Echidna Splenule: A Case Study of Continuous Splenogonadal Fusion

Splenogonadal fusion (SGF) is a rare congenital anomaly of an aberrant accessory spleen-gonad connection. We present a rare case of continuous splenogonadal fusion in a full-term male with a left undescended testis, multiple congenital limb anomalies, and syndromic facies. Diagnostic laparoscopy revealed the "Echidna Splenule," a snake-like intraperitoneal splenule coursing from the spleen along the left paracolic region and engulfing an atrophic intra-abdominal testis preventing spontaneous descent and distally herniating into the left open internal inguinal ring. The atrophic testis and Echidna Splenule were resected. Splenogonadal fusion should be considered in children with left undescended testis and concomitant limb and facial anomalies.

The Pseudo-Bladder: A Case of the Prostatic Urethra Masquerading as the Bladder

Congenital bladder underdevelopment has detrimental genitourinary effects. We present a male infant with declining renal function, recurrent urinary tract infections, and epididymo-orchitis, in the setting of bilateral high grade hydronephrosis and vesicoureteral reflux. Cystoscopic evaluation revealed the presumed "bladder" to be a massively dilated prostatic urethra. The small dysplastic "true bladder" was found at the anterior surface of the prostatic urethra with massively dilated ureteral orifices. Temporizing diversion was performed in the form of bilateral cutaneous ureterostomies, with an ultimate plan for reconstructive bladder surgery. This case presents diagnostic challenges utilizing current modalities due to a massively dilated prostatic urethra in the rare case of bladder dysplasia.

Can emergency department physicians safely and effectively initiate thrombolysis for acute ischemic stroke?

OBJECTIVE

To review the clinical outcomes of stroke patients treated with IV tissue plasminogen activator (tPA; alteplase) in a community setting and to compare outcomes when treatment was initiated by a neurologist or an emergency department (ED) physician in telephone consultation with a neurologist and radiologist.

METHODS

Clinical information was prospectively collected for 43 stroke patients treated with IV tPA (alteplase) within a five-hospital network of affiliated community hospitals. Blinded 3-month outcomes were obtained with telephone interview or patient visit.

RESULTS

Excellent functional recovery measured by a Modified Rankin score of 0 to 1 (42%), symptomatic intracerebral hemorrhages (7%), and mortality (16.3%) were similar to those reported by National Institute of Neurological Disorders and Stroke (39%, 7.7%, 17.3%). After initial screening by an ED physician, 20 patients were directly examined by a stroke neurologist who then prescribed tPA. Twenty-three patients received tPA prescribed by an ED physician after telephone consultation with a neurologist and review of the head CT by a radiologist. Functional outcome, symptomatic intracerebral bleeding rate, and mortality rate were similar between these groups. Door-to-needle time was similar. Protocol deviations were much higher when ED physicians prescribed the tPA compared to when neurologists did (30% versus 5%). These protocol deviations were reduced with staff education.

CONCLUSIONS

The clinical results of the National Institute of Neurological Disorders and Stroke tPA Stroke Trial were replicated in this small series of patients treated in a community setting. Outcomes were similar whether the prescribing physician was a neurologist or an ED physician.

Primary malignant nerve sheath tumor of the gasserian ganglion: a report of two cases

Primary tumors of the gasserian ganglion are usually benign, and secondary tumors are malignant. We report two cases of a malignant primary tumor of the gasserian ganglion, bringing the total in the world literature to five. The presentation, etiological features, and treatment of these cases are reviewed, together with a review of the literature. Preoperative differentiation from a benign tumor is not possible with certainty. A combination of operation and radiation therapy seems to be the best treatment at present.