The impact of M-component type and immunoglobulin concentration on the risk of malignant transformation in patients with monoclonal gammopathy of undetermined significance

BACKGROUND AND OBJECTIVES

In this study the impact of gender, age, type of M-component and concentration of immunoglobulins on the risk of malignant transformation in monoclonal gammopathy of undetermined significance (MGUS) was assessed.

DESIGN AND METHODS

We identified 1,247 cases of MGUS in the period 1978 to 1993 in North Jutland County, Denmark. Data on cancer occurrence in the MGUS cohort were obtained from the Danish Cancer Registry. The expected numbers of incident cancer cases were calculated from age-, sex-, county-, and period-specific cancer incidence rates. The impact of the variables mentioned above on the risk of malignant transformation was analyzed in Poisson regression models.

RESULTS

The relative risk of IgA compared to IgG was 1.8 (95% confidence interval, 1.1-3.0), while the relative risk of IgM compared to IgG was 1.1 (0.7-1.9). For all three types of MGUS, the risk of malignant transformation was higher among females than among males, and the risk increased with increasing concentration of immunoglobulin with very high risks for the patients with the highest levels of immunoglobulin. Hypogammaglobulinemia was associated with malignant transformation in patients with IgG type MGUS. For IgG and IgM MGUS, the risk decreased with increasing age and with follow-up beyond one year.

INTERPRETATION AND CONCLUSIONS

Female sex, IgA M-component type and high concentration of the immunoglobulin comprising the M-component were associated with a high risk of malignant transformation. Hypogammaglobulinemia, young age at diagnosis and short follow-up were risk factors in particular for those with IgG MGUS.

[Intravenous thrombolytic treatment of acute basilar artery occlusion]

BACKGROUND

Acute stroke with basilar artery occlusion is a serious condition with high mortality and severe disability.

MATERIAL AND METHODS

We describe three patients with acute artery basilar occlusion treated with thrombolytic agent given intravenously.

RESULTS

One patient demonstrated early and considerable clinical improvement parallel to thrombolytic therapy started two and a half hour after ictus, but suffered a new occlusion and died in a "locked-in syndrome". One patient demonstrated moderate clinical improvement after less than six hours and survived with disability. One patient demonstrated no clinical improvement with thrombolytic therapy started six hours after ictus and later died of an injured brainstem. No patients had serious bleeding.

INTERPRETATION

Intravenous, systemic thrombolytic treatment may have a beneficial effect in acute basilar occlusion.

[Early CT changes in acute cerebral infarction]

BACKGROUND

The aim of this study was to evaluate neurological clinical findings and cerebral computed tomography (CT) findings in patients with acute stroke within six hours after stroke onset.

MATERIAL AND METHODS

42 patients with presumed stroke in the middle cerebral artery territory were clinically assessed with the Scandinavian Stroke Scale Score. CT scans were assessed in a standardized manner by one neuroradiologist.

RESULTS

The clinical deficit did not forecast the CT findings. Patients with several early CT signs of ischaemia, and especially those with hypodensity in less than one third of the middle cerebral artery area had lower clinical scores than patients with fewer signs. Hypodensity in the insular region was the overall most frequent finding.

INTERPRETATION

Clinical findings do not give definite information about the ischaemic damage in the acute phase of cerebral infarction. CT scans may give valuable information primarily when there are positive findings.

[Early CT signs in acute cerebral ischemia]

BACKGROUND

Patients who suffer from acute stroke should be examined with computed tomography (CT) of the brain immediately after admission. If evaluated systematically, this examination may give more information than just "bleeding excluded".

MATERIAL AND METHODS

CT scans of the brain in four patients with acute ischaemic stroke admitted to our department illustrate the typical early CT signs in acute cerebral ischaemia.

RESULTS

This article describes the systematic evaluation of a CT in acute stroke, when the following questions need to be answered: Is there a hyperdense middle cerebral artery sign (HMCAS), or hypodensity in other major intracranial arteries? Is there a hypodensity in the basal ganglia? Is there hypodensity (loss of cortical-subcortical discrimination) or oedema (decreasing volume of the Sylvian fissure) in the insular region? Is there hypodensity (loss of cortical-subcortical discrimination) or oedema (effacement of sulci or compression of ventricles) in other parts of the distribution of the middle cerebral artery or other arteries?

INTERPRETATION

An early CT in acute stroke patients may yield valuable information if evaluated properly. The presence or absence of early CT sign have implications for diagnosis, prognosis, choice of supplementary examinations, and choice of treatment.

[Dolichoectasia of the intracranial arteries and stroke]

Intracranial arterial dolichoectasia is a condition related to stroke. The prevalence in patients suffering from their first cerebral infarction is estimated to be 3%. Patients with dolichoectasia are more likely to have lacunar infarctions than those without. They have a higher survival rate and better functional prognosis after first cerebral infarction, but a higher rate of stroke recurrence. The aetiology and pathogenesis of the condition is unknown. Only 0.5% of patients suffering a first cerebral infarction have dolichoectasia of both the carotid and vertebrobasilar system. We describe a case of atypical dolichoectasia affecting both circulatory systems as well as the middle and anterior cerebral arteries, with intracerebral haemorrhage.

[Thrombolytic therapy in acute cerebral infarction--a time study when organizing a new therapeutic option]

Cerebral thrombolysis is a therapeutic option for patients with acute cerebral infarction, but its use can be limited by delayed hospital admission. The aim of this study was to examine this delay, to improve admission routines and thus increase the number of potential candidates for treatment. In the first part of the study, time from first symptoms until hospital admission (time from first symptoms to contact with the primary health care system, and from contact to admission) was registered for 100 patients with acute stroke. Time spent to cerebral CT scan, and within the hospital was also registered. Measures to shorten admission time were then instituted, including information to the public and to primary health care professionals. An identical study was then performed on another 124 patients. Referral procedures were significantly improved, whereas time taken for patients to contact the primary health care system remained unchanged. Direct contact by emergency telephone secured the fastest admissions. The number of patients admitted within two hours after stroke onset increased from 17% to 26%. Four patients (3%) were treated with thrombolysis. Our study indicates that improved admission routines reduce admission delay. More public information is necessary to change patient behaviour.

[Stroke. An effective evaluation and specialized treatment]

Stroke is an acute disorder with a high fatality rate and with severe residual impairment among many of the survivors. Advances in neuroimaging and ultrasound have increased our understanding of the disease process. New drugs seem to reduce the neuronal damage caused by brain infarction if they are administered within the first few hours after onset of stroke. Management of stroke patients in a specialised stroke unit hastens recovery and is associated with a sustained reduction in mortality. Both recovery and survival can be jeopardized by cerebral, systemic, and cardiac complications, which may be attenuated by rigorous attention to general medical factors. Treatment of acute stroke will certainly change dramatically in coming years.

Subclavian steal phenomenon. Clinical and hemodynamic aspects

Fifty-eight patients with subclavian artery stenosis were classified as having definite or probable vertebrobasilar symptoms, carotid symptoms or no symptoms. The vertebral artery flow pattern was graded as no subclavian steal (Grade 0), systolic deceleration (Grade 1), alternating flow (Grade 2), or reversed flow (Grade 3). We found a statistically significant association between the occurrence of vertebrobasilar symptoms and the subclavian steal phenomenon Grades 2-3. No significant association could be established between time course, type or severity of symptoms and grade of steal phenomenon. The flow disturbance is probably one causal factor for the occurrence of symptoms. Reversed vertebral artery flow is commonly asymptomatic, however, and other non-identified cofactors must be operative in symptomatic patients.

Bilateral non-traumatic carotid cavernous sinus fistula with spontaneous closure

A case of bilateral spontaneous carotid cavernous sinus fistula is presented. The diagnostic value of Doppler ultrasound examination is discussed, as well as therapeutic measurements, such as manual compression of the carotid artery and embolization treatment. The frequent spontaneous closure of these fistulas is emphasized, and a conservative attitude is recommended.

[Mollaret's meningitis]

Mollarets meningitis is a rare form of recurrent aseptic meningitis where a diagnostic feature is the characteristic cytologic picture in the cerebrospinal fluid. The article presents two cases that were clinically diagnosed as Mollarets meningitis. The cytologic picture of the cerebrospinal fluid is described and the major clinical aspects and the differential diagnoses are discussed briefly.

Cerebral air embolism after transthoracic aspiration with a 0.6 mm (23 gauge) needle

A 54 yr old man experienced weakness in his legs, ataxia and subsequent urinary retention after a percutaneous fine-needle aspiration of a tumor in the right lower lobe. Clinical neurological examination and electroencephalography revealed signs of a brain stem lesion, probably due to an air embolism to the basilar artery. The symptoms and signs gradually disappeared prior to, as well as after, hyperbaric oxygen treatment. We believe this to be the first case of air embolism after transthoracic puncture with a 23 gauge needle to be reported in medical literature.

Cerebral air embolism after transthoracic aspiration with a 0.6 mm (23 gauge) needle

A 54 yr old man experienced weakness in his legs, ataxia and subsequent urinary retention after a percutaneous fine-needle aspiration of a tumor in the right lower lobe. Clinical neurological examination and electroencephalography revealed signs of a brain stem lesion, probably due to an air embolism to the basilar artery. The symptoms and signs gradually disappeared prior to, as well as after, hyperbaric oxygen treatment. We believe this to be the first case of air embolism after transthoracic puncture with a 23 gauge needle to be reported in medical literature.

[Balloon dilatation of subclavian artery stenosis and brachiocephalic trunk stenosis]

We report our initial experiences concerning percutaneous transluminal angioplasty of four subclavian artery stenoses and one innominate artery stenosis in four patients. In two patients the indication for percutaneous transluminal angioplasty was a severe subclavian steal syndrome, in one patient prophylactic treatment together with carotid endarterectomy before coronary bypass surgery, and in one patient a brainstem infarction. Percutaneous transluminal angioplasty resulted in normal vertebral artery blood flow in all patients and in complete relief of symptoms in the two patients with a subclavian steal syndrome. We experienced no cerebrovascular complications and only one minor peripheral complication. During a follow-up period of seven to 18 months there has been no re-occlusion and no sign of increasing subclavian steal phenomenon. We draw the following conclusions: Selection criteria for percutaneous transluminal angioplasty must be very strict. Doppler sonography before percutaneous transluminal angioplasty is necessary to evaluate the haemodynamic effect of subclavian stenosis upon the vertebral arteries. Doppler sonographic monitoring during percutaneous transluminal angioplasty should be a routine. The risk of cerebral complications is low. Gradual normalisation of vertebral blood flow after percutaneous transluminal angioplasty is common. Percutaneous transluminal angioplasty is judged to be a safe and effective treatment for patients suffering from subclavian steal syndrome.