International Journal of Case Reports and Images (IJCRI)
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Edorium Journals,正常發行
選擇卷期
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Introduction: Endoscopic third ventriculostomy is a minimally invasive neurosurgical procedure which is the most commonly used to treat hydrocephalus via creating an opening in the floor of the third ventricle which allows excess cerebrospinal fluid to flow into surrounding basal cisterns by bypassing obstructions. Use of electromagnetic (AxiEM) neuronavigation to assess precise anatomical landmarks intraoperatively is gaining more importance to achieve accurate results. Endoscopic third ventriculostomy and neuroendoscopic intraventricular surgery overcome the persistent risk of infection and hardware failure associated with ventriculoperitoneal shunting for the treatment of hydrocephalus. However, the surgical technique is associated with endoscopic third ventriculostomy (ETV) risks neurovascular catastrophe. Case Series: The aim of this case series is to assess the safety and effectiveness in surgical outcomes of adding neuronavigation tracking to endoscopic visualization for intraventricular surgery. A retrospective chart review (case series) of adult and pediatric patients treated with neuronavigation-guided endoscopic third ventriculostomy (ETV) or intraventricular cyst fenestration for radiographically confirmed and clinically significant congenital or acquired hydrocephalus in university hospital setting between 2012-2014; n = 21 patients was performed. Herein, we present our surgical outcomes and complications with an average follow-up of 20 months. Conclusion: Intraoperative neuronavigation provides a safe corridor for neuroendoscopy and avoids the complications of skull fixation in both adult and pediatric patients. Adding image guidance to neuroendoscopy increases safety margins for targeting accuracy, especially for patients with challenging anatomic landmarks.
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Introduction: Liver cirrhosis leads to a serious complication mainly the development of portal hypertension which causes catastrophic consequences namely variceal bleeding, encephalopathy, and hepatocellular carcinoma. Bleeding is commonly caused by ruptured esophageal, gastric, and rarely ectopic varices. We report here a patient with liver cirrhosis who presented with obscure upper gastrointestinal bleeding proved to be due to an ectopic varix. Case Report: Our patient is a 55-year-old known hepatitis C virus related cirrhotic man who presented with recurrent melena and hematochezia without abdominal pain. Physical examination was remarkable for pallor, jaundice, and ascites. Following resuscitation, upper endoscopy showed non-bleeding esophageal varices and colonoscopy was unremarkable. Further workup with CT angiography revealed the presence of sub mucosal varix at the level of a small bowel jejunal loop. This was successfully embolized by coiling under ultrasound guidance by the interventional radiologist. Conclusion: This report refreshes the minds about the proper diagnosis and management of obscure upper gastrointestinal bleeding caused by ectopic varices and emphasizes the important role of the interventional radiologist in this matter.
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Introduction: Posterior reversible leukoencephalopathy syndrome (PRES) is a syndrome consisting of neurological symptoms including headaches, visual changes, and seizures often occurring in the setting of uncontrolled hypertension. Diagnosis is often confirmed by characteristic findings on neuroimaging studies. Case Report: We present a case of a 25-year-old African-American woman with a history of chronic pelvic pain secondary to recurrent endometriosis presenting with chief complaints of fever and pelvic pain. She was treated with laparoscopic ablation three months prior. Workup revealed bilateral tubo-ovarian abscesses and the patient underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. Postoperatively, the patient had new onset hypertension which eventually lead to a seizure episode. The patient was transferred to the ICU, started on nicardipine and Keppra and her hypertension improved within several hours. Neuroimaging findings on MRI scan revealed lesions in the occipital and parietal lobes consistent with PRES. Outpatient workup conducted several months afterwards uncovered a diagnosis of systemic lupus erythematosus, leading us to conclude that the postoperative hypertensive emergency and PRES were secondary to undiagnosed SLE. Conclusion: The rare complication of PRES has been described in a variety of settings including SLE in which endothelial dysfunction of the intracerebral vasculature leads to characteristic PRES symptoms. Patients, especially those in the postoperative setting covered by multiple specialty providers, with new onset hypertension and neurological symptoms should warrant further workup as they may indicate underlying etiologies such as SLE or other described risk factors for PRES.
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Introduction: Hemophagocytic lymphohistiocytosis (HLH) is well known to the rheumatologist as a devastating complication of a rheumatologic disease, being one of the few rheumatologic emergencies. Its treatment is usually started on the basis of presumption without waiting for confirmatory evidence. The diagnosis of HLH is usually missed when it appears in any of its many and varied chronic manifestation. It can be a great mimic with symptoms pertaining to any organ system of the human body. Once diagnosed it is imperative to find the trigger in order to prevent recurrences. Case Report: We present a case where HLH caused by Epstein-Barr virus (EBV) infection, presenting as recurring panniculitis; which continued for years before being diagnosed. Treatment with additional anti- CD20 therapy prevented further recurrences. Conclusion: We recommend integrating anti- CD20 therapy as part of the treatment regimen of HLH triggered by EBV.
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Introduction: Syndromic craniosynostosis with growth restriction often causes increased intracranial pressure requiring shunting. Crouzon syndrome also known as branchial arch syndrome is an autosomal dominant disorder which has multiple phenotypic characteristics including proptosis, low set ears, bilateral strabismus, orofacial deformities affecting maxilla and mandible, and most importantly abnormal fusion of skull sutures also known as craniosynostosis. Case Report: A 17-year-old male presented with severe Crouzon syndrome and brachycephaly who had a delayed cranial vault expansion. He subsequently developed intermittent shunt malfunction, which progressed to a complete obstruction. After successful endoscopic third ventriculostomy and return to baseline function the shunt was tied off. Conclusion: Endoscopic third ventriculostomy (ETV) can be performed safely and effectively for shunt malfunction after cranial vault expansion in patients who may not have been candidates previously. By using ETV in addition to known traditional techniques of cranial vault expansion, patient's prognosis and postoperative recovery can be expedited.
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Introduction: Adult hypophosphatasia (HPP) is a rare inheritable metabolic disease affecting primarily the skeletal system resulting in decreased mineralization of bone. Hypophosphatasia has a variable inheritance pattern with the more severe form inherited as autosomal recessive. The diagnosis is based on decreased serum alkaline phosphatase (ALP) and an increased urinary phosphorylethanolamine (PEA). Patients with HPP suffer from multiple fractures, have limited mobility, rely on the use of assistive devices, and have a diminished quality of life. Case Report: A 47-year-old female was presented with a pathologic tibial shaft fracture that was treated with a flexible nail. Conclusion: Currently, there are no definitive treatment guidelines for fracture care in adults with HPP. Load sharing devices have been recommended due to their load-sharing properties and the osteoporotic bone quality in affected patients.
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Introduction: We present a patient with an unusual cause of biliary obstruction. Case Report: A 50-year-old male was presented with a five-month history of worsening recurrent biliary abdominal pain and fevers. There was no previous biliary surgery. His workup revealed a normal bilirubin with elevation of other liver tests. Abdominal ultrasound demonstrated a common bile duct (CBD) diameter of 6 mm and cholelithiasis. A magnetic resonance cholangiopancreatography was unremarkable. An endoscopic ultrasound showed gallbladder sludge and stones, as well as CBD wall thickening with sludge in its mid to distal segments. At endoscopic retrograde cholangiopancreatography, a CBD filling defect was noted. After sphincterotomy, a balloon catheter extracted what looked like a cast occupying the entire lower CBD, extending into the cystic duct. This was retrieved in one piece using a rat tooth forceps and sent for pathology. The patient was discharged without complication. Cholecystectomy was recommended. Pathological analysis revealed the concretion was made of vegetable material. There have only been eight cases of biliary phytobezoar described in the modern English medical literature. Most reports describe the occurrence of a biliary phytobezoar presenting up to 40 years following a surgical bilioenteric anastomosis either with associated choledocholithiasis or alone. There exist only two case reports of patients having developed a biliary phytobezoar in the absence of any bilioenteric anastomosis or fistula. In both, the bezoar acted as a nidus for CBD stone formation, although the mechanism for developing a phytobezoar is not completely understood. Conclusion: We describe the first reported case of an isolated biliary phytobezoar in the absence of previous biliary surgery or bilioenteric fistula.
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Introduction: Patellar fractures account for 1% of all fractures. Fractures of the patella occur from either a direct impact or eccentric contraction of the extensor mechanism. Treatment is dependent on the fracture pattern, displacement, articular surface congruity, and the status of the patient's extensor mechanism. Several techniques have been described for patellar fracture fixation. Case Report: We present a case of a 60-year-old female who had a segmental fracture of the patella that included a small distal pole fragment. Initially, the fracture was fixed with lag screw fixation of the two major fragments. Subsequently, the small inferior pole fragment was fixed to the proximal construct with three-bone tunnel suture fixation technique. Conclusion: This stable construct enabled us to start the patient on an early range of motion exercise program and has resulted in a good functional result at second-year follow-up. To our knowledge, this type of bony construct has not been reported before.