Steroid-responsive recurrent encephalopathy in a patient with cerebral amyloid angiopathy.
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Aged, 80 and over↗
Biomedical subjects
Michael A Farrell
Publications and source records attributed to Michael A Farrell.
Malignant hypertension during cryoablation of an adrenal gland tumor.
The authors report a case of hypertensive crisis during cryoablation of an adrenal metastasis. This case is of particular interest not only because of the nature of the complication but also because of the timing of the hypertensive crisis. Based on their observations, the authors suggest that it may be prudent to pretreat this patient population with alpha-adrenergic blocking medications (eg, phenoxybenzamine), as is typically done for patients with neuroendocrine tumors such as pheochromocytoma. Preemptive intervention with these medications requires close collaboration between radiology and anesthesia care teams.
Adrenal Gland Neoplasms↗
Breast lesions: evaluation with US strain imaging--clinical experience of multiple observers.
PURPOSE: To prospectively determine the accuracy of using an ultrasonographic (US) strain imaging technique known as lesion size comparison to differentiate benign from malignant breast lesions. MATERIALS AND METHODS: Institutional Review Board approval and patient informed consent were obtained for this HIPPA-compliant study. US strain imaging was performed prospectively for 89 breast lesions in 88 patients. Lesions were imaged by using freehand compression and a real-time strain imaging algorithm. Five observers obtained manual measurements of lesion height, width, and area from B-mode and strain images. By using these size measurements, individual observer and group performances were assessed by using the area under the receiver operating characteristic curve (A(z)). The performance of a single size parameter versus that of a combination of size parameters was evaluated by using univariate and multivariate logistic regression. RESULTS: Group A(z) values showed that width ratio and area ratio yielded the best results for differentiating benign and malignant breast lesions, and they were not statistically different from one another (P = .499). For the group, the performance of area and width, which was superior to that of height and aspect ratio, was statistically significant for all cases (P < .011) except for those that compared area with aspect ratio (P = .118). By using a group threshold of 1.04 for width ratio and 1.13 for area ratio, the sensitivity and specificity of the technique were 96% and 21%, respectively, for width and 96% and 24%, respectively, for area. The best observer achieved a sensitivity of 96% and a specificity of 61% by using the area ratio. For all but one observer, combined size parameters did not improve observer performance (P > .258). Significant interobserver performance variability was observed (P < .001). CONCLUSION: Results suggest that US strain imaging has the potential to aid diagnosis of breast lesions. However, manually tracing lesion boundaries for size ratio differentiation in a busy clinical setting did not match the diagnostic performance levels previously reported. Focusing on measurements of lesion width, along with additional observer training or automated processes, may yield a suitable method for routine clinical application.
Adult↗
Painful metastases involving bone: percutaneous image-guided cryoablation--prospective trial interim analysis.
PURPOSE: To prospectively determine the safety and effectiveness of percutaneous cryoablation for the reduction of pain, improvement in the activities of daily life, and reduction in the use of analgesic medications for patients with painful metastatic lesions involving bone. MATERIALS AND METHODS: This study was compliant with HIPAA and was approved by the institutional review board. Written informed consent was obtained. During 18 months, 14 patients (eight men, six women; age range, 21-72 years; mean age, 54 years) with one or two painful metastatic lesions involving bone, with a score of 4 or greater out of 10 for worst pain in a 24-hour period, and who did not respond to or refused conventional radiation treatment or chemotherapy were treated with percutaneous cryoablation. Patient response was measured with the Brief Pain Inventory, and analgesic use was recorded before and after the procedure at days 1 and 4, weekly for 4 weeks, and then every other week for a total of 6 months. Complications were monitored. Analysis of the primary end points was undertaken with paired comparison procedures by using paired t tests across individual time points supplemented with repeated measures analysis of variance. RESULTS: Treated lesions were 1-11 cm in diameter. Before cryoablation, the mean score for worst pain in a 24-hour period was 6.7 of 10; the score decreased to 3.8 (P = .003) 4 weeks after treatment. Mean pain interference with activities of daily living was 5.5 of 10 before treatment and decreased to 3.2 (P = .004) 4 weeks after treatment. All eight (100%) patients (exact 95% binomial confidence interval: 63%, 100%) for whom narcotics were prescribed prior to the procedure reported a reduction in these medications after cryoablation. No serious complications were observed. CONCLUSION: Percutaneous cryoablation is a safe and effective method for palliation of pain due to metastatic disease involving bone.
Activities of Daily Living↗
Primary cerebellopontine angle craniopharyngioma in a patient with gardner syndrome. Case report and review of the literature.
The authors report on the case of a craniopharyngioma arising in the cerebellopontine angle (CPA) in a patient with Gardner syndrome. Although familial adenomatous polyposis (FAP) is associated with intracranial neoplasms, the current case is only the third reported craniopharyngioma in a patient with Gardner syndrome. Two of these tumors, including that of the current case, originated in the CPA, an unusual location for craniopharyngiomas. The literature concerning FAP and its associations with intracranial neoplasia, as well as the pathogenesis of craniopharyngiomas in the posterior fossa, is discussed.
Adult↗
Image-guided ablation of painful metastatic bone tumors: a new and effective approach to a difficult problem.
Painful skeletal metastases are a common problem in cancer patients. Although external beam radiation therapy is the current standard of care for cancer patients who present with localized bone pain, 20-30% of patients treated with this modality do not experience pain relief, and few further options exist for these patients. For many patients with painful metastatic skeletal disease, analgesics remain the only alternative treatment option. Recently, image-guided percutaneous methods of tumor destruction have proven effective for treatment of this difficult problem. This review describes the application, limitations, and effectiveness of percutaneous ablative methods including ethanol, methyl methacrylate, laser-induced interstitial thermotherapy (LITT), cryoablation, and percutaneous radiofrequency ablation (RFA) for palliation of painful skeletal metastases.
Bone Neoplasms↗
Intraperitoneal drop metastasis after radiofrequency ablation of pararenal tumor recurrences.
We report the case of a 66-year-old woman who developed intraperitoneal drop metastasis after radiofrequency ablation of recurrent renal cell carcinoma. This patient had undergone multiple nephron-sparing procedures, including radiofrequency ablation to treat local recurrences. At routine follow-up, she was noted to have two intraperitoneal drop metastases, one in the right paracolic gutter and the other in the cul-de-sac of Douglas. The metastases were treated with complete surgical resection. To our knowledge, this is the first reported case of drop metastasis after radiofrequency ablation, drawing attention to the potential complications of this new treatment modality.
Aged↗
Spontaneous adrenal hemorrhage during pregnancy: a review of the literature and a case report of successful conservative management.
Spontaneous adrenal hemorrhage is an acute hemorrhage of the adrenal gland that occurs in the absence of trauma or anticoagulant therapy. The incidence of this condition in pregnancy is unknown. We describe a patient with spontaneous unilateral adrenal hemorrhage that occurred during the third trimester of pregnancy. She was successfully managed conservatively with complete resolution of symptoms and had an uncomplicated perinatal outcome. We review the literature on spontaneous adrenal hemorrhage, including clinical signs and symptoms, diagnostic tests, and management of spontaneous adrenal hemorrhage, to help other practitioners to recognize and appropriately treat this rare condition.
Adrenal Gland Diseases↗
Successful treatment of hepatocellular adenoma with percutaneous radiofrequency ablation.
OBJECTIVE: The purpose of our study was to report the safe and successful treatment of hepatocellular adenoma with percutaneous radiofrequency ablation. CONCLUSION: Our limited experience indicates that percutaneous radiofrequency ablation is both safe and effective in the treatment of the small hepatocellular adenoma in carefully selected patients.
Adenoma↗
Percutaneous image-guided radiofrequency ablation of painful metastases involving bone: a multicenter study.
PURPOSE: Few options are available for pain relief in patients with bone metastases who fail standard treatments. We sought to determine the benefit of radiofrequency ablation (RFA) in providing pain relief for patients with refractory pain secondary to metastases involving bone. PATIENTS AND METHODS: Thirty-one US and 12 European patients with painful osteolytic metastases involving bone were treated with image-guided RFA using a multitip needle. Treated patients had > or = 4/10 pain and had either failed or were poor candidates for standard treatments such as radiation or opioid analgesics. Using the Brief Pain Inventory-Short Form, worst pain intensity was the primary end point, with a 2-unit drop considered clinically significant. RESULTS: Forty-three patients were treated (median follow-up, 16 weeks). Before RFA, the mean score for worst pain was 7.9 (range, 4/10 to 10/10). Four, 12, and 24 weeks following treatment, worst pain decreased to 4.5 (P <.0001), 3.0 (P <.0001), and 1.4 (P =.0005), respectively. Ninety-five percent (41 of 43 patients) experienced a decrease in pain that was considered clinically significant. Opioid usage significantly decreased at weeks 8 and 12. Adverse events were seen in 3 patients and included (1) a second-degree skin burn at the grounding pad site, (2) transient bowel and bladder incontinence following treatment of a metastasis involving the sacrum, and (3) a fracture of the acetabulum following RFA of an acetabular lesion. CONCLUSION: RFA of painful osteolytic metastases provides significant pain relief for cancer patients who have failed standard treatments.
Adult↗
Hypertensive crisis in a patient undergoing percutaneous radiofrequency ablation of an adrenal mass under general anesthesia.
Radiofrequency ablation (RFA) is an effective therapeutic intervention for a variety of neoplastic lesions. Many of these procedures are conducted with patients under general anesthesia. Although RFA is associated with infrequent complications, it is not without risk. Injury to adjacent normal structures is a major concern during RFA of cancerous lesions. Unintended injury to normal adrenal tissue during RFA of adrenal tumors can lead to hypertensive crisis, a potentially catastrophic complication. Hemodynamic consequences of RFA of primary or metastatic adrenal masses have not been reported. We report a case of hypertensive crisis (249/140 mm Hg), tachycardia, and ventricular arrhythmia in an 82-yr-old woman undergoing RFA of renal cell carcinoma metastatic to the adrenal gland. Anesthesiologists should be aware of this potentially catastrophic complication. Direct-acting vasodilators and short-acting beta(1)-adrenergic antagonists should be immediately available, and intraarterial blood pressure monitoring should be seriously considered when providing care for patients undergoing RFA of an adrenal mass.
Adrenal Gland Neoplasms↗
Diagnosis of cavitating mesenteric lymph node syndrome in celiac disease using MRI.
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Celiac Disease↗
Eosinophilic-lymphocytic myocarditis after smallpox vaccination.
Smallpox is an eradicated viral disease that has re-emerged as a potential bioterrorism threat. Smallpox vaccination was historically the most effective defence measure against wild smallpox virus. The risk of myopericarditis after vaccination might limit this option. We report a case of biopsy-proven eosinophilic-lymphocytic myocarditis diagnosed in vivo with histological evidence for eosinophil-mediated cardiac myocyte necrosis shortly after smallpox vaccination. Furthermore, we report a beneficial haemodynamic response to high-dose corticosteroids. A better understanding of the aberrant immune mechanism of myocyte injury after smallpox vaccination might improve the risk/benefit assessment for people considering smallpox vaccination and better smallpox vaccines in the future.
Adult↗
Polymyositis masquerading as motor neuron disease.
BACKGROUND: Several conditions have been reported to mimic motor neuron disease (MND), and misdiagnosis remains a common clinical problem. OBJECTIVE: To report a case of bulbar-onset polymyositis where the initial clinical presentation was suggestive of MND. CASE DESCRIPTION: A 73-year-old woman was admitted for investigation of acute-onset dysphagia without dysarthria. Examination revealed nasal dysphonia and severe oropharyngeal weakness. Subtle upper-limb weakness, brisk tendon reflexes, and fasciculations in the right deltoid muscle were also demonstrated. A clinical diagnosis of MND was entertained. The serum creatine kinase value was within the reference range. Findings from electromyographic studies, however, were suggestive of a myopathic rather than a neurodegenerative process, and a muscle biopsy specimen was diagnostic of polymyositis. The dysphagia rapidly resolved upon treatment with corticosteroids and azathioprine. CONCLUSIONS: Bulbar-onset polymyositis may mimic MND, particularly in the absence of inflammatory markers or elevated muscle enzyme levels. Caution should be exercised in the clinical diagnosis of bulbar dysfunction, and further investigations such as electromyography and muscle biopsy are indicated to confirm the diagnosis.
Adrenal Cortex Hormones↗
Prospective controlled assessment of variable stiffness enteroscopy.
BACKGROUND: Push enteroscopy is a well-established technique for evaluation of the small intestine. However, looping of the enteroscope within the stomach limits depth of insertion. Stiffening overtubes that minimize gastric looping are tolerated marginally by patients and disliked by endoscopists. A variable stiffness instrument has the potential to eliminate the need for an overtube while still minimizing gastric looping. The performance of a prototype variable stiffness enteroscope was compared prospectively with that of a conventional push enteroscope with and without use of an overtube. METHODS: Consecutive patients undergoing enteroscopy were randomized to have the procedure with a variable stiffness instrument, a conventional instrument with overtube, or a conventional instrument without overtube. Depth of insertion distal to the ligament of Treitz was determined by plain abdominal radiography. OBSERVATIONS: In total, 67 patients were randomized to variable stiffness enteroscopy (25 patients), enteroscopy with overtube (23 patients), and enteroscopy without overtube (19 patients). Median depth of insertion distal to the ligament of Treitz, respectively, for each group, was 89 cm, 68 cm and 41 cm (p = 0.03). In multivariate analysis, variable stiffness instrument use was predictive of intubation to 65 cm distal to the ligament of Treitz (odds ratio 5.53: 95% CI [1.25, 31.25] vs. no overtube, and odds ratio 2.50: 95% CI [0.63, 11.1] vs. overtube). Procedure duration and overall patient tolerance did not differ significantly among the 3 groups, although more patients in the overtube group required additional sedation than patients in the variable stiffness group (p = 0.03). Both endoscopists' (r = 0.34) and nurses' (r = 0.36) estimates of patient discomfort during the procedure correlated poorly with patient tolerance. CONCLUSIONS: A variable stiffness push enteroscope enhances insertion depth compared with the conventional instrument with or without overtube. Further studies are required to determine whether this improved performance increases diagnostic yield.
Aged↗
Case 60: Cavitating mesenteric lymph node syndrome.
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Celiac Disease↗
Pancreatic malignancy: value of arterial, pancreatic, and hepatic phase imaging with multi-detector row CT.
PURPOSE: To assess the value of arterial, pancreatic, and hepatic phase imaging at multi-detector row computed tomography (CT) of the pancreas for pancreatic malignancy. MATERIALS AND METHODS: Thirty-nine patients suspected of having resectable pancreatic adenocarcinoma underwent triple-phase multi-detector row CT. Images obtained during each phase were interpreted by one radiologist who evaluated presence of tumor, vascular invasion, and flow artifacts in the superior mesenteric vein and measured attenuation of tumor, normal pancreas, aorta, and superior mesenteric vein. Results were compared with histologic, follow-up, and correlative imaging findings. RESULTS: Mean tumor-to-gland attenuation difference was greatest on images obtained in the pancreatic phase (42 HU) versus that on those obtained in the hepatic phase (35 HU) and in the arterial phase (25 HU). For tumor detection, sensitivity of the images obtained in pancreatic (0.97 [29 of 30]) and hepatic (0.93 [28 of 30]) phases was superior to that of those obtained in arterial phase (0.63 [19 of 30]) (P < or =.008). For vascular invasion detection, sensitivity of images obtained in the hepatic phase (0.83) was better than that of those obtained in the pancreatic (0.58) and arterial (0.25) phases. Images obtained in the pancreatic phase demonstrated more flow artifacts and decreased attenuation in the superior mesenteric vein, compared with the artifacts revealed on images obtained in the hepatic phase. CONCLUSION: Routine acquisition of images in the arterial phase is unnecessary for detection of pancreatic adenocarcinoma. Images of the pancreas obtained in the hepatic phase with multi-detector row CT most accurately display vascular invasion.
Adenocarcinoma↗
Late-onset neuroaxonal leucoencephalopathy with spheroids and vascular amyloid.
A 54-year-old man with a 7-year history of early-onset, slowly progressive dementia and motor impairment characterised by diffuse, non-enhancing white matter signal change. Neuropathologic examination demonstrated subcortical pigmentation with neuroaxonal spheroid formation, profound axonal loss with secondary myelin degeneration and widespread betaA4 immunopositivity involving meningeal and subcortical vessels. There was relative sparing of brain stem and cerebellar white matter. The neocortex was normal. The appearances expand the spectrum of adult-onset neuroaxonal leucoencephalopathy with spheroids (NALS) and demonstrate that vascular betaA4 amyloid plays a key role in the white matter pathology of NALS.
Age of Onset↗