Cerebral Protection with a Temporary Ascending Aorta-External Carotid Artery Bypass during Common Carotid Artery Revascularization

Atherosclerosis is a systemic disease, and multiarterial involvement is common. Involvement of all the supra-aortic arteries may occur in the same patient making cerebral revascularization challenging. In this report, we present complete supra-aortic revascularization, that is, revascularization of the bilateral common carotid and subclavian arteries in a 51-year-old male patient with occluded brachiocephalic trunk, left subclavian artery, and proximally stenotic left common carotid artery. A temporary ascending aorta to left external carotid artery bypass provided meticulous cerebral protection with pulsatile cerebral flow in the presence of a proximal arterial clamp; hence, a neurologically uneventful procedure during bilateral common carotid artery revascularization.

Flow Diversion with Low-Profile Braided Stents for the Treatment of Very Small or Uncoilable Intracranial Aneurysms at or Distal to the Circle of Willis

BACKGROUND AND PURPOSE

The endovascular treatment of aneurysms located at or distal to the circle of Willis and not amenable to coiling remains a challenge. We report our experience with flow-diversion treatment using low-profile braided stents as a stent monotherapy procedure for treating distally located very small or uncoilable aneurysms.

MATERIALS AND METHODS

We retrospectively reviewed our data bases to identify patients with aneurysms located at or distal to the circle of Willis who were treated with stent monotherapy using low-profile braided stents. The immediate and follow-up angiographic findings and clinical status of the patients were assessed.

RESULTS

Twenty aneurysms in 19 patients were included in the study. The mean size of the aneurysms was 4.7 ± 2.4 mm. Patients were treated via telescopic implantation of 2 stents for 11 aneurysms; single-stent placement was used for the remaining aneurysms. The technical success rate was 95%. We observed a technical complication in 1 case (5.3%) and a late ischemic event in another (5.3%). The final angiographies during a mean follow-up of 14.7 months showed complete aneurysm occlusion in 73.7%. The complete occlusion rate of the aneurysms treated with telescopic stent placement was 81.8%. The modified Rankin scale scores of all patients at the last follow-up were between 0 and 2.

CONCLUSIONS

Flow diversion with low-profile braided stents as a stent monotherapy procedure for very small or uncoilable intracranial aneurysms located at or beyond the circle of Willis is a promising, relatively safe, and durable endovascular procedure.

How to Clamp and Bypass if There Is Single Artery Supply to the Head and That Contains Severe Stenosis?

Takayasu arteritis manifests with arterial occlusions and aneurysms. Revascularization is sometimes challenging, especially when carotid arteries are affected. In this report, we present a carotid artery revascularization technique in a patient who was admitted with orthostatic and postprandial transient ischemic attacks, resulting in a diagnosis of bilaterally occluded subclavian and vertebral arteries, occluded left common carotid artery, and severely stenosed right common carotid artery. Clamping of the right carotid artery was a challenge; however, our technique provides a neurologically safe revascularization.

Predictive Value of C-reactive Protein in Patients with Unstable Angina Pectoris Undergoing Coronary Artery Stent Implantation

In-stent restenosis is a major problem following coronary stent implantation, and inflammation plays an active role. We evaluated the effectiveness of the inflammatory marker C-reactive protein (CRP) as a predictor of in-stent restenosis after successful stent implantation, in 86 patients with unstable angina pectoris. Plasma CRP was measured in all patients before the procedure, and at 48-72 h and 1, 2 and 3 months post-procedure. An angiographic loss of 50% at follow-up was accepted as in-stent restenosis. We found negative and positive predictive values of the pre-procedural plasma CRP for determining 6-month in-stent restenosis of 34% and 61%, respectively. We also found a strong correlation between the 3-month post-procedural CRP value and 6-month in-stent restenosis; the negative and positive predictive values being 8% and 76%, respectively. In conclusion, we showed that a plasma CRP value > 3 mg/l in the third month after coronary stent implantation was a strong predictor of angiographic in-stent restenosis.

COBALAMIN C DEFICIENCY WITH INFANTILE SPASM AND CUTANEOUS FINDINGS: A UNIQUE CASE

Cobalamin C (CbIC) deficiency is a rare disorder of vitamin B12 metabolism which results from impaired conversion of both its active forms methylcobalamin and adenosylcobalamin. Early onset cblC typically presents in the first year of life with hypotonia, lethargy, seizures, microcephaly, hydrocephalus, developmental delay and other multisystem involvement including hematologic, ocular, renal, hepatic and cardiac symptoms. We report a case of a female infant with cblC deficiency who presented with seizures, developmental delay and hypopigmented cutaneous lesions. To our knowledge, the patient is the first diagnosed with cblC deficiency who had skin hypopigmentation.

Color Doppler analysis of female reproductive vasculature in Behçet's disease

Behçet's disease (BD) may affect female reproductive vasculature. We aimed to evaluate Doppler sonographic characteristics of female reproductive vasculature and also ovarian volume, endometrial thickness (EMT) and antral follicle count of BD patients in comparison with a healthy control group. Seventeen premenopausal women aged between 18-45 years with BD, and a control group of 31 age- and body mass index-matched healthy women was included in the study. Uterine, spiral and intraovarian artery blood flow were examined by Doppler sonography in the late follicular phase. Resistance index, pulsatility index and systolic/diastolic ratio were recorded together with ovarian volume, EMT and antral follicle count. In particular this is a pilot study including the evaluation of the spiral and uterine arteries in BD. Doppler sonographic parameters, ovarian volume, EMT and antral follicle count of BD patients and healthy controls were not found to be statistically different. As a result of our analysis, we found similar Doppler sonographic features of both BD patients and the control group. Further studies conducted on a larger sample population with more aggressive BD symptoms may reveal the actual effect of BD on the female reproductive system.

Genetic Alterations in Differentiated Thyroid Cancer Patients with Acromegaly

AIM

Acromegaly is associated with increased thyroid cancer risk. We aimed to analyze the frequency of point mutations of BRAF and RAS genes, and RET/PTC, PAX8/PPARγ gene rearrangements in patients with acromegaly having differentiated thyroid cancers (DTC) and their relation with clinical and histological features.

MATERIALS AND METHODS

14 acromegalic patients (8 male, 6 female) with DTC were included. BRAF V600E and NRAS codon 61 point mutations, RET/PTC1, RET/PTC3, and PAX8/PPARγ gene rearrangements were analyzed in thyroidectomy specimens. We selected 14 non-acromegalic patients with DTC as a control group.

RESULTS

2 patients (14.3%) were detected to have positive BRAF V600E and 3 patients (21.4%) were detected to have NRAS codon 61 mutation. NRAS codon 61 was the most frequent genetic alteration. Patients with positive mutation had aggressive histologic features more frequently than patients without mutations. Comparison of the acromegalic and non-acromegalic patients with DTC revealed that BRAF V600E mutation was more frequent in non-acromegalic patients with DTC (14.2% vs. 64.3%, p=0.02). RET/PTC 1/ 3, PAX8/PPARγ gene rearrangements were not detected in any patient. None of the patients including the patients with positive point mutations had recurrence, and local and/or distant metastasis.

CONCLUSION

NRAS codon 61 is the most frequent genetic alteration in this acromegaly series with DTC. Since acromegalic patients have lower prevalance of BRAF V600E mutation, BRAF V600E mutation may not be a causative factor in development of DTC in acromegaly. Despite the relation of BRAF V600E and NRAS codon 61 mutations with aggresive histopathologic features, their impact on tumor prognosis remains to be defined in acromegaly in further studies.

Stent-Assisted Coiling of Wide-Neck Intracranial Aneurysms Using Low-Profile LEO Baby Stents: Initial and Midterm Results

BACKGROUND AND PURPOSE

Low-profile self-expandable stents were recently introduced for the treatment of wide-neck intracranial aneurysms. This study investigated the initial and midterm clinical and angiographic results of LEO Baby stent-assisted coiling in the treatment of wide-neck intracranial aneurysms.

MATERIALS AND METHODS

A retrospective review was performed to identify patients who were treated with LEO Baby stent-assisted coiling. Eighty patients with 80 wide-neck intracranial aneurysms were included in the study. Eleven patients (13.8%) presented with subarachnoid hemorrhage. All patients were treated with LEO Baby stent-assisted coiling. Technical success and immediate postprocedural clinical and angiographic outcomes were evaluated. Seventy-three patients attended angiographic and clinical follow-up for a mean duration of 7.2 ± 3.8 months. Periprocedural and delayed complications were reviewed. Preprocedural and follow-up clinical statuses were assessed by using the modified Rankin Scale.

RESULTS

The technical success rate of the procedure was 97.5%. The immediate postprocedural angiography revealed a complete occlusion of the aneurysm in 75% of the 80 patients. The last follow-up angiograms showed complete occlusion in 85.7% of the 77 patients with an angiographic follow-up. Of the 77 patients with a follow-up angiography, 6.5% showed an increase in the filling status of the aneurysm and 5.2% required retreatment. The overall procedure-related complication rate, including asymptomatic complications, was 11.3%. The permanent morbidity rate was 3.8%. There was no mortality in this study.

CONCLUSIONS

This case series demonstrates the relative safety, efficacy, and midterm durability of the LEO Baby stent-assisted coiling procedure for the treatment of wide-neck intracranial aneurysms.

Dual stenting using low-profile LEO baby stents for the endovascular management of challenging intracranial aneurysms

BACKGROUND AND PURPOSE

Endovascular treatment of wide-neck, complex, and distally located cerebral aneurysms is a challenging issue. This study evaluated the safety and efficacy of dual stent placement by using a low-profile stent system (LEO Baby) for the treatment of challenging distal intracranial aneurysms.

MATERIALS AND METHODS

We retrospectively reviewed patients in whom at least 1 LEO Baby stent was used in the context of dual stent placement for the treatment of intracranial aneurysms. Patients who were treated with dual stent-assisted coil embolization and telescopic implantation of LEO Baby stents were included in the study. Clinical and angiographic findings, procedural data, and follow-up are reported.

RESULTS

Twelve patients were included in this study. Three patients presented with subarachnoid hemorrhage in the subacute-chronic phase, and the remaining patients had unruptured aneurysms. Nine patients were treated by using the dual stent-assisted coiling method. X- (nonintersecting), Y- (intersecting and reversible), T-, and parallel-stent configurations were performed for the dual stent-assisted coiling procedures. Three patients were treated by using telescopic stent placement for a flow diverter-like effect. The procedures were successful in all cases. Technical complications without a significant clinical adverse event developed in 2 patients. The 3- and 6-month control MRAs and DSAs demonstrated complete occlusion of the aneurysms in all patients except 1. All patients had good clinical outcomes on follow-up (mRS ≤1).

CONCLUSIONS

The results of this small study showed the feasibility of dual stent placement by using low-profile LEO Baby stents to treat distally located complex intracranial aneurysms.

Effect of Education on the Rate of and the Understanding of Risk Factors for Intravascular Catheter–Related Infections

Objective.

Intravascular catheters are indispensable tools in modern medical therapy. In spite of their great benefits, however, the widespread use of catheters leads to several complications, including infections that cause significant morbidity, mortality, and economic losses for hospitalized patients.

Design.

This study was conducted at Farabi Hospital, a 495-bed facility at Karadeniz Technical University Medical School in Trabzon, Turkey, and involved 3 separate periods: preeducation, education, and posteducation. Patients with intravascular catheters were monitored daily, as were the results of their physical examinations. The information acquired was recorded in a questionnaire.

Results.

During the preeducation period (October 2003 through March 2004), 405 intravascular catheters inserted into 241 patients were observed for 5,445 catheter-days. Seventy-one cases of intravascular catheter-related infection (CRI) were identified, giving a CRI rate of 13.04 infections per 1,000 catheter-days. The catheter-related bloodstream infection (CRBSI) rate was 8.3 infections per 1,000 catheter-days, and the exit-site infection (ESI) rate was 3.5 infections per 1,000 catheter-days. During the posteducation period (June through November 2004), 365 intravascular catheters inserted into 193 patients were observed for 5,940 catheter-days. Forty-five cases of CRI were identified, giving a rate of 7.6 infections per 1,000 catheter-days. The CRBSI rate was 4.7 infections per 1,000 catheter-days, and the ESI rate was 2.2 infections per 1,000 catheter-days. When findings from the 2 periods were compared, it was determined that education reduced CRI incidence by 41.7%.

Conclusion.

CRI can be prevented when hospital personnel are well informed about these infections. We compared the knowledge levels of the relevant personnel in our hospital before and after theoretical and practical training and identified a significant increase in knowledge after training (P < .0001 ). Parallel to this, although still below ideal levels, we identified a significant improvement in the incidence of CRI during the posteducation period (P = .004). The rate was low for the first 3 months of this period but increased 2.08 times after the third month. In conclusion, regular training for the residents in charge of inserting intravascular catheters and the nurses and interns who maintain the catheters is highly effective in reducing the rate of CRI in large teaching hospitals.

REVERSIBLE CLINICAL AND MAGNETIC RESONANCE IMAGING FINDINGS IN LATE-ONSET COBALAMIN C DEFECT

Cobalamin C (Cbl C) disease is an inborn error of intracellular cobalamin metabolism. Two distinct clinical types are defined according to the age of onset. We describe an 8 year old girl with late-onset Cbl C disease presenting with neuropsychiatric symptoms. Mutation analysis revealed homozygous c.394C>T (p.R132X) mutation in the MMACHC gene. Serial magnetic resonance imaging (MRI) before and after the treatment are provided. MRI of the brain before treatment showed bilateral patchy focal hyperintensities in the white matter and cortical atrophy. After treatment with intramuscular hydroxycobalamin, oral folinic acid, oral betaine, normalization of MRI findings can be achieved in addition to clinical improvement. We present this case to draw attention to the reversibility of clinical and MRI findings in the late onset Cbl C disease after treatment.

A rare mutation in EIF2B4 gene in an epileptic child with vanishing white matter disease: a case report

A 12-month old boy presented with intractable seizures present since 3-month of age. He had, previously, been admitted numerous times to the pediatric emergency room for intractable and prolonged seizures during the course of his disease. Differential diagnosis was made to exclude several inborn metabolic disorders, including vitamin B6 deficiency, biotinidase deficiency and nonketotic hyperglycinemia. Although the initial brain MRI revealed a mild cerebral and cerebellar white matter involvement, follow-up images showed diffuse cerebral and cerebellar white matter dysmyelination, progressive rarefaction and cystic degeneration. A genetic analysis was performed for vanishing white matter (VWM) disease and a homozygote c. 1091G>A mutation was detected at the EIF2B4 gene. This case emphasizes the fact that VWM disease may present with refractory seizures since early infancy.

Low prevalence of growth hormone deficiency in Turkish patients with Hashimoto's thyroiditis

BACKGROUND

Hashimoto's Thyroiditis (HT) is frequently isolated, but may also be associated with other autoimmune disorders. Autoimmune hypophysitis can result in growth hormone deficiency (GHD). Various prevalences of GHD have been reported in HT in several different ethnic populations.

AIM

The aim of this study was assessing the prevalence of GHD in Turkish population with HT.

MATERIALS AND METHODS

Two hundred twenty-seven (208 females and 19 males, mean age 40.1 ± 10.8 years, range 18-64 years) patients with euthyroid HT were included.

RESULTS

All patients were euthyroid with or without T4 treatment (median TSH 2.2 mIU/L, range 0.2-4.2 mIU/L; median FT4 15.6 pmol/L, range 12-22 pmol/L; and median FT3 4.5 pmol/L, range 3.0-6.2 pmol/L), and median TPO-Ab was 817 IU/mL (range 63 to >3,000). One hundred and thirty-six of them were using medications including L-thyroxine (59.9 %). Insulin-like growth factor-I (IGF-I) levels of 210 patients (92.5 %) were normal. Glucagon stimulation testing in 17 subjects revealed GHD (peak <3 mcg/L) in two subjects. We then performed insulin tolerance test (ITT) to both of them as the gold standard confirmatory test. One patient had no GH response to ITT, either. Our data reveal the prevalence of GHD (based on low IGF-I and ITT result) in this particular group of Turkish HT patients as 0.4 %.

CONCLUSION

We conclude that the isolated GHD is rarely observed in HT in our population. The prevalence of GHD is 0.4 % in this particular group of Turkish HT patients suggesting that routine investigation of GHD is not mandatory.

Effect of epidermal growth factor receptor status on the outcomes of patients with metastatic gastric cancer: A pilot study

The expression of epidermal growth factor receptor (EGFR) has been linked to clinical outcome in several solid tumors. However, the clinical significance of EGFR (c-erbB1) in gastric cancer remains unclear. The present study was designed to detect the clinical implications of EGFR in the Turkish population. Paraffin-embedded tissue microarrays containing gastric cancer tissue were obtained from 30 patients. EGFR expression was detected using immunohistochemistry. The correlation of this biomarker to the clinicopathological features and survival of patients with gastric cancer was studied. The overall positivity rate of EGFR was 63.3%. EGFR expression was significantly correlated with an improved progression-free survival (PFS) and overall survival (OS) rate (P=0.039 and 0.01, respectively). EGFR expression is a good prognostic marker for patients with gastric cancer.

Effect of exercise on appetite-regulating hormones in overweight women

Over the past decade, our knowledge of how homeostatic systems regulate food intake and body weight has increased with the discovery of circulating peptides such as leptin, acyl ghrelin, des-acyl ghrelin and obestatin. These hormones regulate the appetite and food intake by sending signals to the brain regarding the body's nutritional status. The purpose of this study was to investigate the response of appetite-regulating hormones to exercise. Nine overweight women undertook two 2 h trials in a randomized crossover design. In the exercise trial, subjects ran for 60 min at 50% of maximal oxygen uptake followed by a 60 min rest period. In the control trial, subjects rested for 2 h. Obestatin, acyl ghrelin, des-acyl ghrelin and leptin concentrations were measured at baseline and at 20, 40, 60, 90 and 120 min after baseline. A two-way ANOVA revealed a significant (P < 0.05) interaction effect for leptin and acyl ghrelin. However, changes in obestatin and des-acyl ghrelin concentration were statistically insignificant (P > 0.05). The data indicated that although acute treadmill exercise resulted in a significant change in acyl ghrelin and leptin levels, it had no effect on plasma obestatin and des-acyl ghrelin levels.

Safety and tolerability of first-line bevacizumab in metastatic colorectal cancer

PURPOSE

To determine the clinical features of bevacizumab-associated toxicities in metastatic colorectal cancer (MCRC) patients.

METHODS

The medical records of 60 patients with MCRC who were treated with chemotherapy including bevacizumab in the first-line setting were retrospectively evaluated.

RESULTS

Bevacizumab was administered along with irinotecan plus 5-fluorouracil7sol;leucovorin (5-FU/LV) to 44 patients, 57horbar;FU7sol;LV+oxaliplatin to 8 patients, capecitabine+oxaliplatin to 6 patients and 5-FU/LV to 2 patients. The total number of the cycles received was 381 (median 6, range 17horbar;13). The most common bevacizumab-related toxicity was grade 1-2 bleeding (28%) followed by hypertension (17%). Grade 1-2 proteinuria was seen in 8% of the patients (no grade 3-4 proteinuria). Arterial thromboembolic events (ATE) were not observed, however 3 patients (5%) had experienced grade 3-4 venous thromboembolic events. In 3 patients (5%) grade 1-2 wound complications were seen (delayed wound healing in the place of the venous access device in 2, and wound infection in 1). In addition, gastrointestinal perforation (GIP) was seen in 3 (5%) patients. Two of the patients were treated by surgical intervention and one patient died of sepsis.

CONCLUSION

Bevacizumab is well tolerated when combined with various chemotherapy regimens. As bevacizumab is becoming widely used in the routine oncology practice, further studies which investigate the mechanism of bevacizumab-associated toxicities are warranted to develop effective management strategies for these adverse events.

N-acetylaspartate concentration in corpus callosum is positively correlated with intelligence in adolescents

The corpus callosum is the largest white matter bundle in the brain and integrates inter-hemispheric cortices during sensory-motor and high-order cognitive processes. The aim of the present study was to investigate the associations between the metabolite concentrations in the corpus callosum and intelligence among adolescents. Thirty male adolescents aged between 14 and 16 years were included into the study. We measured the intelligence quotient (IQ) scores of the subjects by using the Wechsler Intelligence Scale for Children-Revised (verbal, performance and full-scale IQ) test. We used proton MR spectroscopy to measure the absolute concentrations of N-acetylasparate (NAA), creatine (Cr) and choline (Cho) in the genu, midbody and isthmus/splenium regions of the corpus callosum. We also measured the whole brain parenchymal size and used it as a confounding factor in the statistical analyses. We assessed the correlations between neurometabolite concentrations and verbal, performance and full-scale IQ scores. We found a significant positive correlation between the whole brain parenchymal size and the full-scale IQ scores. And, the NAA concentration in the isthmus/splenium region was positively correlated with the performance IQ and full-scale IQ scores. NAA is a marker of neuro/axonal integrity. NAA concentration in white matter is related to the structural and functional integrity of axonal fibers. The positive correlation of the IQ scores with the NAA concentrations in the isthmus/splenium region indicates that more efficient inter-hemispheric data transfer between parieto-occipital cortices may enhance intellectual performance.

MRS findings in electrical status epilepticus in sleep: Report of two cases

Background

To evaluate the changes in brain metabolites by H1 magnetic resonance spectroscopy in two patients with electrical status epilepticus.

Case Description

Two boys (aged 6 and 7 years) with electrical status epilepticus in sleep have been evaluated. N-acetyl aspartate levels were slightly elevated, and showed no decline in the postictal period. Creatine and choline levels were similar to that in controls. No evidence of neuronal cell damage was seen.

Conclusion

Electrical status epilepticus is a balanced condition of hypermetabolism, when not accompanied with seizure.