circumscribed, round or lobulated, and multilocular cystic or solid and cystic. Moreover, they frequently included internal hemorrhage and sponge-like multicystic components.

Preoperative CT image-based assessment for estimating risk of ovarian torsion in women with ovarian lesions and pelvic pain

To define and weight the preoperative CT findings for ovarian torsion and to develop an integrated nomogram for estimating the probability of ovarian torsion in women with ovarian lesion and pelvic pain. This retrospective study included 218 women with surgically resected ovarian lesions who underwent preoperative contrast-enhanced CT for pelvic pain from January 2014 to February 2019. Significant imaging findings for torsion were extracted using regression analyses and a regression coefficient-based nomogram was constructed. The diagnostic performance with sensitivity, specificity, and accuracy of the significant imaging findings and the nomogram were assessed. A total of 255 ovarian lesions (123 lesions with torsion and 132 lesions without torsion) were evaluated. Multivariable regression analysis showed that whirl sign (odds ratio [OR] 11.000; p < 0.001), tubal thickening (OR 4.621; p = 0.001), unusual location of ovarian lesion (OR 2.712; p = 0.020), and hemorrhagic component within adnexal lesion (OR 2.537; p = 0.028) were independent significant parameters predicting ovarian torsion. Tubal thickening showed the highest sensitivity (91.1%) and whirl sign showed the highest specificity (94.7%). When probabilities of ovarian torsion of 0.5 or more in the nomogram were diagnosed as ovarian torsion, sensitivity, specificity, and accuracy of the nomogram were 78.1%, 91.7%, and 85.1%, respectively. The whirl sign, tubal thickening, unusual location of ovarian lesion, and hemorrhagic component within adnexal lesion, and an integrated nomogram derived from these significant findings can be useful for predicting ovarian torsion.

An unusual case of melanoma metastasis in the buccal space: learning by mistakes to distinguish it from salivary neoplasms

BackgroundThe buccal space is an unusual location of malignancies. We report here the case of a woman with a melanoma metastasis in buccal fat pad, to evaluate the imaging features which might lead to the correct, although uncommon, diagnosis.Case presentationA 71-year-old woman presented with a painless visible swelling of the left cheek. MRI revealed the presence of a solid lesion located in the buccal fat pad with features suggestive of malignancy. It showed T1 hyperintensity and T2 hypointensity, and restriction of diffusion. Histological examination showed neoplastic cells compatible with melanoma.DiscussionThe lesion features (T1 hyperintensity and T2 hypointensity) initially lead our team to believe that there was a hemorrhagic component, possibly a residue of the biopsy. However, when associated with other malignancy features, such as low apparent diffusion coefficient (ADC) values and contrast enhancement, they should evoke the suspect of melanoma, provided that no biopsy was performed and no trauma occurred in the 3–7 days before.

Computed Tomography in the Diagnosis of Ascites: The Role of Fluid Attenuation Values.

Intraperitoneal fluid accumulations are a common matter in current clinical practice, being encountered by most medical and surgical fields. To assess ascites fluid with attenuation values in the form of Hounsfield units (HU) in order to determine a non-invasive differentiation criterion for the diagnosis of intraperitoneal collections. Sixty patients with known intra-peritoneal collections who underwent computed tomography (CT) for reasons such as tumor staging, post-surgical follow-up or other indications, were retrospectively included in this study. All subjects had a final pathological analysis of the fluid collections. Two radiologists measured the attenuation values for each collection. The averaged values were used for comparing benign and malignancy-related ascites (MRA), bland and hemorrhagic ascites and infected and noninfected fluid collections by consuming the Mann-Whitney U test. Also, the receiver operating characteristic analysis was performed for the statistically significant results (P&lt;0.05), and the area under the curve (AUC) was calculated. Attenuation values could differentiate between benign and MRA (P=0.04; AUC=0.656; sensitivity, 65.52%; specificity, 71.43%) but failed to distinguish between bland ascites and ascites with hemorrhagic component (P=0.85), and between infected and noninfected fluid collections (P=0.47). Although the results are statistically significant, the substrate of differentiation between benign and MRA ascites cannot be clearly stated. As being the first study to investigate this issue, it opens the way for other researches in the field to determine the dynamics of imaging quantitative measurements according to the fluid's pathological features.

Predictors of dopamine agonist resistance in prolactinoma patients

BackgroundSurgical resection of prolactinomas resistant to dopamine agonists is frequently incomplete due to fibrotic changes of the tumour under pharmacological therapy. In order to identify a subgroup of patients who may benefit from early surgery, we thought to investigate possible predictive factors of pharmacological resistance of prolactinomas to dopamine agonists.MethodsWe retrospectively analyzed a database of a Belgian tertiary reference center for patients with pituitary tumours from 2014 to 2016. The groups of interest were patients with dopamine agonist responsive and resistant prolactinomas. The possible predictive factors, including MRI findings, endocrinological parameters, response of tumour and patient factors for dopamine agonist resistance were investigated.ResultsWe included 69 patients of whom 52 were women (75,4%) and 17 were men (24,6%). Rate of dopamine agonist resistance was 15.9%. We identified four significant predictors of dopamine agonist resistance: male gender, a large tumour volume, prolonged time to prolactin normalization and presence of a cystic, hemorrhagic and/or necrotic component. In addition, symptoms due to mass effect, high baseline prolactin level and a high contrast capture on MRI are factors that can be taken into consideration.ConclusionWe identified predictive factors for pharmacological resistance and developed a scoring system for patient specific prediction of resistance to dopamine agonists. This scoring system may have impact on the timing and decision of surgery in prolactinoma patients after further prospective evaluation.

Long-term outcome of a surgically resected intracranial vascular hamartoma in a dog

A 13-year-old, 6.25-kg (13.8-lb) female mongrel was referred to the authors’ hospital with an acute-onset left pleurothotonus and intermittent opisthotonus. Neurological examination showed clinical signs consistent with a multifocal brain...

MON-299 Risk Factors of Re-Growth of Non-Functional Pituitary Adenomas

The aim of investigation to determine clinical aggressiveness diagnostic markers in patients with non-functional pituitary adenomas (NFPA) in the formation of gravity neuroendocrine disease symptoms. Material and Methods: We observed in 87 patients (including man - 44 women -43) of which have a verified diagnosis of NFPA after surgery - 31 which were subjected transnasal adenomectomy of the pituitary (TAG). Further analysis was performed on these patients, who were followed from 1 to 3 years. Results. After the analysis of the frequency of remission and relapse NFPA data selectively in patients we studied the correlation between various parameters and the frequency of relapses. NFPA developed the scale of aggressiveness allowed to identify the risk factors of markers on the 3rd degrees, allowing to create a set of measures of tumor growth relapse prevention. According to MRI data of the brain and pituitary gland, in 15 patients an endosellar tumor was found, in 16 - an endo-extrasellar tumor. In an MRI study, the structure of the NFPA had a predominantly soft tissue (n = 16) and cystic (n = 11) structure. In 4 cases (13%), the structure of the NFPA was represented by a hemorrhagic component, and in 2 (6.4%) of them, both cystic and hemorrhagic components were present. In 18 patients, microadenoma was revealed, in 12 - pituitary macroadenoma and in 1 - a giant pituitary adenoma. The developed scale of aggression markers of NFPA allowed identifying factors by 3 degrees, which allows developing a complex of measures for the prevention of tumor growth recurrence. Conclusions. 1) According to our data, the number of patients with large-cell chromophobic pituitary adenoma predominated - 24 (77.5%). In 2nd place were patients with small cell NFPA - 6 cases (19.3%). And only in 1 case was observed (3.2%) a giant malignant pituitary macroadenoma with recurrence of growth and metastasis in the brain of a teenage girl, in which dark-cell pituitary adenoma was histologically determined, 2) According to our preliminary data, the markers of aggressiveness of the course of NFPA are: young patient age, first symptoms of the disease manifest, large tumor size, asymmetry and deformation of the pituitary gland, signs of tumor invasion into adjacent tissues / arteries / cavernous sinus, presence of small cell and / or dark extracellular chromophobic adenomas, STH hypopituitarism, panhypopituitarism.

Development of Nanobodies Against Hemorrhagic and Myotoxic Components of Bothrops atrox Snake Venom.

Snake envenoming is a globally neglected public health problem. Antivenoms produced using animal hyperimmune plasma remain the standard therapy for snakebites. Although effective against systemic effects, conventional antivenoms have limited efficacy against local tissue damage. In addition, potential hypersensitivity reactions, high costs for animal maintenance, and difficulties in obtaining batch-to-batch homogeneity are some of the factors that have motivated the search for innovative and improved therapeutic products against such envenoming. In this study, we have developed a set of nanobodies (recombinant single-domain antigen-binding fragments from camelid heavy chain-only antibodies) against Bothrops atrox snake venom hemorrhagic and myotoxic components. An immune library was constructed after immunizing a Lama glama with whole venom of B. atrox, from which nanobodies were selected by phage display using partially purified hemorrhagic and myotoxic proteins. Biopanning selections retrieved 18 and eight different nanobodies against the hemorrhagic and the myotoxic proteins, respectively. In vivo assays in mice showed that five nanobodies inhibited the hemorrhagic activity of the proteins; three neutralized the hemorrhagic activity of whole B. atrox venom, while four nanobodies inhibited the myotoxic protein. A mixture of the anti-hemorrhagic and anti-myotoxic nanobodies neutralized the local tissue hemorrhage and myonecrosis induced by the whole venom, although the nanobody mixture failed to prevent the venom lethality. Nevertheless, our results demonstrate the efficacy and usefulness of these nanobodies to neutralize important pathologies of the venom, highlighting their potential as innovative therapeutic agents against envenoming by B. atrox, a viperid species causing many casualties in South America.

Improving Upper Limb Function in a Person with Stroke Using Proprioceptive Neuromuscular Facilitation Approach: A Case Study

A sixty-six-year-old male presented with right upper limb weakness of three years duration. Radiologicalstudies identified an acute infarct with haemorrhagic component and absence of flow in the left middlecerebral artery. This case report discusses his presentation and effect of proprioceptive neuromuscularfacilitation (PNF) approach in stroke to improve upper limb function

Radiologic and Pathologic Findings of a Huge Solitary Fibrous Tumor of the Liver with Malignant Transformation: A Case Report

: Solitary fibrous tumors (SFTs) are mesenchymal tumors that mostly occur in the pleural cavity. Extra-thoracic location is rare and hepatic origin is extremely rare. Most lesions are benign, 10% - 15% show aggressive behavior and few metastasizing SFTs have been reported. Imaging features of solitary fibrous tumors of the liver (SFTLs) are nonspecific and definite diagnosis usually needs histopathological and immunohistochemistry evaluation. We report ultrasound, CT and MRI features of such a rare malignant SFTL in a 47-year-old man who came with vague abdominal symptoms in detail along with reviewing literature considering imaging features which is valuable for radiologists. The lesion seen as a huge dominantly cystic lesion on ultrasound was initially misinterpreted as hydatid. On CT scan it was seen as a large encapsulated mass with arterial hyper-enhancement and delayed contrast retention and multiple cystic spaces. On MRI, solid components showed iso-intensity to adjacent liver on T1 and T2 images, small areas of restriction on diffusion weighted imaging (DWI) and few hemorrhagic cystic components beside enhancement pattern and multiple large cystic components similar to CT scan. Our patient was admitted for resection of huge hepatic mass and experienced an episode of altered mental status due to hypoglycemia during hospital admission, which is a rare finding in SFTL. The patient underwent right hepatectomy and solitary fibrous tumor was confirmed on pathologic examination of the resected tumor. Hypoglycemic episodes were resolved and the patient was asymptomatic in 28 months follow-up.

Spontaneous Resolution of Primary Hypercortisolism of Cushing Disease After Pituitary Hemorrhage

To describe a case of spontaneous resolution of primary hypercortisolism from Cushing disease (CD) due to pituitary apoplexy (PA). Clinical, laboratory, and pathologic information are described. A 59-year-old female presented with a headache, a 2.3 cm sellar mass with a questionable hemorrhagic component, and clinical signs of hypercortisolism. On further evaluation, she had an increased 24-hour urine free cortisol, abnormal serum cortisol during a low dose dexamethasone suppression test, and an elevated plasma adrenocorticotropic hormone (ACTH), consistent with pituitary CD. As she was being prepared for surgical resection, she was noted to have spontaneous biochemical remission associated with resolution of her symptoms of hypercortisolism, and a repeat magnetic resonance imaging scan showed shrinkage of the sellar mass. She has been managed conservatively since and remains in clinical/biochemical remission until present time, 18 months following her initial presentation. We report a case of spontaneous resolution of CD from symptomatic hemorrhage within an ACTH-secreting pituitary adenoma, or PA. This has been rarely reported in the medical literature. The fact that she did not pass through a phase of adrenal withdrawal, makes us suspect a residual functional adenoma within or around the sella which may eventually grow, causing her disease to recur, as has been reported. Hence, continued monitoring will be required.

Solitary fibrous tumor of pleura (symptoms, diagnosis, treatment)

Optimization of diagnosis and treatment of patients with solitary fibrous tumor of pleura, analysis of overall survival and disease-free survival, predictors of recurrence. There were 66 patients with solitary fibrous tumor of pleura (26 men and 40 women) aged 57.6 years (range 26-80 years). Asymptomatic course was found in 29 (44%) patients, various symptoms - in 37 (56%) patients. Thoracotomy was applied in 36 patients, thoracoscopy - in 30 patients. Immunohistochemical examination included analysis of definition of Stat6 expression. Benign variant of SFT was diagnosed in 50 (75.7%) patients, malignant variant - in 16 (24.3%) patients. STAT6 expression was observed in all cases. Postoperative morbidity was 9%, mortality - 1.6%. Recurrence was diagnosed in 2 (4%) patients with benign variant of disease and in 5 (31.2%) patients with malignant variant (2 of them died from progression of disease). Progression-free survival was 89.4%, overall survival - 95.4%. Predictors of recurrence are tumor dimension over 10 cm, necrosis and/or hemorrhagic component of tumor, mitotic count of at least four per 10 high-power fields. Olitary fibrous tumor of pleura is a rare mesenchymal fibroblastic neoplasm growing from submesothelial layer. Differential and preoperative morphological diagnosis of SFT is difficult and demands a special immunohistochemical examination with analysis of Stat 6 expression. Surgery is preferred for tumor de novo and recurrent neoplasm.