ObjectiveTo determine the optimal management of symptomatic nonparasitic liver cysts. Summary Background DataManagement options for symptomatic nonparasitic liver cysts lack substantiation through comparative studies with respect to safety and long-term effectiveness. MethodsA retrospective review of the surgical management of patients with hepatic cysts between October 1988 and August 1997 was undertaken to determine morbidity rates and to assess long-term recurrence. ResultsThirty-eight patients (35 women, 3 men) underwent 48 operations for symptomatic hepatic cysts of mean diameter 12 cm, with a mean follow-up of 41 months. Twenty-three patients had simple cysts, and 15 patients had polycystic liver disease (PCLD). The symptomatic recurrence rates after laparoscopic or open deroofing for simple cysts were 8% and 29%, and for PCLD 71 % and 20%, respectively. There were no symptomatic recurrences after 14 hepatic resections. There were no perisurgical deaths; however, morbidity rates were significant after laparoscopic deroofing, open deroofing, and hepatic resection (25%, 36%, and 50%, respectively).

Hypoxic-ischaemic brain injury is common and usually due to cardiac arrest or profound hypotension. The clinical pattern and outcome depend on the severity of the initial insult, the effectiveness of immediate resuscitation and transfer, and the post-resuscitation management on the intensive care unit. Clinical assessment is difficult and so often these days compromised by sedation, neuromuscular blockade, ventilation, hypothermia and inotropic management. Investigations can add valuable information, in particular brain MRI shows characteristic patterns depending on the severity of the injury and the timing of imaging. EEG patterns may also suggest the possibility of a good outcome. There is no entirely reliable algorithm of clinical signs or investigations which allow a definitive prognosis but the combination of careful repeated observations and appropriate ancillary investigations allows the neurologist to give an informed and accurate opinion of the likely outcome, and to advise on management. Overall, the prognosis is extremely poor and only a quarter of patients survive to hospital discharge, and often even then with severe neurological or cognitive deficits.

In this retrospective study of patients with HIBI, MRI and EEG provided valuable information concerning prognosis.

Posterior ischaemic optic neuropathy is a rare cause of visual loss believed to be due to infarction in the territory of the pial branches of the ophthalmic artery. The disorder most commonly occurs in the context of prolonged surgery or giant cell arteritis, and the absence of clinical signs in the eye means that the diagnosis is one of exclusion. Here, we present two cases studies of patients who developed posterior ischaemic optic neuropathy confirmed by the observation of secondary changes on diffusion-weighted imaging sequences. In the first case visual loss followed robotic pelvic surgery, and in the second case it was associated with multiorgan dysfunction secondary to severe pancreatitis. Our cases demonstrate that in the right clinical context, diffusion-weighted imaging can provide a positive diagnosis of acute posterior ischaemic optic nerve injury in the acute phase.

We present a case of multiphasic ADEM associated with both human metapneumovirus and influenza type A (swine specific H1N1) with good recovery after treatment with methylprednisolone and oseltamivir.A 60-year-old Ghanaian man presented with 1-week history of intermittent fevers, pleuritic chest pain and cough productive of blood-stained sputum. He had not left the country for 20 years and had not had any recent illnesses or vaccinations. On admission he was in type 1 respiratory failure with widespread consolidation throughout both lung fields. He was intubated, ventilated and commenced on antibiotics for bilateral community-acquired pneumonia. Human metapneumovirus RNA was isolated from his sputum. He improved but on day 11 became acutely confused with weakness in his left-sided limbs. There was increased tone, and absent ankle reflexes and a left extensor plantar response. Magnetic resonance imaging (MRI) brain showed bilateral multiple hyperintense lesions in the white matter of both hemispheres and right cerebral peduncle consistent with ADEM ( Fig. 1). Lumbar puncture was normal; oligoclonal bands were not present. Electroencephalogram (EEG) was consistent with underlying encephalopathy. He was treated with a 5-day course of pulsed iv methylprednisolone followed by 60 mg prednisolone. He made a significant improvement and was discharged 2 months later with little residual neurological deficit.He re-presented 5 months later complaining of 1 week of coryzal symptoms, headaches and intermittent fevers. On examination, he had bilateral pneumonia and type 1 respiratory failure. He was intubated and ventilated. Initial virology screening was positive for influenza type A (swine specific H1N1), and he received 5 days of oseltamivir. He made a good improvement and was extubated after 4 days. However, on day 18, he became acutely confused. Examination revealed a pseudo-pyramidal pattern of weakness in the lower limbs, worse on the left. MRI brain scan showed maturation of the previous white matter lesions, with new lesions in the pons and midbrain tegmentum: changes consistent with recurrence of ADEM (Fig. 2). He was given 1 g pulsed iv methylprednisolone for 5 days followed by 60 mg prednisolone. He improved and was discharged following 3 months of neuro-physiotherapy.ADEM is a rare autoimmune demyelinating disorder with preceding viral or bacterial infection in approximately 50-70% of cases [1][2][3][4][5]. A wide range of pathogens have been reported, including Epstein-Barr virus, measles and herpes, but this is the first reported case of ADEM associated with both human metapneumovirus and influenza type A (H1N1).MRI has high sensitivity for lesion detection. It can also be used to exclude differential diagnoses such as neuromyelitis optica (which has spinal lesions extending over three or more segments). Lesions in ADEM are frequently evident on T2-weighted or fluid attenuated inversion recovery (FLAIR) images. They are typically large, multiple and asymmetric, and usually involve the subcortical and central whit...