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During labor— (i) Not to give prophylactic ergometrine during second stage of labor generic 20 mg tadora free shipping erectile dysfunction medication patents. Rh-positive with direct Coombs’ test positive babies having: (i) Cord blood bilirubin level > 4 mg/dl and hemoglobin level is < 11 gm/dl order 20mg tadora fast delivery erectile dysfunction after drug use. Obstetric examination revealed symphysiofundal height of 40 cm and abdominal girth at the level of umbilicus was 120 cm order 20 mg tadora overnight delivery erectile dysfunction free samples. One over the right spinoumbilical line and the other over the left spinoumbilical line at a higher level. From the history: (i) Use of ovulation inducing drugs and (ii) Family history of twinning. Symptoms: Increased nausea, vomiting, cardiorespiratory embar- rassment, pedal edema, unusual enlargement of the abdomen. Auscultation: Two distinct fetal heart sounds heard at two separate sites by two observers with a difference in heart rates by at least 10 beats/ minute. What additional information can be obtained on ultrasonography besides the presence of two fetuses? The following combinations are in the descending order of frequency: (i) Both cephalic (most common 40% and most favorable) (ii) First cephalic, second breech (26%) Fig. Considering the number of complications both to the mother and the fetus — twin pregnancy is a high risk one. The antenatal management protocol should be: (i) Diet—Increased dietary supplementation (additional 300 kcal/day). The dead fetus is flattened, mumified and compressed between the membranes of the living fetus and the uterine wall. Women with twins should be delivered preferably at an equipped center having an intensive neonatal care unit. Arrangement is made for availability of one unit of cross-matched blood to ensure the availability of the senior obstetrician, the anesthetist and the neonatologist. How can you diagnose chorio- nicity of twin pregnancy and what is its significance? Ultrasound scan around 10–12 weeks can identify “twin peaks” or “Lambda” sign a projection of placental tissue that grows into the interchorionic space of the two placentas. Thick intertwin membrane confirms dichorionicity (arrows) intervening membrane > 2 Obstetric Case Discussions 77 A B Fig. In dichorionic diamniotic twin gestations, the chorion and amnion for each twin reflect away from the fused placenta to form the intertwin membrane. A potential space exists in the intertwin membrane, which is filled by proliferating placental villi giving rise to the twin peak sign. Twin peak sign appears as a triangle with the base at the chorionic surface and the apex in the intertwin membrane; (B) In monochorionic, diamriotic twins, the intertwin membrane is composed of two amnions only (Am, amnion; Cn, Chorion) mm indicates dichorionic and diamniotic twins (Figs 2. It is the “chorionicity” not the “Zygosity” which is related to the degree of complications. Obstetric examination revealed : Uterus 36 weeks size, uterus felt flaccid, single fetus, cephalic presentation. Absence of fetal cardiac motion (real time) and all other body movements for a period of 5–10 minutes of careful observation with real time sonography is a presumptive evidence of fetal death. Spalding sign — Irregular overlapping of cranial bones (i) Hyperflexion of the spine (ii) Crowding of the ribs Usually these features take (iii) Appearance of gas shadow in the some time (7–10 days) to appear, expect the Robert’s heart chambers and blood vessels sign (12 hours) (Robert’s sign) Q. The fetal deaths are due to complications in pregnancy related to the mother, fetus or the placenta. The important causes are: (A) Maternal (5–10%) • Hypertensive disorders • Diabetes (Fig. Investigations: Absence of cardiac motion on ultrasonography using real time is a strong presumptive evidence of fetal death. In about 80% of cases spontaneous expulsion occurs within 10–14 days of the fetal death. Termination of pregnancy when required should always be done by medical induction (oxytocin or/and prostaglandin). Methods of induction are: Clinical examination of the woman including pelvic examination is done. Once delivery occurs—Evaluation of the stillbirth infant is to be done and bereavement management is also to be done. The indications are: Central placenta previa and previous cesarean scar (two or more). Infant examination: Malformations, maceration; umbilical cord: entanglement of cord, number of cord vessels, cord prolapse, true knot (Fig. The couple should be seen in the postpartum clinic after 6 weeks with the investigation reports. Clinical examination revealed: On inspection huge abdominal enlargement from symphysis pubis to xiphisternum. Symphysiofundal height measured was 41 cm and the abdominal girth measured at the level of umbilicus was 122 cm. The different causes for disproportionate enlarge- ment of the uterus are: (1) wrong date, (2) multiple Fig. Clinically: Excessive volume of liquor causing discomfort to the patient and/ or causing difficulties to the clinical diagnosis of the lie and presentation of the fetus. Clinically it is suggested but ultrasonographic assessment would be the best way to confirm the diagnosis. The major anomalies include : anencephaly, open spina bifida, esophageal or duodenal atresia, diaphragmatic hernia, fetal hydrops and cardiac anomalies. What are the different investigations that you plan to do in your case besides the routine ones? It has also got other benefits: (i) to exclude multiple pregnancy, (ii) to note the lie and presentation of the fetus, (iii) to diagnose fetal congenital malformations (mentioned above) and (iv) placental localization. Maternal: (i) Pre-eclampsia, (ii) malpresentation, (iii) premature rupture of membranes, (iv) preterm labor, (v) placental abruption, (vi) cord prolapse, (vii) uterine atony and (viii) postpartum hemorrhage. Puerperium: (i) Subinvolution, and (ii) increased risk of infection and puerperal morbidity. Fetal: Increased perinatal mortality (50%) due to congenital malformations and prematurity. Fetal urine and the amniotic epithelium secretion are the major sources of amniotic fluid and fetal swallowing is the major mode of absorption. Therefore either excessive production or deficient absorption is the basic underlying pathology. Usually, cases with mild degree of polyhydramnios do not require any active intervention. Aim of investigations is to look for any cause of polyhydramnios like fetal congenital malformation, maternal diabetes, rhesus isoimmunization, etc. Subsequent management would be according to the pathology: (a) When fetal congenital malformation is present—delivery is an option with counseling. Obstetric Case Discussions 83 (b) When fetal malformation is absent—pregnancy may be continued till 37 weeks (as she is < 37 week of gestation now). Management will be done if any complicating factor (diabetes mellitus) is detected.

This space readily communicates anterior pelvic fascia lies anterior and lateral to the with the subperitoneal space of the sigmoid 2 discount tadora line icd-9-cm code for erectile dysfunction,13 urinary bladder generic 20 mg tadora overnight delivery drugs for erectile dysfunction in nigeria, prevesical effusions assume in mesocolon buy tadora online erectile dysfunction protocol review article. The ‘‘crown’’ portion of the molar tooth lies anterior to the urin- The presacral space is situated in front of the ary bladder, between the umbilicovesical fascia and sacrum and the coccyx, and defined anteriorly by transversalis fascia of the anterior abdominal wall, the posterior pelvic fascia and posteriorly by parie- displacing the bladder posteriorly (Figs. The ‘‘root’’ portion of the molar tooth areolar and connective tissue, devoid of vascular, extends posteriorly and inferiorly, between the nervous, or lymphatic structures. It is not recog- umbilicovesical fascia along with the anterior pelvic nized on cross-sectional images in the normal sub- fascia and the parietal pelvic fascia, displacing ject. It is delineated, however, in disease states as the bladder medially or away from the midline if the fasciae become more conspicuous (Figs. The root portion has also been pathology of the sacrum or coccyx: fracture referred to as a paravesical collection, but it is (Fig. A fluid collection (b) in the presacral space (arrowheads) containing a hematocrit level (short arrows), indicating layering of blood, is consistent with a hematoma due to a sacral fracture (black arrow)(c) more superiorly. Also, in (c) contrast medium extends into the extraperitoneal fat posteriorly and the properitoneal fat (*) anterolaterally. The triangular perivesical fatty triangle, surrounding the urachus and obliterated umbilical artery, is partially demarcated by contrast media (white arrow). The triangular perivesical fatty space around the urachus and obliterated umbilical arteries (arrows) is spared, outlined by a surrounding prevesical collection, some of which is opacified by contrast medium (*) leaking from the urinary bladder. Note the thickened, prominent perirectal fascia (perf) and posterior pelvic fascia (ppf). Largeamountofascites,eitherlocu- while the extraperitoneal prevesical collection lated or free, may form a molar tooth appearance in usually obliterates this fat (Figs. However, with collections of intraper- The umbilicovesical fascia that surrounds the itoneal fluid, the urinary bladder is displaced infer- urachus and obliterated umbilical arteries is not iorly rather than posteriorly and medially (Figs. Furthermore, the ‘‘root’’ portion is the umbilicovesical fascia becomes obvious when formed by accumulation of ascites in the bilateral there is adjacent prevesical fluid. The prevesical pararectal fossae or parasigmoidal fossae and collections surround but do not involve a trian- therefore located more superiorly. Additionally, gular segment of fat in the anterior abdominal ascites usually preserves the properitoneal fat wall, which represents the superior extension of 214 7. At this level, prevesical collections can extend directly through the thin transversalis fascia, along perforating branches of the inferior epigastric vessels, to come into direct contact with the rectus abdominis muscles (Figs. Fluid can then extend along these muscles into the 9 more superior portions of the rectus sheath. Simi- larly, rectus sheath hematomas can follow the same pathway into the prevesical space (Fig. In fact, when large collections involve both of these compartments, it can be difficult to determine whether the effusions originated in the prevesical 9 space or the rectus sheath. Large heterogeneous ganglioneuroma (*) courses within the prevesical space before it enters arising in the presacral space displaces the colon and the internal inguinal ring to become part of the sper- urinary bladder (ub) anteriorly and obliterates the matic cord. The prevesical collec- then, that prevesical fluid can extend along the vas tions usually obliterate the properitoneal fat deferens into the inguinal canal and subsequently except this triangular segment (Figs. Like the vas deferens, the distal portion of the Below the arcuate line, which lies approximately round ligament courses within the prevesical space as halfway between the umbilicus and pubic symphy- it enters the internal inguinal ring after hooking sis, the rectus abdominis muscles are lined poster- 22 around the proximal inferior epigastric vessels. As the external iliac vessels course below the ingu- This is because the posterior lamina of the apo- inal ligament to become the femoral vessels, they neurosis of the internal oblique muscle and the are enveloped by the femoral sheath, which consists aponeurosis of the transversus abdominis muscle, of a downward prolongation of transversalis fascia Abnormal Imaging Features 215 a b c Fig. This sheath is extension of contrast medium from the prevesical occupied by the femoral artery and vein laterally and space into the perivesical space or more frequently by the femoral canal medially. Since the external iliac vice versa is common in vivo, resulting in partial or vessels lie lateral to the peritoneum, within a com- complete obliteration of the perivesical fat (Fig. The prevesical space is continuous laterally with the Clinically, these effusions may be mistaken for extraperitoneal fat of the anterior abdominal wall, bladder wall thickening or perivesical tumor exten- which in turn is continuous with the properitoneal and sion. Thus, prevesical effusions can bladder may be mistaken for intraperitoneal fluid 9,10 extend laterally around the parietal peritoneum to within the cul-de-sac. When large collec- Perirectal Pathology tions involve both the abdominal and pelvic extraper- In contrast to the prevesical space where the most itoneal compartments, it can be difficult to predict common abnormal findings are related to spontaneous whether the effusions originated in the prevesical 5–10 or traumatic hematoma or other fluid collections, space or the retroperitoneum (Figs. Identifying fasciae and the resulting spaces is Perivesical Fluid Collections important for detecting and localizing pathologic pro- cesses and determining extent of the disease, thus influ- Perivesical collections are rarely seen without asso- encing clinical management and therapy. Perivesical collections are It is particularly helpful in the staging and manage- small since the fluid is within a relatively narrow ment of rectal cancer. Because the perirectal space is space around the urinary bladder confined by the mainly filled with adipose tissue, the extent of rectal umbilicovesical fascia. If the thin umbilicovesical fascia is impregnable, as tumor has reached the perirectal fascia, it is most likely text continues on page 219 216 7. Inflammatory changes are also seen in the adjacent right posterolateral abdominal wall, affecting the muscle (arrows), subcutaneous fat, and dermal layer (arrowheads) despite a ‘‘clean’’ posterior pararenal space. The urinary bladder also is compressed and displaced to the left by the prevesical fluid collection (*). Pelvic nodal metastatic disease from prostate cancer with edematous changes secondary to lymphatic blockage. Edematous changes are also present in the extraperitoneal space (wavy black arrows). Pancreatitis causing mild thickening of all extraperitoneal fasciae including the remote perirectal fascia. During pancreatitis (a, c, e) and after resolution of pancreatitis (b, d, f) at same corresponding levels. Thickening of the adjacent left anterior renal fascia (arrows) and right posterior renal fascia (arrowheads) is present. The umbilicovesical fascia (uvf), also not typically identifiable, is evident, closely apposed to the urinary bladder. The right obliterated umbilical artery (ua) and ductus deferens (dd) are also visualized. Pancreatitis causing mild thickening of all extraperitoneal fasciae including the remote perirectal fascia. How- spaces in the supine position, any fluid collection ever, thickening of the fascia alone that may be due to that develops in the pelvic extraperitoneal spaces, reactive inflammatory changes may not necessarily including a hematoma, can track into the presacral represent tumor involvement. Enlarged Primary or secondary bone tumor from the sacrum or lymph nodes may be often due to hyperplastic nature coccyx may also involve this space (Fig. It is because of these false positives that cross-sectional imaging has a high sensitivity but low specificity in the staging of 16 rectal cancer. Extension Across Fascial Planes Perirectal abscess and cellulitis are associated with Crohn disease and infectious proctitis in homosexual In many clinical situations, it is not uncommon to see fluid collections in one space migrate to males. In these cases, a more important anatomic another space illogically, beyond the boundaries consideration that may impact therapy is the levator ani muscle. For example, in the pel- approaches for supralevator abscess and the more vis, there may be posterior extension of a prevesi- common infralevator one are quite different.

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Cholinesterase inhibitors inactivate acetylcho- Acetylcholine mobilization and release by the nerve linesterase by reversibly binding to the enzyme tadora 20 mg mastercard erectile dysfunction fertility treatment. The stability of the bond infuences the duration In excessive doses order tadora with visa erectile dysfunction urethral inserts, acetylcholinesterase inhibi- of action generic tadora 20mg online erectile dysfunction 18. The electrostatic attraction and hydro- 4 tors paradoxically potentiate a nondepolariz- gen bonding of edrophonium are short-lived; the ing neuromuscular blockade. Nicotinic Muscarinic Two mechanisms may explain this latter efect: an Location Autonomic ganglia Glands increase in acetylcholine (which increases motor Sympathetic Lacrimal end-plate depolarization) and inhibition of pseu- ganglia Salivary docholinesterase activity. Neostigmine and to some Parasympathetic Gastric extent pyridostigmine display some limited pseudo- ganglia Smooth muscle Skeletal muscle Bronchial cholinesterase-inhibiting activity, but their efect on Gastrointestinal acetylcholinesterase is much greater. In Blood vessels Heart large doses, neostigmine can cause a weak depolar- Sinoatrial node izing neuromuscular blockade. Organ System Muscarinic Side Effects Unwanted muscarinic side efects are mini- mized by prior or concomitant administration of Cardiovascular Decreased heart rate, bradyarrhythmias anticholinergic medications, such as atropine sulfate or glycopyrrolate. The duration of action is similar Pulmonary Bronchospasm, bronchial among the cholinesterase inhibitors. Clearance is secretions due to both hepatic metabolism (25% to 50%) and Cerebral Diffuse excitation 1 renal excretion (50% to 75%). Tus, any pro- 5 longation of action of a nondepolarizing mus- Gastrointestinal Intestinal spasm, increased salivation cle relaxant from renal or hepatic insufciency will probably be accompanied by a corresponding Genitourinary Increased bladder tone increase in the duration of action of a cholinesterase Ophthalmological Pupillary constriction inhibitor. Moreover, the absence of any palpable single twitches following 5 sec of tetanic stimulation inhibitors can acThat cholinergic receptors of several at 50 Hz implies a very intensive blockade that can- other organ systems, including the cardiovascular not be reversed. Inactivation of The time required to fully reverse a nondepo- nicotinic acetylcholine receptors in the central 6 larizing block depends on several factors, nervous system may play a role in the action including the choice and dose of cholinesterase of general anesthetics. Unlike physostigmine, inhibitor administered, the muscle relaxant being cholinesterase inhibitors used to reverse antagonized, and the extent of the blockade before neuromuscular blockers do not cross the reversal. Clinical signs of adequate agents, and concurrent excretion or metabolism reversal also vary in sensitivity (sustained head lif > provides a proportionally faster reversal of the inspiratory force > vital capacity > tidal volume). Tese T erefore, the suggested end points of recov- 8 advantages can be lost in conditions associated with ery are sustained tetanus for 5 sec in response severe end-organ disease (eg, the use of vecuronium to a 100-Hz stimulus in anesthetized patients or sus- in a patient with liver failure) or enzyme defcien- tained head or leg lif in awake patients. Newer cies (eg, mivacurium in a patient with homozygous quantitative methods for assessing recovery from atypical pseudocholinesterase). Depending on the neuromuscular blockade, such as acceleromyogra- dose of muscle relaxant that has been given, sponta- phy, may further reduce the incidence of residual neous recovery to a level adequate for pharmaco- postoperative neuromuscular paralysis. A reversal agent should be routinely given to Physical Structure 7 patients who have received nondepolarizing Neostigmine consists of a carbamate moiety and a muscle relaxants unless full reversal can be demon- quaternary ammonium group (Figure 12–4 ). The strated or the postoperative plan includes continued former provides covalent bonding to acetylcholines- intubation and ventilation. The latter renders the molecule lipid insoluble, adequate sedation must also be provided. A peripheral nerve stimulator should also be used to monitor the progress and confrm the ade- Dosage & Packaging quacy of reversal. In general, the higher the fre- The maximum recommended dose of neostigmine quency of stimulation, the greater the sensitivity of is 0. Usual Dose of Usual Dose of Recommended Anticholinergic per mg of Cholinesterase Inhibitor Cholinesterase Inhibitor Anticholinergic Cholinesterase Inhibitor Neostigmine 0. Neostigmine is most commonly packaged as 10 mL of a 1 mg/mL solu- Physical Structure tion, although 0. Pyridostigmine Clinical Considerations shares neostigmine’s covalent binding to acetylcho- The efects of neostigmine (0. The duration of action is prolonged The onset of action of pyridostigmine is slower in geriatric patients. Muscarinic side efects are (10–15 min) than that of neostigmine, and its minimized by prior or concomitant administration duration is slightly longer (>2 h). Glyco- is associated with less tachycardia than is experi- pyrrolate is preferred because its slower onset of enced with atropine (0. Neostigmine is also used to treat myas- must rely on noncovalent bonding to the acetyl- thenia gravis, urinary bladder atony, and paralytic cholinesterase enzyme. In addition, it reverses some of Edrophonium is less than 10% as potent as neostig- the central nervous system depression and delirium mine. Tese efects are transient, and repeated Edrophonium has the most rapid onset of action doses may be required. Bradycardia is infrequent in (1–2 min) and the shortest duration of efect of the recommended dosage range, but atropine should any of the cholinesterase inhibitors. Because glycopyrrolate should not be used, because longer-acting muscle does not cross the blood–brain barrier, it will not relaxants may outlast the efects of edrophonium. Edrophonium may not be as efective as include excessive salivation, vomiting, and convul- neostigmine at reversing intense neuromuscular sions. In equipotent doses, muscarinic efects physostigmine is almost completely metabolized by of edrophonium are less pronounced than those of plasma esterases, so renal excretion is not important. Terefore, it Drugs is lipid soluble and is the only clinically available Volatile anesthetics cholinesterase inhibitor that freely passes the blood– Antibiotics: Aminoglycosides, polymyxin B, neomycin, tetracycline, clindamycin brain barrier. Dantrolene Verapamil Dosage & Packaging Furosemide Lidocaine The dose of physostigmine is 0. In addition, some specifc agents with rocuronium-induced neuromuscular blockade in a the potential of reversing the neuromuscular block- consistent manner. Because of some concerns about ing efects of nondepolarizing muscle relaxants merit hypersensitivity and allergic reactions, sugamma- brief discussion. Sugammadex is able to reverse gantacurium, and other fumarates rapidly combine aminosteroid-induced neuromuscular blockade, with L -cysteine in vitro to form less active degrada- whereas cysteine has been shown to reverse the tion products (adducts). Exogenous administration neuromuscular blocking efects of gantacurium and of L-cysteine (10–50 mg/kg intravenously) given to other fumarates. Tis Sugammadex is a novel selective relaxant-binding unique method of antagonism by adduct formation agent that is currently available for clinical use and inactivation is still in the investigative stage, in Europe. It is a modifed gamma-cyclodextrin especially in terms of its safety and efcacy in (su refers to sugar, and gammadex refers to the struc- humans. Hydrophobic A 66-year-old woman weighing 85 kg is brought interactions trap the drug (eg, rocuronium) in 9 to the recovery room following cholecystectomy. Tis terminates the conclusion of the procedure, the anesthesi- the neuromuscular blocking action and restrains ologist administered 6 mg of morphine sulfate the drug in extracellular fuid where it cannot for postoperative pain control and 3 mg of neo- interact with nicotinic acetylcholine receptors. Although the patient was Clinical Considerations apparently breathing normally on arrival in the Sugammadex has been administered in doses recovery room, her tidal volume progressively of 4–8 mg/kg. The ability to sustain a head lift for of morphine sulfate, a lack of sensory stimulation 5 sec, however, indicates that fewer than 33% of in the recovery area, fatigue of respiratory muscles, receptors are occupied by muscle relaxant. Could the patient still have residual Ventilation should be assisted to reduce the neuromuscular blockade?

Standard graphs relating age and Growth hormone Clinical note height are available for the normal popu- insuffciency In the investigation of lation cheap tadora 20 mg overnight delivery erectile dysfunction pills free trial. Accurate measurements of height should be made to establish whether a normal looking children Any child whose height for age falls child is small for chronological age purchase tadora 20mg mastercard impotence at 40. The chart purchase 20 mg tadora otc antihypertensive that causes erectile dysfunction, or who exhibits a slow growth 6 and 12 months to assess the growth diagnosis is frequently overlooked. The height of the parents should required, then the earlier it is given the also be assessed. The bone age is the best better the chance that the child will even- predictor of fnal height in a child with tually reach normal size. Some centres Growth rate (cm/yr) In most growth disorders bone have now abandoned the use of insulin- age is delayed and by itself is of induced hypoglycaemia as a diagnostic 23 22 little diagnostic value, but taken test in children because of its hazards, 21 together with height and chron- and instead use the arginine stimulation 20 ological age, a prediction of fnal test. It is now 20 routinely measured in the diagnosis and especially monitoring of treated 75g oral glucose acromegaly, with an elevated level sug- 15 gestive of active disease. Trans-sphenoidal hypophysectomy is the frst-line treatment for most acromegalic 0 patients. This is usually reserved Time (minutes) for patients whose disease remains Acromegalic patient active despite surgery. Dopamine agonists like n bromocriptine were widely used in impaired glucose tolerance or Excessive growth the past, but response rates were diabetes mellitus. The advent of long-acting Growth hormone excess in children is synthetic analogues of somatostatin, characterized by extremely rapid linear Diagnosis such as octreotide, has transformed growth (gigantism). Acrome- drugs with side effects, and it is causes of tall stature in children are rare galic patients do not suppress fully in sensible to screen patients for and include: response to hyperglycaemia (Fig 43. The relative defciency of James is 5 years old and is much smaller than his classmates at school. His growth rate has testosterone is associated with been monitored and has clearly dropped off markedly in the past year. This is a whose concentration in plasma is consequence of a I I around 100 nmol/L. Most cells are capable of receptors on liver taking up T4 and deiodinating it to the cell membranes, with a subsequent more biologically active T3. Exactly transthyretin (formerly called prealbu- how this is accomplished is not yet fully min) around 5%. It is the unbound, or ‘free’, T4 and T3 concen- Goitre trations that are important for the bio- logical effects of the hormones, including A goitre is an enlarged thyroid gland the feedback to the pituitary and hypoth- (Fig 44. Changes in binding protein con- hypothyroidism, hyperthyroidism or a centration complicate the interpretation euthyroid state. Hypothyroid children n If a patient’s thyroid is producing good example of how better have delayed skeletal maturation, short too much thyroid hormone, then the technology has helped in the stature and delayed puberty. Examples are: T4 status must be used instead to n insulin-dependent diabetes mellitus monitor the adequacy of n autoimmune hypoparathyroidism replacement. Following the n autoimmune destruction of the adrenal cortex causing Addison’s disease introduction of replacement n pernicious anaemia thyroxine or of anti-thyroid n vitiligo. This applies particularly to the Case history 34 monitoring of anti-thyroid treatment; patients can become profoundly A 49-year-old woman receiving hormone replacement therapy was found to have a hypothyroid quite quickly. No lymphadenopathy was detectable and clinically she appeared to be n Total T3 or free T3. A technetium scan revealed a ‘cold’ nodule and an ultrasound scan indicated it may be useful to have an estimate of was cystic. The titre of autoantibodies to thyroid tissue antigens may be helpful in the Thyroid pathophysiology diagnosis and monitoring of autoimmune thyroid disease. Various drugs affect thyroid function n A patient may have severe thyroid disease, such as a large goitre or thyroid cancer, yet tests. The effects of some of these are have normal concentrations of thyroid hormones in blood. It is therefore easily missed clini- hypothyroidism may indicate the need (Fig 45. Central or 2º n confirmed hypothyroidism illness hypothyroidism radioiodine or surgical treatment of hyperthyroidism. Primary hypothyroidism is failure of the thyroid gland itself and is one of the most com- monly encountered endocrine prob- lems. This 55-year-old woman was frst hypothyroidism the T3 would be main- doses of thyroxine – 25 µg (i. A low This almost developing angina or suffering a 3 Her thyroid hormone results at frst indicated invariably due to the presence of non- myocardial infarction. Increased amounts of T are n Patients with severe non-thyroidal illness may show apparent abnormalities in thyroid 4 hormone results, known as the ‘sick euthyoid or low T3 syndrome’ or non-thyroidal illness converted to the biologically inactive pattern of results. The total T4 con- tration is found to be within the refer- n palpitation – sinus tachycardia or centration in a serum sample does not ence interval. Subsequent investigations atrial fbrillation always refect metabolic status, because reveal an elevated T3 concentration. This n agitation and tremor of changes in binding protein concentra- is referred to as ‘T3 toxicosis’. Rather, the thyroid and orbital muscle may have a common antigen that is recognized by the circulating Free T Bound T4 4 autoantibodies. Others may present with weight loss that may lead to anxiety n Antithyroid drugs (such as (Fig 46. It may pursue a separate or and a futile search for malignant carbimazole and propylthiouracil). Therapy with sodium radioiodine, and steroid treatment may 131I is commonly used in older be required. Thus ‘thyroid function tests’ should be checked regularly to detect developing Case history 36 hypothyroidism. Many patients who have her recent visit to the thyroid clinic now show: subtotal thyroidectomy may later require thyroxine replacement. In these circumstances it must be remembered that it takes a number of Hyperthyroidism weeks before the tissue effects of thyroid hormones accurately refect the concen- n Autoimmune disease is the commonest cause of hyperthyroidism. The steroids with cortisol- • aldosterone adrenal cortex is the source of the two like effects are called important steroid hormones, aldoster- glucocorticoids. The adrenal compounds can act Zona fasciculata Adrenal medulla is embryologically and histo- as anti-infammatory • cortisol cortex logically distinct from the cortex and is or immunosuppressive • adrenal androgens part of the sympathetic nervous system. Synthetic gluco- Zona reticularis Medullary cells synthesize, store and corticoids have found • cortisol • adrenal androgens secrete adrenaline, along with noradren- therapeutic applications aline and dopamine. The adrenal medul- in a wide range of clinical Medulla lary hormones are discussed further on situations, e.

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Contribut- bone turnover have very limited use in ing factors are genetic purchase cheap tadora on-line impotence word meaning, dietary intake of the diagnosis of osteoporosis order tadora pills in toronto smoking and erectile dysfunction statistics, but calcium and vitamin D and physical can occasionally be helpful in determin- exercise buy tadora 20 mg without prescription erectile dysfunction treatment comparison. Osteoporo- Treatment is aimed at strengthening the sis may also be secondary to endocrine bone and preventing fractures. The common- est cause of secondary osteoporosis is Osteoporosis corticosteroid use. Diagnosis ■ Although both sexes show a gradual bone loss throughout life, women lose bone rapidly A detailed clinical history helps to in the postmenopausal years. Others are paracrine factors, which are not released into the circulation, but which act on adjacent cells, e. Finally, autocrine factors act on the very cells responsible for their Endocrine Paracrine Autocrine synthesis. These different kinds of regulation are illustrated regulation regulation regulation in Figure 40. For hormone accurately, the result of a certain level; this will correspond to a example, the hypothalamic factor single measurement may be diffcult certain intended concentration of T4. This is because the means of negative feedback from T4, has just three amino acids, whilst concentration may vary substantially the hypothalamus senses any difference the pituitary gonadotrophins are for various reasons, some of which between the actual concentration of T4 large glycoproteins with subunits. Steroid and Negative feedback control is ubiquitous Assessment of endocrine thyroid hormones bind to specifc in endocrinology, but there is one control hormone-binding glycoproteins in notable example of positive feedback. It is the unbound or ‘free’ During the follicular phase of the men- Many endocrine diseases arise from fraction of the hormone that is strual cycle, the release by the hypo- failure of control mechanisms (Table biologically active. The reasons for Types of endocrine revolutionized endocrinology by this switch are not entirely clear (after control permitting the measurement of all, the hypothalamic-pituitary-ovarian hormones that had previously been Negative feedback axis normally operates as a negative well below the limits of detection. The basic operation of a negative feed- feedback loop), but positive feedback However, despite the refnement of back loop is shown in Figure 40. It is requires a threshold concentration of immunoassay technology by, for perhaps easier to understand the fea- oestradiol (thought to be in the region example, the introduction of tures of such a loop with reference to a of 700 pmol/L) to persist for at least 48 40 Endocrine control 81 Episodic secretion Stress response Circadian rhythm Stimulus – Hypothalamus Time Hormone A Variable concentration of hormone in plasma Fig 40. Up to 40% of the population Third endocrine gland may have unsuspected antibodies that can interfere with immunoassays, by interacting either with the analyte being measured or with the antibody being used in the immunoassay mixture. These antibodies can produce Hormone C falsely lowered or falsely raised results, with potentially serious consequences. Crucially, these interferences are specifc to the patient’s serum, so quality control will not detect the problem. If there is a discrepancy between the Target cells clinical and biochemical pictures, or if a result is totally respond to hormone C unexpected, this possibility should always be considered. Moreover, this kind of relationship applies to Indeed, these are routine in the investigation of some disor- all trophins released by the anterior pituitary, including ders like acromegaly. They are dealt with in detail in pages growth hormone, the trophic hormone for insulin-like 82–83. The overriding infuence of stress on the endocrine system makes the diagnosis of Dynamic function tests endocrine disorders in the critically ill patient very diffcult. Ill patients may have hyperglycaemia, high Where the results of clinical assessment and baseline bio- serum cortisol or abnormal thyroid hormone results. Failure of hormone responsiveness ■ Hormone concentrations in plasma are very variable. Often, the stimulus Thyroxine T4 test is indicated where there is clinical is an exogenous analogue of a trophic Triiodothyronine T3 or biochemical evidence of hypogonad- hormone; in other cases it is provided ism, particularly in the absence of the by biochemical or physiological stress, Table 41. Enough thyroidism, the pituitary response to secretion, so hyperglycaemia suppresses insulin is administered to produce hypoglycaemic stress (blood glucose <2. Likewise, the long Syn- is therefore highly suggestive of acrome- suppression tests acthen test may be performed as a galy. The reasons for the dif- Synacthen tests ferent protocols are often practical pected overactivity of the hypothalamic- Short Synacthen test pituitary-adrenal axis. If a patient requires of agreement on what constitutes an following morning at 08:00 or 09:00. Secondary n Dynamic function tests are often required for the diagnosis of endocrine disorders. Differentiating between these, after tional (that is they secrete hormones) or glucose, free fatty acids) in turn exclusion of stress, drugs and other non-functional. However, comprehensive assess- ment of anterior pituitary reserve requires a combined anterior pituitary + + + + + – function test (Fig 42. It is usual also to assess basal thyroid (thyroxine) and gonadal (testo- sterone or oestradiol) function. Thyroid Adrenal Gonads Liver and Breast and The administration of insulin is con- cortex other tissues other tissues traindicated if there is established coro- Fig 42. A clinician 42 Pituitary function 85 Cortisol nmol/L Glucose (mmol/L) The clinical presentation of hypopitui- Prolactin 6. Dopamine agonist drugs like bromocriptine and cabergoline are widely used to treat hyperprolactinaemia, especially when Case history 32 due to microprolactinomas. They A 36-year-old man complained of impaired vision while driving, particularly at night. The impact of radiation on pituitary function is cumulative, and irradiated patients require annual dynamic function testing of their anterior pituitary reserve thereafter. Pituitary function n Adenomas secreting each of the anterior pituitary hormones have been identifed. There are many causes of hypopituitar- n It is important to establish if a pituitary tumour, whether hormone secreting or not, has ism, a relatively uncommon condition in interfered with the other hypothalamic–pituitary connections. These causes include as possible causes, dynamic tests and detailed radiology are used to differentiate between prolactinoma and idiopathic hypersecretion. The next stage is a normal variant of the popula- relatively steady growth for around 9 tion. If the pituitary does not Anterior short produce suffcient growth hormone, the pituitary n inherited diseases such as yearly growth rate during this period achondroplasia, the may be halved and the child will be of commonest cause of severe short stature. This enables them to take up throughout the day, and single serum Adrenal cortex cholesterol rapidly, from which the measurements are of limited value in adrenal steroid hormones are synthe- clinical practice. Aldosterone is produced exclusively by also involved in the regulation of aldos- It plays a major role in metabolism the zona glomerulosa and is primarily terone synthesis. Aldosterone is respon- by promoting protein breakdown in controlled by the renin–angiotensin sible for promoting sodium reabsorption muscle and connective tissue and the system (p. Thus, cortisol pro- many of the same enzymes involved in aldosterone-like activity is called a min- vides the substrates necessary for gluco- cortisol biosynthesis. All of the 21-hydroxylated neogenesis, which it promotes in the losa lacks the 17-hydroxylase enzyme steroids have mineralocorticoid effects liver. Aldosterone, electrolyte disturbances may involve aline (norepinephrine) through their through its action in promoting sodium severe hyponatraemia and hyperkalae- inotropic effects on the heart and their reabsorption, maintains the extracellu- mia if aldosterone biosynthesis is also vasoconstrictor actions on the arterioles lar volume. If the condition is not diag- nosed quickly the afficted infant may Case history 37 die. Because of the lack of cortisol, nega- A 40-year-old man was investigated for severe skeletal muscle pains. Elevated plasma concentrations are Adrenocortical pathophysiology diagnostic as early as 2 days after birth.

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Rare cases of a transmesocolic hernia combined 66 with a transomental hernia or with a paraduodenal 67 hernia have been reported purchase cheap tadora line erectile dysfunction 43 years old. Hernias Through the Falciform Ligament Internal hernias through the falciform ligament are 68 rare purchase tadora online now impotence yahoo. Intrahepatic anastomoses bowel loops have herniated through a large defect in the between the biliary tree and bowel for hilar cholan- transverse mesocolon into the lesser sac best buy for tadora erectile dysfunction quality of life, displacing the 70,71 giocarcinoma may mimic this appearance transverse colon inferiorly and posteriorly. These loops are tethered toward the site of volvulus to the left of the level of the falciform ligament; to the right, the thin-walled loops proximal to the obstructing hernia are air-filled and dilated (white asterisks). Internal Abdominal Hernias an excessively long afferent limb that protrudes into the retroanastomotic space. About half of these hernias manifest themselves within 1 month and another 25% within 1 year after 73 the operation, with symptoms of cramping abdominal pain and signs of a high small bowel obstruction. These non-specific findings may be mistaken for stomal edema, dumping, or pancreati- tis, and the correct diagnosis may be delayed until 8,9,73 strangulation has developed. This contributes to the reported mortality rate of 32% for surgically treated cases and almost 100% for untreated 9 patients. Hepatojejunostomy simulating a hernia through mesenteric vessels, and mesentery in the periumbili- the falciform ligament. There may be mural thick- In this patient with a cholangiocarcinoma of the common bile ening and dilatation of herniated bowel loops. Retroanastomotic Hernias Supravesical and Pelvic Hernias Retroanastomotic hernias occur usually in patients who have undergone partial gastrectomy and gastro- 9,72 jejunostomy, particularly of the antecolic variety. As the peritoneum follows the surfaces of the pelvic The superior border of the hernial ring is formed by viscera and walls, along with congenital or acquired the transverse mesocolon, the inferior border by the defects in its structure, several pouches and fossae are ligament of Treitz, and the anterior aspect by the formed (Fig. The herniated loop is between the remnants of the median and the left or 75 usually the efferent jejunal segment or, less commonly, right umbilical ligaments. Lateral drawing of the retroanastomotic hernial ring in the antecolic gastrojejunostomy. Supravesical and Pelvic Hernias 403 Hernias through a defect of the broad ligament account for only 4–5% of all internal hernias. The herniated intestine is usually the ileum, and the condi- 76 tion typically occurs in parous women. However, depending on the direc- tion of herniation, hernias through the broad ligament may appear similar to supravesical or perirectal inter- nal hernias. Distinguishing a hernia through the perirectal fossa from other similar pelvic Fig. A 32-year-old man who had undergone subtotal gastrectomy with antecolic gastrojejunostomy for stomach cancer 6 days previously. At surgery, a 100 cm length of efferent loop was herniated through the defect behind the anastomosis with reversible bowel ischemia. A 67-year-old man 40 days after subtotal gastrectomy with antecolic gastrojejunostomy for stomach cancer. At surgery, a 5 cm length of afferent loop was herniated through the defect behind the anastomosis. Location of internal hernias, pouches, and fossae of the pelvic cavity in a female. A ¼ supravesical hernia, B ¼ hernia through the broad ligament, 1 ¼ vesicouterine pouch, 2 ¼ Douglas (rectouterine) pouch, 3 ¼ perirectal fossa. A Petersen hernia may occur scopic bariatric procedures now being performed behind the Roux limb, but this is quite rare for medically complicated obesity, an increasing because surgeons are careful to close this defect number of a new category of internal hernias are atthetimeofsurgery(Fig. The procedure involves fashioning a small gastric demonstrate segmental dilation of small bowel, dis- pouch from the proximal stomach with side-to- tention of the remaining stomach and duodenum, side anastomosis made between the pouch and and stretching of the mesentery and vessels through the Roux limb. A pinching at the point of long and a jejunojejunostomy re-establishes conti- obstruction may be identified and, in a mesocolic nuity. Following a laparoscopic Roux-en-Y gastric hernia, coronal images demonstrate the deflated bypass, the incidence of small bowel obstruction Roux limb cephalad to the transverse colon 81 secondary to internal hernia occurs in up to 5% (Fig. A vascular swirling of the mesentery 80 when there is associated volvulus may be conspicu- of patients. These hernias develop within spaces 81–84 created by the construction and routing of the ous (Fig. Lockhart and colleagues Roux limb and occur in two principal defects: reported the mesenteric swirl as the best indicator of 83 an internal hernia under these circumstances. Prompt surgical intervention includes assessment of bowel viability, as well as reduction and closure of all internal hernia defects. Stretching of the mesentery and vessels at the level of the defect A ¼ mesocolic, B ¼ Petersen’s, C ¼ mesomesenteric. Surg Gynecol Obstet hernias due to developmental and rotational 1935; 60:1052–1071. Haku T, Daidouji K, Kawamura H et al: Internal mesenteric vein: A new diagnostic clue to left para- herniation through a defect of the broad ligament duodenal hernias? See also internal Morgagni hernia, 363 with perineural invasion to celiac abdominal hernia Morison’s pouch, 34, 71 plexus, 62 bilateral, 392 abscesses, 82 embryology and anatomy clinical manifestations of, 383 fluid-filled, 72 development, 21, 259–260 imaging features, 383–387 metastatic seeding in, 98 extensive spread of fluid, 157 large left, 387 seeded deposits from primary carcinoma extravasation with extension, 149 large right, 388 in pelvis to, 97 frontal diagram of fusion fasciae of left, 382–383, 389–390 triangular-dependent recess of, 81 colon, duodenum and, 153 midgut volvulus, 391 mucinous cystadenocarcinoma of ovary, 99 gas producing infection of, 134–135 right, 383, 385, 390–391 mucocele of appendix and pseudomyxoma inflammatory phlegmon and fluid, small left, 383, 386, 389 peritone, 289 evolution of, 266 small right, 386 inflammatory tissue in, 267 whirl sign of small bowel volvulus, 391 N intraductal papillary mucinous tumor, 273 paragangliomas, 324 neoadjuvant chemoradiation ligaments and peritoneal folds around, 261 paravesical space, 31 therapy, 300 mesenteric relationships, 260 pelvis, 71. See also flow of ascites forms series of pools peritoneal ligaments, 243–245 internal abdominal hernia within recesses, 92 peritoneal recesses around, 245 of afferent loop, 402–403 involved by peritoneal phreno-esophageal ligament, 243 of efferent loop, 402 carinomatoses, 91 peritoneal ligaments, 243–244 retroduodenal and intramural duodenal relationships to pooled ascites, 91 and fold around, 245 hematoma, 132 roots, 71 gastrocolic ligament and greater retroduodenal pancreatic fascia ruffled nature, 27, 91 omentum, 244 of Treitz, 16 seeded ovarian carcinoma along, gastrohepatic and hepatoduodenal retroperitoneal fibrosis, 182, 184. See also sustentaculum lienis, 72 etiology and pathogenesis, 169 gynecologic disease spread factors, 169–170 spread of, 350–351 T postpelvilithotomy, 172 vena cava foramen, 11 terminal ileum radiologic findings, 170–172 vena caval hiatus, 32 seeded carcinoma involving, 93 surgical specimen of, 170 venous tumor thrombus, 364, 369 testis, 329 treatment, 172 ventral mesogastrium cancer, 334 5 weeks after hysterectomy, 173 liver, bile duct and ventral pancreas, 45 maturation of, 329–330 urinoma. See uriniferous perirenal ventral and dorsal thickened renal fascia, 135 pseudocyst subperitoneal connection, 25 thoracoabdominal continuum, 10–12 urogenital organs, male vulvar cancer. See also prostate gland, 331 internal abdominal hernia seminal vesicles, 331 W testis and scrotum, 332 whirling pattern of mesentery, 278 . Use a slightly 1 Positioning the patient curved needle to gently assess ossicular mobility 2 Examination under the microscope, and continuity (Table 5. Use fne crocodile forceps and the slightly curved needle to manipulate the prosthesis 2 Examination under the microscope, gently into place and achieve a snug ft. The tympanomeatal fap elevation prosthesis should sit comfortably on the head of Inject 1–2 ml of local anaesthetic and adrenaline in the stapes. Malleus or incus should be placed onto the form of 2% lignocaine and 1/80,000 adrenaline the prosthesis making sure there is no deviation using a dental syringe. Use Check that the prosthesis is not resting on the a Plester D-knife to make two longitudinal incisions. J piece of tragal cartilage between the tympanic Lift the annulus out of the annular rim using a membrane and the prosthesis. Replace the fat canal elevator and use a slightly curved needle tympanomeatal fap and pack with pieces of to enter the middle ear space. Fold the fap forwards to expose the middle 6 Positioning the prosthesis ear cavity. J 1 Positioning the patient 3 Confrming the diagnosis and measuring Position the patient on a head ring with the Use a slightly curved needle to palpate the ossicular operating table head-up.

This phenomenon occurs even if decompression cheap tadora on line erectile dysfunction causes n treatment, particularly as a second resort buy tadora 20 mg line erectile dysfunction shake recipe, duraplasty is performed cheap tadora online visa erectile dysfunction causes smoking, since a completely including craniocervical decompression without watertight closure is not always possible to or with duraplasty, fourth ventricular stenting, achieve. The pseudomeningoceles can occasion- endoscopic third ventriculostomy, tonsillar ally produce enough mass effect to aggravate the reduction, and syringohydromyelia decompres- syringohydromyelia. In particular, fourth ventricular stenting can meningoceles can also fuctuate in size over time, be performed when there is obstruction of the particularly with changes related to intracranial fourth ventricular outfow in patients with refrac- shunting (Fig. The adhesions are best depicted on structures on T1- and T2-weighted sequences high-resolution cisternogram type sequences, (Fig. These are often located posterior to the imaging, which is essentially related to ischemia cerebellum or at the craniocervical junction and at the margins of the resected tissues, along with attach to the overlying dura or dural graft microhemorrhages (Fig. Over with aggravated symptoms after decompres- time, the ischemia evolves to encephalomalacia sion surgery for Chiari I malformation due to with further shrinkage of the inferior cerebellum further inferior descent of the cerebellum, and greater fow across the neo-foramen which can compress the upper spinal cord and magnum. This complication can be predis- include hemorrhage, infection, stroke, cerebrospi- posed by a neo-foramen magnum that is too nal fuid leak with pseudomeningocele formation, large. Chiari decompression surgery was also performed 6 Imaging of Cerebrospinal Fluid Shunts, Drains, and Diversion Techniques 303 a b d c Fig. The patient is status post image (a) shows edema in the bilateral medial cerebellar re-exploration of Chiari decompression, direct midline hemispheres. Childs plain radiograph “shunt series” in the evaluation of Brain 10(6):404–413 6 Imaging of Cerebrospinal Fluid Shunts, Drains, and Diversion Techniques 307 Küpeli E, Yilmaz C, Akçay S (2010) Pleural effusion fol- Cystoperitoneal and lowing ventriculopleural shunt: case reports and Cystoventriculostomy Shunts review of the literature. Surg Neurol 72(Suppl 1):S29–S33; dis- arachnoid cyst: a 20-year follow-up after stereotactic cussion S33–S34 internal drainage: case report and review of the litera- ture. Neurosurg Focus 9(6):ecp1 Syringosubarachnoid and Ventriculo-Cisternal (Torkildsen) Syringopleural Shunts Shunts Cacciola F, Capozza M, Perrini P, Benedetto N, Di Morota N, Ihara S, Araki T (2010) Torkildsen shunt: re- Lorenzo N (2009) Syringopleural shunt as a rescue evaluation of the historical procedure. Childs Nerv procedure in patients with syringomyelia refractory to Syst 26(12):1705–1710 restoration of cerebrospinal fuid fow. Surg Neurol 51(1):27–30 Ergungor F, Taskin Y (2000) Surgical management of syringomyelia-Chiari complex. Eur Spine J 9(6): 553–557 Percutaneously Accessed Hida K, Iwasaki Y (2001) Syringosubarachnoid shunt for Cerebrospinal Fluid Reservoirs syringomyelia associated with Chiari I malformation. Neurology 46(6):1524–1530 Nerv Syst 26(11):1505–1515 Gallmann W, Gonzalez-Toledo E, Riel-Romero R (2010) Perria C (1988) Modifed Holter Rickham reservoir: a Intraventricular fat from retrograde fow through a lum- device percutaneous photodynamic treatment of cystic boperitoneal shunt. J Neurosurg Sci 32(3): Uretsky S (2009) Surgical interventions for idiopathic 99–101 intracranial hypertension. Armored brain: a (4):847–858; discussion 858–859 case report and review of the literature. Radiographics 18(3):635–651 Morota N, Fujiyama Y (2004) Endoscopic coagulation of choroid plexus as treatment for hydrocephalus: indica- tion and surgical technique. Turk ventriculoperitoneal shunt insertion: does it always Neurosurg 20(4):519–523 merit shunt revision? Zentralbl Neurochir 69(3): 152– Vinchon M, Dhellemmes P, Laureau E, Soto-Ares G (2007) 154; discussion 154 Progressive myelopathy due to meningeal thickening in shunted patients: description of a novel entity and the role of surgery. J Intern Med 1989;225(6): imaging of ventriculoperitoneal shunt malfunctions 423–425. A rare cause of right atrial mass: thrombus forma- Ascites and abdominal pseudocysts following ven- tion and infection complicating a ventriculoatrial triculoperitoneal shunt surgery: variations of the same shunt for hydrocephalus. Br J, Brown F (2000) Effects of posterior fossa decom- J Neurosurg 25(6):747–749 pression with and without duraplasty on Chiari Nawashiro H, Otani N, Katoh H, Ohnuki A, Ogata S, Shima malformation-associated hydromyelia. Neurology 76(16): 1377–1382 Imaging of the Postoperative Skull 7 Base and Cerebellopontine Angle Daniel Thomas Ginat, Peleg M. This may require both During anterior cranial resection, the frontal transnasal and anterior skull base (i. The dura is repaired predisposes to local ischemia at the site of retrac- tor placement. Aggressive retraction, which might be implemented for removal of large tumors, can avulse the lenticulostriate vessels, D. Radiation therapy is often administered for This may injure the rectus muscles and other malignant tumors treated via anterior craniofacial orbital contents (Fig. As the normal air fow signal abnormality and ring-enhancing lesions in through the nasal sinuses is frequently disrupted, the distribution of radiation feld and mainly occurs mucocele formation and chronic infammatory 6 months to 1 year after treatment (Fig. Axial diffusion-weighted image obtained after recent anterior cranial resection shows restricted diffusion in the right putamen and oper- cular region of the right frontal lobe, likely secondary to retraction (arrows) 316 D. There is extensive signal abnormality sur- rounding the abscess, which represents cerebritis 7 Imaging of the Postoperative Skull Base and Cerebellopontine Angle 317 a Fig. The patient presented with right restrictive esotropia following anterior cranial resection and radiation treatment of a squamous cell car- cinoma. Consequently, ing is to determine if growth has occurred with residual tumor often remains despite additional associated complications, such as hydrocepha- radiation and chemotherapy. Nevertheless, the lus, and if there is a dominant cystic component main gain of surgery is to the associated reduce that could be targeted in a minimally invasive mass effect. The patient under- went prior transcranial craniopharyngioma debulking, with residual enhancing and cystic suprasellar components (a). Bone remodeling is a chronic pro- Transsphenoidal surgery consists of accessing cess that sometimes occurs after transsphenoidal the sella via the nasal cavity and paranasal sinuses resection. This phenomenon manifests as thick- and typically involves some degree of resecting ening, ossifcation, and high T1 signal intensity, the posterior bony septum back to the sphenoid most commonly along the planum sphenoidale face and performing sphenoidotomy (Fig. The process of drilling through bone during the Nasal stents and sinonasal fuid related to transsphenoidal approach can leave behind bloody mucus drainage can be encountered on metallic debris that has detached from the surgi- early postoperative imaging (Fig. These metal particles can be The early postoperative imaging appearance deposited anywhere along the path of the access of the pituitary after transsphenoidal resection is route, such as in the nasal cavity and sphenoid variable, ranging from no enhancement to nodu- sinus. Although it is usually too minute to be lar enhancement to peripheral rim enhancement. In addition, there may be a postoperative resection via transsphenoidal approach alone. Less inva- tion tissue can be diffcult to differentiate from sive endoscopic transsphenoidal-transventricular residual tumor on imaging initially. However, on combined approaches can also be performed in follow-up, granulation tissue typically involutes, selected cases. The packing serves to pre- adenoma resection can be useful for differenti- vent cerebrospinal fuid leakage, hemorrhage, ating residual tumor from postoperative surgical and prolapse of intracranial contents into larger changes. Fat grafts are hyperintense on both of pituitary macroadenomas is usually distributed T1- and T2-weighted sequences and decrease in lateral to the sella, where it is diffcult to attain size over time, such that in most cases, the fat and left behind in order to minimize complica- grafts resorb completely after 1 year following tions (Fig. Coronal 7 Imaging of the Postoperative Skull Base and Cerebellopontine Angle 323 Fig. When large, these can material can extend posteriorly and compress cause mass effect upon surrounding structures the brainstem (Fig. Scar tissue can tion is uncommon, but can manifest as pseudoan- obstruct the egress of mucous secretions, result- eurysm and/or subarachnoid hemorrhage, which ing in their accumulation. Most arterial complica- are often homogeneously iso- to hyperintense tions related to transsphenoidal surgery involve on T1- and T2-weighted sequences and display the internal carotid artery, but the ophthalmic, peripheral enhancement. These may sometimes posterior communicating, and anterior cerebral be multilocular.