Friday 2 December 2016

Varicose Veins: Complete guide.

Q. What are Varicose veins?

A. Varicose veins and telangiectasia (spider veins) are the visible surface manifestations of an underlying problem with reverse venous flow, which is also termed venous insufficiency. Mild forms of venous insufficiency are merely uncomfortable, annoying, or cosmetically disfiguring, but severe venous disease can produce serious systemic consequences and can lead to loss of life or limb.

Q. Who is at risk of developing varicose veins?

A. Human evolution to Bipedal posture has come with a side effect of its own. All professionals requiring prolonged standing as a part of their job are prone to develop varicose veins. For ex:
Teachers and professors.
Bus conductors.

Obesity is an independent risk factor.  Varicose veins tend to be inherited, and become more prominent as a person ages.

Q. Do I have Varicose Veins? What symptoms will I develop if I have varicose veins?

A. Common symptoms of varicose veins include:
Leg heaviness
Exercise intolerance
Pain or tenderness
Burning sensations
Skin changes

Q. What are the complications if Varicose Veins are left untreated?

A. Complications of varicose veins 

Varicose veins can cause complications because they stop your blood flowing properly.
Some possible complications of varicose veins are explained below.

Varicose veins near the surface of your skin can sometimes bleed if you cut or bump your leg. The bleeding may be difficult to stop. You should lie down, raise your leg and apply direct pressure to the wound. Seek immediate medical advice if this doesn't stop the bleeding.

If blood clots form in superficial veins, it could lead to conditions such as thrombophlebitis or deep vein thrombosis.

Thrombophlebitis is swelling (inflammation) of the veins in your leg caused by blood clots forming in the vein. This can occur within your varicose veins and can be painful, look red and feel warm.
When thrombophlebitis occurs in one of the superficial veins in your leg it's known as superficial thrombophlebitis.
Like varicose veins, thrombophlebitis can be treated with compression stockings. In some cases, non-steroidal anti-inflammatories (NSAIDs), such as ibuprofen, may be prescribed.

Deep vein thrombosis
Deep vein thrombosis may develop in up to 20% of people who develop a blood clot in superficial veins.
It can cause pain and swelling in the leg, and may lead to serious complications such as pulmonary embolism.

Chronic venous insufficiency

If the blood in your veins doesn't flow properly, it can interfere with the way your skin exchanges oxygen, nutrients and waste products with your blood. If the exchange is disrupted over a long period of time, it's known as chronic venous insufficiency. Chronic venous insufficiency can sometimes cause other conditions to develop, including those described below.

Varicose eczema
Varicose eczema is a condition that causes your skin to become red, scaly and flaky. You may also develop blisters and crusting of your skin. This condition is often permanent, but does not lead to any major problems.

Lipodermatosclerosis causes your skin to become hardened and tight, and you may find it turns a red or brown colour. The condition usually affects the calf area.

Venous ulcers
A venous ulcer develops when there is increased pressure in the veins of your lower leg. This causes fluid to seep from your vein and collect under the skin.
The fluid can cause the skin to thicken, swell and eventually break down to form an ulcer. Venous ulcers most commonly form in the ankle area.
You should see your GP immediately if you notice any unusual changes in your skin, such as those mentioned above. These conditions can usually be easily treated, but it's important you receive treatment as soon as possible.

Q. How do I confirm if I have Varicose Veins?

A. Doppler Ultrasound is the Gold Standard investigation of choice to diagnose Varicose Veins. It is non-invasive, safe and simple. Call us on 02228511151 to get a free Doppler Ultrasound now. 

Q. What treatment Options do I have?

A. Varicose veins don't always need treatment. If your varicose veins are not causing you discomfort, you may not need to have treatment. Treatment of varicose veins is usually necessary:

to ease symptoms – if your varicose veins are causing you pain or discomfort
to treat complications – such as leg ulcers, swelling or skin discolouration
for cosmetic reasons 

You can also read a summary of the pros and cons of the treatments for varicose veins, allowing you to compare your treatment options.

Compression stockings:

If treatment is necessary, your doctor may first recommend up to six months of self care at home, including: 
using compression stockings
taking regular exercise
avoiding standing up for long periods
elevating the affected area when resting

Compression stockings are specially designed to steadily squeeze your legs to improve circulation. They are often tightest at the ankle and get gradually looser as they go further up your leg. This encourages blood to flow upwards towards your heart.

Compression stockings may help relieve the pain, discomfort and swelling in your legs caused by your varicose veins. However, it's not known whether the stockings help prevent your varicose veins getting worse, or if they prevent new varicose veins appearing.

The National Institute for Health and Care Excellence (NICE) only recommends using compression stockings as a long-term treatment for varicose veins if all other treatments are not suitable for you.
You may need to wear compression stockings for the rest of your life if you have deep venous incompetence. Deep venous incompetence is where you have problems with the valves, or blockages, in the deep veins in your legs.

Endothermic ablation:

One of the first treatments offered will usually be endothermal ablation. This involves using energy from lasers (endovenous laser treatment) to seal the affected veins.

Endovenous laser treatment involves having a catheter inserted into your vein and using an ultrasound scan to guide it into the correct position. A tiny laser is passed through the catheter and positioned at the top of your varicose vein.

The laser delivers short bursts of energy that heat up the vein and seal it closed. The laser is slowly pulled along the vein using the ultrasound scan to guide it, allowing the entire length of the vein to be closed.

Endovenous laser treatment is carried out either under local or spinal anaesthetic, based on patient preference. After the procedure you may feel some tightness in your legs, and the affected areas may be bruised and painful. Nerve injury is also possible, but it's usually only temporary.

Ultrasound-guided foam sclerotherapy:

If endothermal ablation treatment is unsuitable for you, you'll usually be offered a treatment called sclerotherapy instead.

This treatment involves injecting special foam into your veins. The foam scars the veins, which seals them closed. Both standard sclerotherapy and foam sclerotherapy are usually carried out under local anaesthetic. After sclerotherapy, your varicose veins should begin to fade after a few weeks. You may require treatment more than once before the vein fades, and there is a chance the vein may reappear.

Although sclerotherapy has proven to be effective, it's not yet known how effective foam sclerotherapy is in the long term. NICE found, on average, the treatment was effective in 84 out of 100 cases. However, in one study, the varicose veins returned in more than half of those treated.
Sclerotherapy can also cause side effects, including:

blood clots in other leg veins
lower back pain
changes to skin colour – for example, brown patches over where the treated veins were
temporary vision problems

You should be able to walk and return to work immediately after having sclerotherapy. You will need to wear compression stockings or bandages for up to a week.  In rare cases, sclerotherapy has been known to have serious potential complications, such as strokes or transient ischaemic attacks.


If endothermal ablation treatments and sclerotherapy are unsuitable for you, you'll usually be offered a surgical procedure called ligation and stripping to remove the affected veins.

Varicose vein surgery is usually carried out under general anaesthetic, which means you will be unconscious during the procedure. You can usually go home the same day, but an overnight stay in hospital is sometimes necessary, particularly if you are having surgery on both legs.

Ligation and stripping:

Most surgeons use a technique called ligation and stripping, which involves tying off the vein in the affected leg and then removing it.

Two small incisions are made, approximately 5cm (2in) in diameter. The first cut is made near your groin at the top of the varicose vein. The second cut is made further down your leg, usually around your knee or ankle. The top of the vein (near your groin) is tied up and sealed. A thin, flexible wire is passed through the bottom of the vein and then carefully pulled out and removed through the lower cut in your leg. 

The blood flow in your legs will not be affected by the surgery. This is because the veins situated deep within your legs will take over the role of the damaged veins.

Ligation and stripping can cause pain, bruising and bleeding. More serious complications are rare, but could include nerve damage or deep vein thrombosis, which is where a blood clot forms in one of the deep veins of the body.

After the procedure, you may need up to three weeks to recover before returning to work, although this depends on your general health and the type of work you do. You may need to wear compression stockings for up to a week after surgery.

Friday 25 November 2016

Chiari I Malformation

Chiari I Malformation

Incidental finding noted on brain scan done for head trauma. No other associated findings are noted. 

Descent > 10 mm.
Chiari I malformation is the most common variant of the Chiari malformations, and it is characterised by a caudal descent of the cerebellar tonsil through the foramen magnum. It was first described in 1891 by Hans Chiari. Chiari I malformations are more frequently encountered in females.
Clinical presentation

Chiari I malformations often remain asymptomatic until adulthood. Symptoms, if present, include headache and those associated with syrinx.
The likelihood of becoming symptomatic is proportional to the degree of descent of the tonsils. All patients who have greater than 12 mm of descent were symptomatic, whereas approximately 30% of those whose descent measured between 5 and 10 mm were asymptomatic. Chiari I malformations are often isolated abnormalities; however, sometimes they are associated with cervical cord syrinx, hydrocephalus and other skeletal anomalies like basilar invagination, atlanto-occipital assimilation, sprengel deformity and klippel feil syndrome.
Differential Diagnosis:
Chiari I needs to be distinguished from:
  • incidental tonsillar ectopia: <5 mm
  • Chiari 1.5 Malformation - Caudal herniation of some portion of brainstem and cerebellar tonsil. 
  • Chiari II malformation - Myelomeningocoele and a small posterior fossa with descent of the brainstem and cerebellar tonsils.
  • acquired tonsillar ectopia
    • lumbar puncture
    • lumboperitoneal shunt
    • basilar invagination
    • raised intracranial pressure
Imaging features:

The diagnosis is suspected on axial images when the medulla is embraced by the tonsils and little if any CSF is present. This is referred to as a Crowded Foramen Magnum.
Crowded Foramen Magnum
he diagnosis is made by measuring how far the tonsils protrude below the margins of the foramen magnum. The distance is measured by drawing a line from the inner margins foramen magnum (basion to opisthion), and measuring the inferior most part of the tonsils. 

  • above foramen magnum: normal
  • <5 mm: benign tonsillar ectopia 
  • >5 mm: Chiari 1 malformation
In neonates, the tonsils are located just below the foramen magnum and descend further during childhood, reaching their lowest point somewhere between 5 and 15 years of age. As the individual ages further the tonsils usually ascend coming to rest at the level of the foramen magnum. A 5mm descent in a child is most likely normal.
Treatment and prognosis:
Treatment is usually reserved only for symptomatic patients or those with a syrinx. It consists of decompressing the posterior fossa, by removing part of the occipital bone, and posterior arch of C1 as well as performing a duroplasty.
    A D Elster and M Y Chen
    Radiology 1992 183:2347-353 

    Thangamadhan BosemaniGunes OrmanEugen BoltshauserAylin TekesThierry A. G. M. Huisman, and Andrea                
    RadioGraphics 2015 35:1200-220 

Thursday 17 November 2016

Salter Harris Type III

Epiphyseal Fractures.

A 19 year old male was referred for a 3D CT, with pain in right knee after a road traffic accident.  What type of epiphyseal injury is present?

The Salter-Harris classification proposed by Salter and Harris is the most widely used system for describing physeal fractures can be remembered by the mnemonic: SALTR
  • Type 1
    • slipped
    • fracture plane passes all the way through the growth plate, not involving bone
    • cannot occur if the growth plate is fused
    • good prognosis
  • type II
    • Fracture line passes above
    • Most common
    • fracture passes across most of the growth plate and up through the metaphysis
    • good prognosis
  • type III
    • Fracture line passes lower
    • fracture plane passes some distance along the growth and down through the epiphysis
    • poorer prognosis
  • type IV
    • Fracture line passes through 
    • intra-articular
    • fracture plane passes directly through the metaphysics, growth plate and down through the epiphysis
    • poor prognosis 
  • type V
    • rammed
    • crushing type injury does not displace the growth plate but damages it by direct compression
    • worst prognosis