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Friday, 29 March 2013

CASE 173: THORACIC OUTLET SYNDROME, Dr NGUYỄN PHƯỚC BẢO QUÂN, MEDIC CENTER in HUẾ


Female  33 years old complains pain in right arm when she has her arm in abduction and elevated position.
Ultrasound findings:


Fig 1: Right side of the image indicates normal dimension on transversal section of the R subclavian artery (arrow) before the test by which the patient elevates her arm in external rotation; left side of the image indicates small dimension on transversal section of the R subclavian artery during the test due to compression between the anterior scalene muscle anteriorly (white arrow head) and exostosis of the first rib posteriorly (black arrow).

Figure 2:The spectrum waveform of the radial artery before and during the test. 





Fig 3: Longitudinal section of the R subclavian artery indicates the stenosed segment with high flow velocity displayed by aliasing phenomenon and  post-stenotic dilatation segment as well. Note that focal thickening of the wall of the R subclavian artery at stenotic region (white arrow).
Fig 4: CT Angio images of the R subclavian artery demonstrate the stenosed segment due to exostosis of the first rib (red arrow) and poststenotic dilatation segment.
Diagnosis: Thoracic outlet syndrome in the first space.
Discussion: Thoracic outlet syndrome (TOS) is the name of a variety of conditions attributed to compression of the neurovascular structures as they traverse the thoracic outlet. (TOS) can occur at 3 spaces: 1/ The first space is the interscalene triangle. It is bordered by the anterior scalene muscle, the middle scalene muscle, and the upper border of the first rib. The interscalene triangle is the most common site for neural compression, vascular compression. 2/ The second space is the costoclavicular triangle, which is bordered by the clavicle, first rib, and scapula and contains the  subclavian artery and vein and the brachial nerves; 3/ The third and final space is beneath the coracoid process just deep to the pectoralis minor tendon; it is referred to as the subcoracoid space.
Reference: 
 1.Daryl A Rosenbaum, MD; Chief Editor: Sherwin SW Ho, MD. Thoracic Outlet Syndrome . http://emedicine.medscape.com.
2/ Paul B. Kreienberg, Dhiraj M.Shah et al. Thoracic outlet syndrome. Vascular diagnosis. Elsevier Saunders. 2005. P.512-522


Sunday, 24 March 2013

CASE 172: HEPATIC ECTOPIC PREGNANCY, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM


Woman 24 yo, amenorrhea for 2 weeks, was suspected  in pregnancy, but ultrasound at pelvis showed uterus without gestational sac or mass beside uterus.


Ultrasound scan at liver detected one hyperechoic focal, hypovascular, round shape, size of 1.86 cm with fluid in central mass.


Blood test beta HCG is of 34k unit. Do you thing it is an ectopic pregnancy in liver and how to make sure the diagnosis for this case?.



MDCT with CE  was done  for  detection  the intrahepatic focal which was  near  the gall-bladder, size of  2cm, hypodense  cystic central and  blood supply by  hepatic artery (see 3 CT images).




ULTRASOUND AND MSCT LIVER SUGGESTED PRIMARY LIVER PREGNANCY WITH high value of beta HCG 32 k unit/ml. Methotrexate is drug of choice for treatment, after 2 weeks of injection of methotrexate the blood test beta HCG will be dropped to normal, the liver focal will get smaller as a cyst. This is a case of PLP (PRIMARY LIVER PREGNANCY) succesfully treated with METHOTREXATE. NO NEED of OPERATION. IT IS RESULT OF EARLY DIAGNOSTIC of PLP.

REFERENCE: Case in MEDIC of DATE 2008: Subhepatic Ectopic Pregnancy 

Wednesday, 13 March 2013

CASE 171: THICKENING OF ANTRUM WALL, Dr PHAN THANH HẢI, MEDIC MEDICAL CENTER, HCMC, VIETNAM


Woman 39yo, anorexia, vomitting and loss weight rapidly.

Ultrasound abdomen first, see the dilated stomach too big, and the antrum thickening of the wall like the uterus cervix (pseudocervix sign). At the pelvis,  uterus was covered around by ascites (see 3 ultrasound pictures).

MDCT ABDOMEN WAS DONE, some FRONTAL, AND SAGITAL SECTIONS SHOWED THE ANTRUM THISKENING OF THE WALL.

GASTRO-ENDOSCOPY SAW THE ANTRUM STENOSIS.


BIOPSY WAS PERFORMED. WAIT FOR MICROSCOPY REPORT.
ALL OF THE DIAGNOSTIC PROCEDURES SPENT FOR 2 HOURS.

Biopsy report  was  gastric  cancer.

Tuesday, 5 March 2013

CASE 170: A BREAST TUMOR, Dr PHAN THANH HẢI, MEDIC, MEDICAL CENTER, HCMC, VIETNAM

Woman 77 yo, by herself detected one lump at her left breast.
Ultrasound  examination: this mass was at  section  of 10 hr  of left breast, size  arround 2 cm ( B mode US picture). 

It was  hypoechoic and  irregular  border, with very strong shadowing (image 2 and 3), and on CDI, hypervascular and  very high PI.


 
On PDI again, this tumor was hypervascular; axillary scan no detected nodes.



Ultrasound first  suggests breast cancer, next step is mammography or  MRI.
 
THIS PATIENT  REFUSED  TO DO MAMMOGRAPHY AND MRI BECAUSE  THE FIRST TECHNIQUE  WAS PAINFUL  AND THE SECOND ONE MADE  CLAUSTROPHOBIA FOR  HER LONG TIME AGO.
MSCT  IS CHOSEN FOR STAGING  THIS CASE. (SEE  3 CT SLICES )
 


MSCT non CE  showed that tumor  was small size of  1.8 cm, spiculate hypercalcification and detected no  lymphatic nodes of axillary or retrosternum, it was staging I.
Biopsy was done and report was breast cancer type NOS.