[Magnetic resonance vessel wall imaging reveals rupture site in subarachnoid hemorrhage with multiple cerebral aneurysms]

We report a case of subarachnoid hemorrhage(SAH)with multiple cerebral aneurysms, in which magnetic resonance vessel wall imaging(MR-VWI)revealed the rupture site. A 68-year-old woman presented with SAH. Computed tomography(CT)showed diffuse SAH(Fisher group 3). 3D-CT angiography revealed two intracranial aneurysms:a 4.2-mm anterior communicating artery aneurysm(Acom An)and a 5.8-mm basilar tip aneurysm(BAtip An). As the BAtip An was the larger of the two, it was deemed the most likely site of rupture;however, high-resolution MR-VWI with gadolinium showed thick wall enhancement in the Acom An and no enhancement in the BAtip An. Thus, we performed a craniotomy for the Acom An. Intraoperative findings confirmed the rupture site at the Acom An. We concluded that high resolution MR-VWI may be useful for identifying the rupture site in patients with spontaneous SAH and multiple cerebral aneurysms.

A case of Langerhans cell histiocytosis of the skull in which preoperative methionine positron emission tomography was useful in comprehending the spreading of the lesion

BACKGROUND

The problem with treatments against skull lesions of Langerhans cell histiocytosis (LCH) is that invasions often reach the bones and dura mater, making it difficult to accurately comprehend the range thereof prior to surgery. We herein report that (11)C-methionine positron emission tomography (PET) (Met-PET) carried out prior to surgery was useful in comprehending the spreading of the lesion.

CASE DESCRIPTION

A 20-year-old female presented with swelling and dull pain on the left side of the head. A slightly heterogeneously reinforced tumor was observed inside the bone defect in the gadolinium-enhanced T1-wighted image upon magnetic resonance imaging (MRI) and the dura mater contacting the tumor was observed with an enhancing effect. Accumulation was poor in the center of the tumor upon Met-PET, and accumulation with a well-defined border was observed in the border thereof as well as the area adjacent to the brain. Surgical resection was performed; the pathological diagnosis was LCH. An invasion of tumor cells was observed in the dura mater with accumulation observed according to Met-PET. Moreover, the accumulation of tumor cells was observed in the area observed with accumulation inside the bone; however, the center part with poor accumulation lacked tumor cells, with fibrous tissue accounting for most parts.

CONCLUSION

Met-PET was believed to be helpful in comprehending the spreading of the tumor in the surroundings of the brain surface for skull lesions.

Bilateral carotid and vertebral rete mirabile presenting with subarachnoid hemorrhage caused by the rupture of spinal artery aneurysm

Rete mirabile (or carotid rete) is a normal structure that plays physiological roles in the lower mammals. However, the rete does not exist in the normal carotid circulation of humans. Carotid rete mirabile (CRM) is a rare condition compensating for congenital dysplastic internal carotid artery. Arterial plexus at the cavernous region, which supplies intradural internal carotid artery instead of the aplastic cavernous portion of internal carotid artery, looks like the "rete mirabile" seen in the lower mammals, and is a characteristic angiographical finding of CRM. In addition to the CRM, existence of segmental occlusion and tortuous collaterals of vertebral artery, so-called carotid and vertebral rete mirabile (CVRM), is a very rare condition. We report a 70-year-old female patient with bilateral CVRM presenting with subarachnoid hemorrhage (SAH) caused by the rupture of a cervical spinal artery aneurysm. Our patient is the oldest, compared with the previously reported four patients with CVRM. Moreover, this is the first report of ruptured spinal artery aneurysm as a cause of SAH associated with CRM/CVRM. To avoid rebleeding in the patient, we successfully treated the patients by performing coil embolization of the remaining spinal aneurysms. In patients with CVRM, aneurysm formation of the cervical spinal artery may be a reasonable consequence because of the hemodynamic stress on the spinal artery as a collateral pathway. Detailed evaluation of the cervical spinal arteries should be performed to detect or to rule out ruptured aneurysm in patients with SAH associated with CVRM.

Prospective randomised comparative study of visual foam sclerotherapy alone or in combination with ultrasound-guided foam sclerotherapy for treatment of superficial venous insufficiency: preliminary report

OBJECTIVE

The aim of the study is to compare ultrasound-guided foam sclerotherapy (UGFS: injection of foam sclerosant under ultrasound guidance) of the great saphenous vein (GSV) combined with visual foam sclerotherapy (VFS: injection of foam sclerosant under visual control) for varicose tributary veins and VFS alone in the treatment of GSV reflux.

DESIGN AND METHODS

A total of 133 limbs in 97 patients with GSV reflux were randomised to receive either VFS alone or VFS combined with UGFS. In both groups, 1% polidocanol foam was used. Assessments included duplex ultrasonography, evaluation of Venous Clinical Severity Scores (VCSS) and CEAP (clinical, etiologic, anatomic, and pathophysiologic) scores. Ultrasonographic inspection of the foam in the GSV was carried out during 5 min before compression was applied. The primary 'end' point of the study was obliteration of the GSV at 6 months.

RESULTS

A total of 51 limbs in 48 patients were treated with UGFS + VFS and the remaining 52 limbs in 49 patients were treated with VFS alone. There were no significant inter-group differences in patient age, male: female ratio, height, weight, body mass index, CEAP clinical scores or VCSS. The GSV diameter was 6.0 ± 1.7 mm (median ± interquartile range) in the UGFS + VFS group and 5.7 ± 1.6 mm in the VFS group (p = 0.419). The mean injected volume of foam for varicose tributary veins was 4 ± 2 ml in the UGFS + VFS group and 6 ± 2 ml in the VFS group, a significantly higher amount of foam being used in the latter (p < 0.001). However, the mean total amount of foam was greater in limbs treated with UFGS + VFS than in those treated with VFS alone (p = 0.017). Ultrasonographic inspection revealed complete vasospasm of the GSV in 37 (72.5%) limbs in the UGFS + VFS group and 29 (55.8%) in the VFS group during sclerotherapy (p = 0.097). At 6-month follow-up, complete occlusion was found in 23 limbs (45.1%) treated with UGFS + VFS and in 22 limbs (42.3%) treated with VFS. The difference between the two groups was not significant (p = 0.775). Reflux was absent in 30 limbs (58.8%) treated with UGFS + VFS and in 37 (71.2%) treated with VFS (p = 0.190). There was no inter-group difference in post-treatment VCSS (p = 0.223).

CONCLUSIONS

These results show that UGFS + VFS and VFS are equally effective for the treatment of GSV reflux, despite the lower volume of foam used for VFS alone.

Foam sclerotherapy for spouting haemorrhage in patients with varicose veins

The bleeding from various veins can be intense and may be mistaken for arterial haemorrhage. Several fatal cases are reported due to delay of treatment and inappropriate first aid. We describe five cases of haemorrhage from varicose veins that were treated with foam sclerotherapy. Polidocanol foam was injected in the various veins using ultrasound guidance. There was no recurrence of haemorrhage in any patient during the 17.4 months follow-up period. Foam sclerotherapy can be performed easily in an out-patient clinic setting. This method is an ideal therapy for haemorrhage from varicose veins because it mitigates problematic varicose veins.

Prognostic impact of calf muscle near-infrared spectroscopy in patients with a first episode of deep vein thrombosis

BACKGROUND

The risk factors that affect the development of post-thrombotic syndrome (PTS) are not fully recognized, and it is difficult to reliably predict which patients are likely to develop PTS in acute phase of deep vein thrombosis (DVT).

AIMS

To investigate changes in calf muscle deoxygenated hemoglobin (HHb) levels after DVT, and to determine the indicative parameters reflecting the progression of PTS.

METHODS

Seventy-six consecutive patients with a first episode of unilateral DVT were prospectively enrolled. Clinical manifestations were categorized according to the CEAP (Clinical, Etiologic, Anatomical, and Pathophysiologic) classification, and the patients were divided into no-PTS (C(0-3)E(s),A(s,d,p),P(r,o)) and PTS (C(4-6)E(s),A(s,d,p),P(r,o)) groups. Near-infrared spectroscopy (NIRS) was used to measure calf muscle HHb levels at 6 months after diagnosis of DVT. The calf venous blood filling index (HHbFI) was calculated on standing, and the venous ejection index and the venous retention index (HHbRI) were then obtained after exercise. All patients were followed up for more than 24 months after the diagnosis of DVT.

RESULTS

Of 76 patients evaluated, 20 (26.3%) had PTS. The NIRS-derived HHbFI and HHbRI were significantly increased in patients who developed PTS in comparison with those who did not (P = 0.04 and P = 0.0001, respectively). HHbRI was significantly increased in patients with iliofemoral DVT in comparison with patients with calf DVT (P = 0.041). An optimal cut-off point of 2.9 for HHbRI showed the strongest ability to predict the development of PTS, with a sensitivity of 100% and a specificity of 82.1%.

CONCLUSIONS

HHbRI as measured by NIRS is significantly increased in patients with iliofemoral DVT as compared with those with calf DVT. Furthermore, HHbRI > 2.9 is a strong predictor of the development of PTS at 6 months.

Successful management of giant ischial decubitus ulcers complicated with urethral disorder

SUMMARY

We report a case of bilateral ischial pressure sores complicated with urethral fistula, caused by previous complete ischiectomy. Successful reconstruction was achieved after closure of the bladder neck. The large defect in the bilateral ischium and perineum was covered simultaneously with a free total plantar flap. The paucity of suitable recipient vessels for microvascular anastomoses was resolved by the creation of an arteriovenous loop, when the closure of bladder neck was performed in a supine position.

Great saphenous vein sparing surgery by angioscopic valvuloplasty combined with axial transposition of a competent tributary vein--5-year follow-up

OBJECTIVE

To evaluate the efficacy and haemodynamic effects of great saphenous vein (GSV) sparing surgery--valvuloplasty combined with axial transposition of a competent tributary vein (A-VACT).

MATERIALS AND METHODS

Eighty-five limbs in 74 patients with isolated GSV incompetence were selected for GSV sparing surgery. After angiographic valvuloplasty, the competent tributary vein was exposed and cut 1.5 cm distal to its insertion point on the GSV. The transected vein was anastomosed end-to-side to the GSV, which was ligated between the tributary insertion site and the anastomosis. Venous valve competence were screened by serial postoperative duplex examination, and venous haemodynamic changes were analyzed using venous filling index (VFI) measured by air plethysmograph pre- and postoperatively. The follow-up period was 5-years.

RESULTS

Sixty-seven patients were included in whom 76 limbs were treated. There was a statistically significant reduction in the vein diameter at the SFJ after 5-years (0.83 S.D. 0.29 cm to 0.46 S.D. 0.12 cm, p=0.0002, Wilcoxon). Similarly, significant reduction was found in the GSV at the 5-year follow-up point (0.63 S.D. 0.19 cm to 0.39 S.D. 0.11 cm, p<0.0001, Wilcoxon). On the other hand, there was significant increase in the diameter of the competent tributary vein postoperatively (0.22 S.D. 0.13 cm to 0.31 S.D. 0.12 cm, p<0.0001, Wilcoxon). Duplex scanning demonstrated reflux at the SFJ in 12 limbs (16%). Similarly, in the GSV, venous reflux was found in 13 limbs (17%). Reflux in the transposed tributary vein was found in 20 limbs (26%). But only 7 limbs (9%) had minor varicose veins' recurrence. VFI remained normal during the follow-up examination. The preoperative VFI confirmed the presence of venous reflux, but there were significant improvement in the VFI values at all postoperative examinations.

CONCLUSIONS

A-VACT procedure improves venous function, resolves varicose veins at 5-years follow-up as well as preserving the GSV for future grafting.

Presence of lower limb deep vein thrombosis and prognosis in patients with symptomatic pulmonary embolism: preliminary report

OBJECTIVES

To investigate the presence of lower limb deep vein thrombosis (DVT) and prognosis in patients with symptomatic pulmonary embolism (PE).

MATERIALS AND METHODS

A total of 203 consecutive referral patients with PE were included. The distribution of DVT was evaluated with compression ultrasound (CUS), and all patients were then followed for 12 months for investigation of recurrence of venous thromboembolism (VTE) and fatal events as adverse outcome.

RESULTS

The mean age of the patients was 62.8 years, and 78 (38.4%) were males. DVT was found in 118 (58.1%) patients. Of these patients, 61 (30.0%) had proximal DVT. Multivariate analysis demonstrated that active cancer, inadequate anticoagulation, leg symptoms, male gender, presence of DVT, presence of proximal DVT, and previous DVT were independent risk factors for adverse outcome. A clinical risk score ranging from 0 to 10 points was generated on the basis of multivariate regression coefficients. Receiver operating characteristic curve analysis showed that an appropriate cut-off point for discriminating between the presence and the absence of an adverse event was 4. Using this category, 166 (81.8%) patients were classified as low risk and 37 (18.2%) as high risk for adverse outcome. The adverse event rates were 6.0% for the low-risk group and 59.5% for the high-risk group.

CONCLUSIONS

This study has confirmed the clinical significance of surveillance CUS in patients with a first episode of PE. Furthermore, a simple risk score on the basis of available variables can identify patients at risk of an adverse outcome in patients with PE.

High peak reflux velocity in the proximal deep veins is a strong predictor of advanced post-thrombotic sequelae

BACKGROUND

The presence of reflux in the femoral vein (FV) and popliteal vein (POPV) after acute deep vein thrombosis (DVT) is considered to contribute to the development of advanced post-thrombotic syndrome (PTS). However, a quantification of reflux has yet to be determined. The purpose of study was to determine the indicative parameters reflecting the progression of PTS.

METHODS

Venous abnormalities were evaluated in 131 limbs out of 130 patients who completed a six-year follow-up after an acute DVT. Clinical manifestations were categorized according to the clinical, etiologic, anatomic, and pathophysiologic (CEAP) classification, and the patients were divided into two groups at a six-year follow-up point: group I, C(0-3)E(s),A(s,d,p),P(r,o), early chronic venous insufficiency (CVI); group II, C(4-6)E(s),A(s,d,p),P(r,o), advanced CVI. Venous segments were examined whether they were occluded or recanalized. The reflux parameters assessed were the diameter (cm), the reflux time (RT; s), the peak reflux velocity (PRV; cm s(-1)), and total refluxed volume, and these parameters were assessed especially in the FV and POPV at the two-year (early phase) and subsequent six-year (late phase) follow-up points after DVT.

RESULTS

There were 98 limbs in group I and 33 in group II. The frequency of venous reflux was significantly higher in group II (<0.0001). In contrast, the proportion of occlusion did not differ between the groups (P = 0.138). The proportions of FV and POPV incompetence were significantly higher in group II (P < 0.0001 and P < 0.0001, respectively). In these veins, the RT did not improve the discrimination power between the two groups. In contrast, the PRV had significant discrimination power in these veins at both the two- and six-year follow-up points. In the superficial venous system, there were no significant differences in any of the determined parameters between the groups. In group II, 19 patients (58%), who had early symptoms of CVI at the two-year follow-up point, subsequently developed advanced symptoms of PTS. After calculating a suitable cutoff point using receiver operating characteristic curves analysis at the two-year follow-up point, multivariable analysis showed that a PRV of >25.4 cm s(-1) in the POPV was the strongest independent predictor of advanced CVI [odds ratio (OR) 60.32; 95% confidence interval (95CI) 43.1-1238.97, P < 0.0001]. Similarly, in the FV, a PRV of >24.5 cm s(-1) was found to be a strong predictor of advanced CVI (OR 25.77, 95CI 10.56-331.12, P < 0.0001).

CONCLUSIONS

These findings suggest that the presence of a high PRV in the proximal deep veins is an independent predictor of advanced symptoms of PTS.

Comparison of Manual Compression Release with Distal Pneumatic Cuff Maneuver in the Ultrasonic Evaluation of Superficial Venous Insufficiency

BACKGROUND

Venous reflux can be elicited either manually or by pneumatic tourniquet, and previous studies did not indicate any significant difference between these manoeuvres in patients with superficial venous insufficiency (SVI).

PURPOSE

To investigate if two methods correlate in patients with CVI.

MATERIALS AND METHODS

Venous reflux was studied in 94 venous segments of 57 limbs in 52 consecutive patients with SVI. Limbs were divided into two groups: group I (CEAP C2-C3) and group II (CEAP C4-C6). A colour duplex scanner was used to determine quantitative venous reflux at the sapheno-femoral junction (SFJ), at the sapheno-popliteal junction (SPJ), and in the greater saphenous vein in the thigh (GSV). Patients received both manual compression and cuff deflation method in eliciting venous reflux. The parameters assessed were the duration of reflux (second) and the peak reflux velocity (cm/s).

STATISTICS

Paired t-test was used to evaluate differences between the two methods. Statistical significance was recorded when the p-value was <0.05. Bland and Altman plot was also used to assess the agreement of the same measurement.

RESULTS

There were 58 venous segments in group I and 36 in group II. In group I, there were no significant differences in the duration of reflux at the SFJ, SPJ, and in the GSV. On the contrary, peak reflux velocity was found to be significantly higher at the SFJ and in the GSV (p=0.022 and 0.006, respectively). In group II, there was no significant difference in the duration of reflux at the SFJ and SPJ between the two methods. On the contrary, manual compression maneuver produced significantly higher peak reflux velocity than at the SFJ and in the GSV (p=0.023 and 0.002, respectively). Bland and Altman plot analysis, manual compression method displayed a relatively good agreement with cuff deflation manoeuvre both in group I and group II. In contrast, concerning the peak reflux velocity, relative wide limits of agreement were found between the two methods.

CONCLUSIONS

Unlike previously published reports, our results lead to apparent discrepancies in the quantitative evaluation of venous reflux using different methodology.

The utility of quantitative calf muscle near-infrared spectroscopy in the follow-up of acute deep vein thrombosis

BACKGROUND

To investigate patterns of venous insufficiency and changes in calf muscle deoxygenated hemoglobin (HHb) levels after an acute deep vein thrombosis (DVT).

METHODS

A total of 78 limbs with an acute DVT involving 156 anatomic segments were evaluated with duplex scanning and near-infrared spectroscopy (NIRS) at 1, 3, 6 and 12 months. Venous segments were examined whether they were occluded, partially recanalized, and totally recanalized, and the development of venous reflux was noted. The NIRS was used to measure calf muscle HHb levels. Calf venous blood filling index (HHbFI) was calculated on standing, then the calf venous ejection index (HHbEI), and the venous retention index (HHbRI) were obtained after exercise.

RESULTS

The segments investigated were the common femoral vein (CFV; 38 segments), femoral vein (FV; 37), popliteal vein (POPV; 44), and calf veins (CV; 37). At 1 year, thrombi had fully resolved in 67% of the segments, 27% remained partially recanalized, 6% were occluded. The venous occlusion was predominant in the FV (24%) at 1 year. On the contrary, rapid recanalization was obtained in CV than proximal veins at each examination (P < 0.01). Venous reflux was predominant in POPV (55%), followed by FV (19%), and no reflux was found in CV. At 1 year, the HHbFI in POPV reflux patients was significantly higher than those with resolution (0.19 +/- 0.14, 0.11 +/- 0.05 microm s, P = 0.009, respectively). Similarly, there was a significant difference in the HHbRI between the two groups (3.08 +/- 1.91, 1.42 +/- 1.56, P = 0.002, respectively). In patients with FV occlusion, the value of HHbRI was significantly higher than those with complete resolution (2.59 +/- 1.50, 1.42 +/- 1.56, P = 0.011, respectively).

CONCLUSIONS

The lower extremity venous segments show different proportions of occlusion, partial recanalization, and total recanalization. The CV shows more rapid recanalization than proximal veins. The NIRS-derived HHbFI and HHbRI could be promising parameters as the overall venous function in the follow-up of acute DVT. These findings might be very helpful for physician in detecting patients who require much longer follow-up studies.

Cerebellar glioblastoma genetically defined as a secondary one

We report here the case of a 29-year-old woman with cerebellar glioblastma. In the present case, tumor lesions were observed in each cerebellar hemisphere. The left-side lesion was diagnosed as glioblastoma, and the right-side lesion as malignant astrocytoma by histopathology. Immunohistochemistry revealed that the tumor cells of the left-side lesion was positive for p53, whereas epidermal growth factor receptors (EGFR) were negative in tumor cells from both sides. Genetic alterations were investigated using a genome DNA microarray (GenoSensor Array 300), which has led us to define this tumor as a secondary glioblastoma. The clinical presentation and genetic findings of this relatively rare entity are discussed.

Vertical-torsional oscillations and dissociated bilateral horizontal gaze palsy in a patient with a pontine cavernous angioma

We report the case of a 16 year old girl with vertical-torsional oscillations. She had a 4 year history of bilateral horizontal gaze palsy caused by a cavernous angioma in the medial part of the dorsal pons. She presented with vertical oscillopsia that had worsened during the past 3 months. Unilateral three dimensional eye movements and bilateral horizontal eye movements were recorded using a magnetic search coil method and direct current electro-oculography, respectively. She had vertical-torsional oscillations (average frequency: 3.0 Hz) leaving vertical saccades and pursuits intact. The average amplitudes of the vertical and torsional components were 2.0 degrees and 0.6 degrees , respectively. Her horizontal rapid eye movements were severely impaired; however, her horizontal pursuits and slow phases of vestibulo-ocular reflex were only partially impaired (gain<0.3, oculomotor range<+/-9 degrees ). Convergence and divergence were intact. Lesions involving the medial part of the dorsal pons and bilateral paramedian pontine reticular formation can induce vertical and torsional oscillations without disruption of vertical rapid eye movements.