Nonhemorrhagic Infarction Research Articles

Non-Hemorrhagic Adrenal Infarction during Pregnancy: The Diagnostic Imaging Keys.

Background: non-hemorrhagic adrenal infarction (NHAI) is a rare cause of acute abdominal/flank pain during pregnancy; in order to ensure prompt and appropriate treatment, this diagnosis should not be overlooked. This case series highlights pertinent imaging findings, including ultrasounds (USs), computed tomography (CT), and magnetic resonance imaging (MRI) of recent NHAI cases. Methods: we compiled all consecutive NHAI cases from two university hospitals over a two-year period and checked the relevant clinical, laboratory, and imaging findings. Relevant articles on NHAI published from January 2010 to March 2021 were analyzed. Results: six cases were found in our database. CT-scans typically showed enlarged, hypodense, and non-enhanced adrenal glands. Unenhanced MRIs allowed for diagnoses and showed enlarged adrenal glands in the signal hyperintensity on T2 and diffusion-weighted imaging, without any signal hyperintensity on T1. In two of our six cases, USs showed swollen adrenal glands with fluid collection. Conclusion: NHAI and its differential diagnosis—in cases of acute pain during pregnancy—highlight the crucial roles of integrated radiological examination and cooperation between obstetricians and radiologists, both of whom should consider the location of the pain, the accessibility and tolerance of MRI, and the radiation exposure of CT. Despite its supposed poor sensitivity, an US performed because the patient reports pain should also be used to examine the adrenal gland regions. Non-enhanced MRI is clearly of value and access to it in emergencies is important to avoid radiation exposure

VERTEBRAL ARTERY DISSECTION AND INCIDENTAL FINDING OF FIBROMUSCULAR DYSPLASIA: A CASE REPORT

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Fibromuscular Dysplasia (FMD) is a nonatherosclerotic, noninflammatory vascular disease. It is a rare condition that occurs more frequently in middle-aged Caucasian women. Its prevalence is not well known. We present a case of FMD in a man with stroke secondary to dissection of the vertebral artery. Increased reporting of FMD cases in recent studies raises concern about under-diagnosis of the condition. CASE PRESENTATION: A 61-year-old Caucasian male with a past medical history of hypertension presented with dysarthria, extreme disequilibrium, and left-sided headache. The patient had normal strength and sensation in all four extremities and negative cerebellar testing on physical exam. He also had a productive cough upon presentation. Computed tomography (CT) head revealed a 3 cm acute non-hemorrhagic left cerebellar infarction. Computed tomography angiography (CTA) Head and Neck showed evidence of vertebral artery dissection on the left side, including the origin of the left posterior inferior cerebellar artery (PICA). The patient had a trial of cerebral angiogram for the vertebral artery dissection, which showed incidental evidence of FMD in the femoral arteries bilaterally. The patient also had vasospasm with the angiography that resolved post-injection of five milligrams of Verapamil intraarterial, and the procedure was discontinued. He was discharged on aspirin and statin, and anticoagulation starting in two weeks. DISCUSSION: There is no clear consensus on the prevalence of FMD in the general population [1]. However, many studies have assessed the prevalence in different patient populations to be around 3%-4% [2]. The United States Registry of FMD revealed the incidence of dissection of the carotid artery in the FMD patient population to be about 75% [1]. The incidence of dissection of the vertebral artery in patients diagnosed with FMD is much lower, about 17% [1]. The most common manifestations of cervical artery dissection (CeAD) are cerebral infarction and transient ischemic attack (TIA). In FMD patients with ischemic stroke or TIA secondary to CeAD, general guidelines for thrombolysis and thrombectomy should be followed. Most recent guidelines recommend treatment with either an anticoagulant or an antiplatelet agent for at least 3–6 months [3]. Endovascular or surgical repairs are mainly reserved for patients with recurrent ischemia despite initial antithrombotic therapy. CONCLUSIONS: FMD is an intriguing vascular disorder with unclear underlying etiology, challenging manifestations, and complex clinical diagnosis. Increased reporting of FMD cases in recent literature raises concern for underdiagnosis. Furthermore, in our case, FMD was incidentally discovered during a diagnostic procedure to evaluate the vertebral artery dissection. Therefore, we recommend further screening of any patient who presents with cephalo-cervical dissection or aneurysm for underlying FMD. REFERENCE #1: Olin, J.W., Froehlich, J., Gu, X., et al. 2012, "The United States Registry for Fibromuscular Dysplasia: results in the first 447 patients", Circulation, vol. 125, no. 25, pp. 3182-3190. REFERENCE #2: Hendricks, N.J., Matsumoto, A.H., Angle, J.F., et al. 2014, "Is fibromuscular dysplasia underdiagnosed? A comparison of the prevalence of FMD seen in CORAL trial participants versus a single institution population of renal donor candidates", Vascular medicine (London, England), vol. 19, no. 5, pp. 363-367. REFERENCE #3: Powers, W.J., Rabinstein, A.A., Ackerson, et al. "2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association", Stroke, vol. 49, no. 3, pp. e46-e110. DISCLOSURES: No relevant relationships by Elizabeth Mause, source=Web Response No relevant relationships by Mohammad Selim, source=Web Response

Primary adrenal insufficiency due to bilateral adrenal infarction in COVID-19: a case report.

Coronavirus disease 2019 (COVID-19) is a proinflammatory and prothrombotic condition, but its impact on adrenal function has not been adequately evaluated. A 46-year-old woman presented with abdominal pain, hypotension, skin hyperpigmentation after COVID-19 infection. The patient had hyponatremia, serum cortisol <1.0 ug/dL, ACTH of 807 pg/mL and aldosterone <3ng/dL. Computed tomography (CT) findings of adrenal enlargement with no parenchymal and minimal peripheral capsular enhancement after contrast were consistent with bilateral adrenal infarction. The patient had autoimmune hepatitis and positive antiphospholipid antibodies, but no previous thrombotic events. The patient was treated with intravenous hydrocortisone, followed by oral hydrocortisone and fludrocortisone. Among 115 articles, we identified nine articles, including case reports, of new-onset adrenal insufficiency and/or adrenal hemorrhage/infarction on CT in COVID-19. Adrenal insufficiency was hormonally diagnosed in five cases, but ACTH levels were measured in only three cases (high in one case and normal/low in other two cases). Bilateral adrenal non- or hemorrhagic infarction was identified in five reports (two had adrenal insufficiency, two had normal cortisol levels and one case had no data). Interestingly, the only case with well-characterized new-onset acute primary adrenal insufficiency after COVID-19 had a previous diagnosis of antiphospholipid syndrome. In our case, antiphospholipid syndrome diagnosis was established only after the adrenal infarction triggered by COVID-19. Our findings support the association between bilateral adrenal infarction and antiphospholipid syndrome triggered by COVID-19. Therefore, patients with positive antiphospholipid antibodies should be closely monitored for symptoms or signs of acute adrenal insufficiency during COVID-19.

Adrenal Infarct as a Presenting Finding in Polycythemia Vera (PV)

Adrenal infarct as a presenting finding in Polycythemia Vera (PV)Marie Guruli, Vitaly KantorovichBackground: While hemorrhagic adrenal infarcts, usually bilateral, have been described in hematologic malignancies, usually PV, no hemorrhagic variant are exceedingly rare. Here we describe a single case of unilateral nonhemorrhagic adrenal infarct.Case Presentation: 30-year- old male with past medical history of type 1 diabetes on insulin, presented with one day history of right upper quadrant (RUQ) abdominal pain. Initially pain was mild but slowly progressed to 10/10 intensity within the next several hours, felt like a sharp and stabbing pain with radiation up to the chest. Patient also reported to have difficulty breathing due to pain, along with nausea and vomiting. Laboratory results showed leukocytosis 11.2, H&H of 19.1/56.8, platelet count of 637, glucose of 283, alkaline phosphatase of 147. Abdominal ultrasonography reported nonspecific mild hepatomegaly and strongly suspected small thrombus within the IVC. Further work up included CTA study was negative for PE (pulmonary embolus), but MRI showed a filling defect in the suprarenal IVC along with right adrenal infarction. Patient was thermodynamically stable. Fortunately, cortisol was 21.3 and DHEA levels were 419, indicating no apparent effect on adrenal function. Patient underwent a bone marrow biopsy and was eventually diagnosed with PV. He was discharged in the stable condition with a close follow up with his endocrinologist for monitoring and repeat MRI for right adrenal infarct within the next few months.Conclusion: This case illustrates the importance to screen patients with PV who presented with similar clinical presentation for possible adrenal insufficiency. It also highlights the importance of undertaking imaging for careful consideration, close follow up to prevent life threatening complications and even death.

Acute Adrenal Infarct in a Pregnant Female With Severe Abdominal Pain

Background: The differential diagnosis for pregnant patient presenting with abdominal pain is broad. Adrenal infarction is a rare cause of such presentation. Clinical Case: A 24-year-old woman, 30 weeks pregnant, presented to the emergency room with severe, sharp, left upper quadrant abdominal pain that radiated to the back and was associated with nausea and vomiting. Abdominal exam showed tenderness to light palpation in the left upper area with voluntary guarding. Genitourinary exam revealed a closed cervical os. Abdominal MRI noted a T2 hypointense left adrenal gland with loss of normal diffusion restriction. Edematous changes were identified within the left perinephric and anterior pararenal spaces. Left adrenal gland non-hemorrhagic infarction with necrosis was diagnosed, and patient was started on enoxaparin. Patient was admitted for hydration and pain control. A morning serum cortisol was equivocal at 10.3 µg/dL with a mid-normal ACTH of 38.9 pg/mL. ACTH stimulation noted a suboptimal cortisol response with a serum cortisol at baseline of 9.1 µg/dL, at 30 minutes 10.7 µg/dL, and at 60 minutes 11.0 µg/dL. Patient was started on stress dose intravenous hydrocortisone. Evaluation for thrombophilia was undertaken and patient initiated on therapeutic weight-based enoxaparin. Investigations for etiology included normal factor V leiden, proteins C and S activity, antithrombin III antigen, antiphospholipid screening, C3 and C4 complement, anti-double stranded DNA antibody, anti-neutrophil cytoplasmic antibody, cryoglobulin, homocysteine, and factor II mutation. Factor VIII activity was increased >200%, which is within expected range during pregnancy. Patient was heterozygous for MTHFR C677T and A1298C mutations. Hydrocortisone was tapered and patient discharged on a physiologic dose, in addition to enoxaparin. Conclusion: Unilateral adrenal infarction is an uncommon entity in general, and even more uncommon during pregnancy (1). Thrombophilia evaluation is warranted as antiphospholipid syndrome and MTHFR gene mutations have been associated with this condition. Given the rarity of this disease, it may not be included in the differential diagnosis of pregnant patients who present with acute abdominal pain. MRI is superior to other imaging modalities due to its sensitivity in detecting adrenal infarct and even hemorrhage, if present. Unfortunately, there are no guideline on managing such patients, but the focus is usually placed on anticoagulation to prevent the infarction of the contralateral adrenal gland, with cautious monitoring as hemorrhagic conversion is possible. Screening patient for adrenal insufficiency for prompt supplementation of corticosteroids if needed is necessary, while attempting to find the underlying cause. Reference: (1) Green P., et al. Unilateral adrenal infarction in pregnancy. BMJ Case reports. 2013; bcr2013009997

Predictors of brain infarction in adult patients on extracorporeal membrane oxygenation: an observational cohort study

Non-hemorrhagic brain infarction (BI) is a recognized complication in adults treated with extracorporeal membrane oxygenation (ECMO) and associated with increased mortality. However, predictors of BI in these patients are poorly understood. The aim of this study was to identify predictors of BI in ECMO-treated adult patients. We conducted an observational cohort study of all adult patients treated with venovenous or venoarterial (VA) ECMO at our center between 2010 and 2018. The primary endpoint was a computed tomography (CT) verified BI. Logistic regression models were employed to identify BI predictors. In total, 275 patients were included, of whom 41 (15%) developed a BI. Pre-ECMO Simplified Acute Physiology Score III, pre-ECMO cardiac arrest, VA ECMO and conversion between ECMO modes were identified as predictors of BI. In the multivariable analysis, VA ECMO demonstrated independent risk association. VA ECMO also remained the independent BI predictor in a sub-group analysis excluding patients who did not undergo a head CT scan during ECMO treatment. The incidence of BI in adult ECMO patients may be higher than previously believed and is independently associated with VA ECMO mode. Larger prospective trials are warranted to validate these findings and ascertain their clinical significance.

Acute Unilateral Nonhemorrhagic Adrenal Infarction in Pregnancy

A 24-year-old woman, 30 weeks pregnant, presented to an emergency room with severe, sharp, constant abdominal pain in the left upper quadrant, which radiated to the back and was associated with nausea and vomiting. She appeared diaphoretic, with dry oral mucous membranes. Abdominal examination showed a gravid uterus, which was tender upon light palpation in the left upper area, with voluntary guarding. Genitourinary examination revealed a closed cervical os, with no blood in the vaginal vault. Abdominal magnetic resonance imaging revealed a T2-hypointense left adrenal gland (Fig.

Labbé vein thrombosis.

Evaluate the prevalence of Labbé vein thrombosis (LVT) and its liability for the lesions observed in the case of associated ipsilateral transverse sinus thrombosis (TST). MRI findings of 58 consecutive patients (≥ 18years) with acute LVT and TST (group 1) were compared with those of 149 patients with acute TST-no LVT (group 2) observed during the same period. The prevalence of LVT was 15.2%. Group 1: TST extended to sigmoid sinus in 94.8%, resulting in complete sinuses occlusion. Any lesion was observed in 81% within LV territory: swelling (n= 5, 8.6%), edema (n= 9; 15.5%), non-hemorrhagic Infarct (n= 1; 1.7%), multiple temporal lobe hemorrhages (n= 31; 53.5%), temporal lobe hematoma (n= 13; 22.4%), and pericerebral hemorrhages (n= 28; 50%). The hemorrhagic lesions were not related to dominant TST or to extensive venous thrombosis. There was a prevalence of left TST- LVT (n= 32; 55.2%) and a higher prevalence of hemorrhagic lesions in this subset (59.4%). Risk factors were also associated (p= 0.03). Group 2: the TST resulted in an occlusion of the TS: (i) complete (n= 16; 10.7%); (ii) incomplete (n= 97; 82.8%); and (iii) segmental, involving the TS before (n= 32; 21.5%) or after (n= 10; 6.7%) LV ending within the TS. No parenchymal/pericerebral lesions were associated. This study shows a strong association between the following: (i) the extent of thrombosis in the TS and the presence of LVT (p< 0.0001), (ii) the concomitance of LVT-TST and the presence of lesions in the LV territory and at the temporo-frontal convexity, (iii) risk factors and group 1 (p= 0.03).

Acute hemiballismus in the absence of subthalamic nucleus lesion

A 68-year-old male, known hypertensive on irregular medication presented with sudden onset of involuntary movements of the left upper limb, in the form of severely violent, arrhythmic, and flinging large amplitude movements for 2 days, suggestive of hemiballismus. Magnetic resonance image of brain revealed a subacute nonhemorrhagic infarct in the posterior limb of the right internal capsule, but no lesion was noted in the subthalamic region. In traditional teaching, hemiballismus has been characterized as almost pathognomonic of a lesion in the subthalamic nucleus (STN). While a lesion occurring directly in the subthalamic nuclei can explain the onset of the movement disorder, a lesion occurring anywhere along the cortico-striatal pathway can also produce similar symptoms. The prognosis is benign in most cases, with almost all patients responding well to treatment and many having spontaneous remission. Our patient improved significantly following Tetrabenazine. Hemiballismus is as such a rare movement disorder. An elderly patient with sudden onset hemiballismus, indicating a vascular insult confirmed by subacute infarct in the posterior limb of the internal capsule, without any lesion in STN merits the report of this rare case.

Unilateral non-haemorrhagic adrenal infarction (NHAI) as a cause of abdominal pain during pregnancy

Unilateral non-haemorrhagic adrenal infarction (NHAI) as a cause of abdominal pain during pregnancy

Twenty-and-a-half syndrome: a case report

BackgroundIn the list of named numerical neuro-ophthalmological syndromes, such as one-and-a-half syndrome and others, we report for the first time twenty-and-a-half syndrome, which is characterized by one-and-a-half syndrome with bilateral seventh and right fifth nerve palsy (1.5 + 7 + 7 + 5 = 20.5) in a patient with ischemic stroke.Case presentationA 45-year-old Asian Hindu woman presented with vomiting and imbalance of 1 day’s duration. She had left-sided ataxic hemiparesis with one-and-a-half syndrome with bilateral seventh and right fifth nerve palsy. Magnetic resonance imaging of her brain revealed acute non-hemorrhagic infarct in the right posterolateral aspect of pons and medulla, with normal brain vessels angiography. We described her disorder as twenty-and-a-half syndrome. She was put on antiplatelet therapy.ConclusionsTwenty-and-a-half syndrome is reported for the first time. It is due to posterior circulation stroke; in our case, it was due to lacunar infarcts in the pons and medulla, manifesting as one-and-a-half syndrome with bilateral seventh and right fifth nerve palsy.

Non-hemorrhagic unilateral adrenal infarct in pregnancy

Non-hemorrhagic unilateral adrenal infarct in pregnancy

Safety profile of superior petrosal vein (the vein of Dandy) sacrifice in neurosurgical procedures: a systematic review.

OBJECTIVE Walter E. Dandy described for the first time the anatomical course of the superior petrosal vein (SPV) and its significance during surgery for trigeminal neuralgia. The patient's safety after sacrifice of this vein is a challenging question, with conflicting views in current literature. The aim of this systematic review was to analyze the current surgical considerations regarding Dandy's vein, as well as provide a concise review of the complications after its obliteration. METHODS A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A thorough literature search was conducted on PubMed, Web of Science, and the Cochrane database; articles were selected systematically based on the PRISMA protocol and reviewed completely, and then relevant data were summarized and discussed. RESULTS A total of 35 publications pertaining to the SPV were included and reviewed. Although certain studies report almost negligible complications of SPV sectioning, there are reports demonstrating the deleterious effects of SPV obliteration when achieving adequate exposure in surgical pathologies like trigeminal neuralgia, vestibular schwannoma, and petroclival meningioma. The incidence of complications after SPV sacrifice (32/50 cases in the authors' series) is 2/32 (6.2%), and that reported in various case series varies from 0.01% to 31%. It includes hemorrhagic and nonhemorrhagic venous infarction of the cerebellum, sigmoid thrombosis, cerebellar hemorrhage, midbrain and pontine infarct, intracerebral hematoma, cerebellar and brainstem edema, acute hydrocephalus, peduncular hallucinosis, hearing loss, facial nerve palsy, coma, and even death. In many studies, the difference in incidence of complications between the SPV-sacrificed group and the SPV-preserved group was significant. CONCLUSIONS The preservation of Dandy's vein is a neurosurgical dilemma. Literature review and experiences from large series suggest that obliterating the vein of Dandy while approaching the superior cerebellopontine angle corridor may be associated with negligible complications. However, the counterview cannot be neglected in light of some series showing an up to 30% complication rate from SPV sacrifice. This review provides the insight that although the incidence of complications due to SPV obliteration is low, they can happen, and the sequelae might be worse than the natural history of the existing pathology. Therefore, SPV preservation should be attempted to optimize patient outcome.

Risk of cerebral venous thrombosis in oral contraceptives pills users

The aim of this study is to assess the relative risk of cerebral venous sinus thrombosis (CVST) in Oral contraceptive pills (OCP) users compared with a control group of non-hormone users. Patients & methodsThis retrospective case-control, age – group matched study done in about two years and included 40 female patients and 30 control females, aged 30–50 years-with 50% of them above the age of 35 years. All patients diagnosed as CVST with the consumption of OCP were included in the study. The diagnosis is based on the MRI & MRV study. T1, T2, FLAIR &Diffusion weighted image. The MRV was done using the 2 D-TOF technique. ResultsThe MRI result was negative (no parenchymal changes) in 16 patients (40%), and positive in the remaining 60%; 12 patients (30%) showed haemorrhagic infarction only, represented by heterogeneous mixed hypo and hyperintesity in the brain parenchyma with brain edema and 8 patients (20%) showed non-haemorrhagic infarction in the form of low SI in T1WI and a high SI in T2WI and FLAIR and restricted diffusion on DWI, 4 (10%) patients showed a parasagittal high T2 SI indicating superior sagittal sinus thrombosis. The control group showed no parenchymal changes in four (20%) females, but showed hemorrhagic infarction in eight (40%) females, and non-hemorrhagic infarction in six (30%) females and parasagittal high T2 SI in two (10%) females. ConclusionThe risk of CVST increased more in women taking OCP than in non-hormonal users. To reduce the risk, Knowledge of it is of crucial importance.

Influence of Myocardial Hemorrhage on Staging of Reperfused Myocardial Infarctions With T2 Cardiac Magnetic Resonance Imaging: Insights Into the Dependence on Infarction Type With Ex Vivo Validation

ObjectivesThis study sought to determine whether T2 cardiac magnetic resonance (CMR) can stage both hemorrhagic and nonhemorrhagic myocardial infarctions (MIs). BackgroundCMR-based staging of MI with or without contrast agents relies on the resolution of T2 elevations in the chronic phase, but whether this approach can be used to stage both hemorrhagic and nonhemorrhagic MIs is unclear. MethodsHemorrhagic (n = 15) and nonhemorrhagic (n = 9) MIs were created in dogs. Multiparametric noncontrast mapping (T1, T2, and T2*) and late gadolinium enhancement (LGE) were performed at 1.5- and 3.0-T at 5 days (acute) and 8 weeks (chronic) post-MI. CMR relaxation values and LGE intensities of hemorrhagic, peri-hemorrhagic, nonhemorrhagic, and remote territories were measured. Histopathology was performed to elucidate CMR findings. ResultsT2 of nonhemorrhagic MIs was significantly elevated in the acute phase relative to remote territories (1.5-T: 39.8 ± 12.8%; 3.0-T: 27.9 ± 16.5%; p < 0.0001 for both) but resolved to remote values by week 8 (1.5-T: −0.0 ± 3.2%; p = 0.678; 3.0-T: −0.5 ± 5.9%; p = 0.601). In hemorrhagic MI, T2 of hemorrhage core was significantly elevated in the acute phase (1.5-T: 17.7 ± 10.0%; 3.0-T: 8.6 ± 8.2%; p < 0.0001 for both) but decreased below remote values by week 8 (1.5-T: −8.2 ± 3.9%; 3.0-T: −5.6 ± 6.0%; p < 0.0001 for both). In contrast, T2 of the periphery of hemorrhage within the MI zone was significantly elevated in the acute phase relative to remote territories (1.5-T: 35.0 ± 16.1%; 3.0-T: 24.2 ± 10.4%; p < 0.0001 for both) and remained elevated at 8 weeks post-MI (1.5-T: 8.6 ± 5.1%; 3.0-T: 6.0 ± 3.3%; p < 0.0001 for both). The observed elevation of T2 in the peri-hemorrhagic zone of MIs and the absence of T2 elevation in nonhemorrhagic MIs were consistent with ongoing or absence of histological evidence of inflammation, respectively. ConclusionsHemorrhagic MIs are associated with persisting myocardial inflammation and edema, which can confound staging of hemorrhagic MIs when T2 elevations alone are used to discriminate between acute and chronic MI. Moreover, given the poor prognosis in patients with hemorrhagic MI, CMR evidence for myocardial hemorrhage with persistent edema may evolve as a risk marker in patients after acute MI.

Acute Nonhemorrhagic Adrenal Infarction in Pregnancy: 10-Year MRI Incidence and Patient Outcomes at a Single Institution.

The purpose of this study was to retrospectively investigate the MRI incidence of nonhemorrhagic adrenal infarction in pregnant women undergoing MRI evaluation of acute abdominal or flank pain, assess the MRI features quantitatively, and report patient outcomes. All abdominal MRI examinations of pregnant women with acute pain at one institution from May 2005 to April 2015 were reviewed. The adrenals were evaluated for abnormal morphologic and signal intensity characteristics described in the literature characterizing nonhemorrhagic adrenal infarction and were compared with the contralateral adrenal by paired t tests. The findings were correlated with clinical presentation. Patient demographics and outcomes were gathered from the medical record. Findings of nonhemorrhagic adrenal infarction were present in 5 of 379 (1.3%) examinations of four pregnant patients (mean age, 28 years; range, 20.8-33.9 years; mean gestational age, 26 weeks; range, 16-35 weeks). MRI features included lengthening (mean, 39.8 versus 21.2 mm) (p = 0.005) and increased T2 signal intensity (p = 0.001) of the infarcted adrenal with surrounding edema and without T1 signal intensity suggesting hemorrhage. No alternative diagnosis was identified. All patients presented with severe acute abdominal or flank pain on the same side as the MRI findings, tenderness to palpation, and mild leukocytosis. All women delivered healthy infants. Unilateral nonhemorrhagic adrenal infarction was identified in 1.3% of abdominal MRI examinations performed for pregnant women with acute abdominal or flank pain. Knowledge of the MRI characteristics of this entity is important for recognizing it and may prevent further potentially invasive tests, procedures, or missed diagnoses.

Management of Cerebrovascular Accident (CVA) through Ayurveda

Cerebrovascular Accident (CVA), the third most common cause of death in developing countries, is the term used to describe episodes of focal brain dysfunction due to focal ischemia or hemorrhage. Acute stroke is characterized most commonly by hemiplegia with or without signs of focal higher cerebral dysfunction that has posed a great problem as far as its management is concerned. Ayurveda can help in such conditions. A 54 years old male patient diagnosed with non-hemorrhagic infarct presented with right side hemiplegia and difficulty in speech was admitted in IPD. This manifestation was compared with Kaphavrita dakshina pakshaghata. Panchakarma procedures including Rookshana, Snehana and Virechana were adopted along with other internal medicines. Assessments were made using National Institute of Health Stroke Scale (NIH-SS), Barthel Index (BI) and Modified Rankin Scale (MRS). At the end of the treatment, there was considerable improvement in the subjective and objective clinical features. The observations reveal that, Panchakarma procedures can play a key role in the management of conditions like CVA. The treatment strategies followed in this study can be safely adopted under the supervision of a trained Ayurveda specialist.

Contribution of diffusion-weighted imaging to conventional MRI for detection of haemorrhagic infarction in ovary torsion

BackgroundTo assess the role of DWI in differentiation haemorrhagic ovary infarction from non-haemorrhagic one.MethodsFor this prospectively designed study, of 117 female patients who presented with acute lower quadrant pain and underwent MRI for suspicion of ovary torsion, results of only 29 patients (mean age, 24.7; SD, ±5.7; age range, 18–37), with surgical and pathological confirmation of adnexal torsion, were included to the study. All patients underwent DWI after conventional MRI. Quantitative and qualitative analysis of both the torsed and contralateral normal ovary were performed. Results of conventional MRI and DWI were noted.ResultsAt operation 15 patients were found to have haemorrhagic infarction while 14 had non-haemorrhagic infarction. Of the 29 patients, 17 torsed ovaries could be salvaged in a viable state. We found statistically significant correlation of the ADC values, between haemorrhagic and non-haemorrhagic ovary infarction. The ADC values were significantly lower in patients with haemorrhagic infarction than non-haemorrhagic ones (p < 0.001). Using an ADC threshold of 1.27, the sensitivity of DWI for haemorrhagic infarction was 0.93 and specificity 0.85.ConclusionDWI may be used with a significant success for the preoperative diagnosis of haemorrhagic infarction. This may be alerting for pre-emptive surgery in avoiding serious complications and preventing irreversible structural damage of the ovary.

Cerebral venous thrombosis as a diagnostic challenge: Clinical and radiological correlation based on the retrospective analysis of own cases.

Cerebral venous thrombosis (CVT) is a rare condition which constitutes 0.5-1% of all strokes. The clinical and radiological picture of CVT is non-specific and can mimic other disorders. The aim of the study was to retrospectively evaluate and correlate clinical and radiological symptoms presented by patients with CVT, both in the initial and follow-up neurological and neuroimaging examinations, with a special emphasis on diagnostic difficulties. Material consisted of 11 patients with CVT (7 women, 4 men). The average age was 43.5, ranging from 23 to 69 years. Clinical symptoms, laboratory findings, risk factors and the results of neuroimaging examinations including CT, MRI and DSA were retrospectively analyzed and correlated. All subjects developed superficial CVT and 1 also deep CVT, with no parenchymal lesions in 2 cases, non-hemorrhagic infarctions in 3 and hemorrhagic lesions in 6 subjects. The most frequent symptoms were headache, seizures and hemiparesis. The major risk factors were hormonal therapies in women and congenital thrombophilia. Factors influencing the clinical course and outcome the most were location and type of brain lesions, with hemorrhagic cortical infarctions bringing the worst prognosis and being associated with the highest rate of persistent neurological deficits, despite the rate of vessel recanalization. In our opinion, quick diagnosis before parenchymal hemorrhagic lesions are visible on CT is of crucial importance and requires a constant alertness and good cooperation of neurologists and radiologists, especially in emergency settings.

Clinical profile of patients with acute non-hemorrhagic infarct that had a hemorrhagic transformation: A five-year case-control study

Background: In the Philippines, stroke is the second leading cause of mortality, with a prevalence of 0-9%, majority being ischemic stroke at 70% compared to hemorrhagic stroke (Navarro JC, et al, 2014). In as much as 10-40% of ischemic stroke, hemorrhagic transformation (HT) is noted, which further increases the morbidity and mortality rate (Jickling GC, et al, 2014). A lot of factors contribute to this transformation; hence it is important to be able to identify them in order to know how to avoid them.