Safety and functionality of transhepatic hemodialysis catheters in chronic hemodialysis patients

PURPOSE

We aimed to investigate the safety and functionality of tunneled transhepatic hemodialysis catheters in chronic hemodialysis patients.

METHODS

Thirty-eight patients (20 women aged 56±10 years and 18 men aged 61±11 years) with transhepatic tunneled hemodialysis catheters were evaluated. The date of the first transhepatic catheterization, indications, procedure details, functional time periods of catheters, reasons for the removal or revision of catheters, catheter-related complications, and current conditions of patients were retrospectively analyzed.

RESULTS

A total of 69 catheters were properly placed in all patients (100% technical success) under imaging guidance during the 91-month follow-up period. The functionality of 35 catheters could not be evaluated: five catheters were removed because of noncomplication related reasons (surgical fistulas were opened in two cases [2/35, 5.7%], transplantation was performed in three cases [3/35, 8.6%]), 18 patients died while their catheters were functional (18/35, 51.4%), and 12 catheters were still functional at the time of the study (12/35, 34.3%). The functionality of catheters was evaluated the remaining 34 catheters that necessitated revision because of complications. Furthermore, only half of the catheters were functional on day 136 when evaluated using Kaplan-Meier analysis. The four main complications were thrombosis (16/34, 47%; complication rate of 0.37 days in 100 catheters), infection (8/34, 23.5%; 0.18 days in 100 catheters), migration (8/34, 23.5%; 0.18 days in 100 catheters), and kinking (2/34, 6%; 0.04 days in 100 catheters).

CONCLUSION

Transhepatic venous catheterization is a safe and functional alternative route in chronic hemodialysis patients without an accessible central venou route. The procedure can be performed with high technical success and low complication rates under imaging guidance.

Effectiveness of percutaneous vertebroplasty in patients with multiple myeloma having vertebral pain

PURPOSE

We aimed to assess the effectiveness, benefits, and reliability of percutaneous vertebroplasty (PV) in patients with vertebral involvement of multiple myeloma.

METHODS

PV procedures performed on 166 vertebrae of 41 patients with multiple myeloma were retrospectively evaluated. Most of our patients were using level 3 (moderate to severe pain) analgesics. Magnetic resonance imaging was performed before the procedure to assess vertebral involvement of multiple myeloma. The following variables were evaluated: affected vertebral levels, loss of vertebral body height, polymethylmethacrylate (PMMA) cement amount applied to the vertebral body during PV, PMMA cement leakages, and pain before and after PV as assessed by a visual analogue scale (VAS).

RESULTS

Median VAS scores of patients decreased from 9 one day before PV, to 6 one day after the procedure, to 3 one week after the procedure, and eventually to 1 three months after the procedure (P < 0.001). During the PV procedure, cement leakage was observed at 68 vertebral levels (41%). The median value of PMMA applied to the vertebral body was 6 mL.

CONCLUSION

Being a minimally invasive and easily performed procedure with low complication rates, PV should be preferred for serious back pain of multiple myeloma patients.

Single-stage endovascular treatment in patients with severe extracranial large vessel stenosis and concomitant ipsilateral unruptured intracranial aneurysm

PURPOSE

We aimed to evaluate the safety and effectiveness of single-stage endovascular treatment in patients with severe extracranial large vessel stenosis and concomitant ipsilateral unruptured intracranial aneurysm.

METHODS

Hospital database was screened for patients who underwent single-stage endovascular treatment between February 2008 and June 2013 and seven patients were identified. The procedures included unilateral carotid artery stenting (CAS) (n=4), bilateral CAS (n=2), and proximal left subclavian artery stenting (n=1) along with ipsilateral intracranial aneurysm treatment (n=7). The mean internal carotid artery stenosis was 81.6% (range, 70%-95%), and the subclavian artery stenosis was 90%. All aneurysms were unruptured. The mean aneurysm diameter was 7.7 mm (range, 5-13 mm). The aneurysms were ipsilateral to the internal carotid artery stenosis (internal carotid artery aneurysm) in five patients, and in the anterior communicating artery in one patient. The patient with subclavian artery stenosis had a fenestration aneurysm in the proximal basilar artery. Stenting of the extracranial large vessel stenosis was performed before aneurysm treatment in all patients. In two patients who underwent bilateral CAS, the contralateral carotid artery stenosis, which had no aneurysm distally, was treated initially.

RESULTS

There were no procedure-related complications or technical failure. The mean clinical follow-up period was 18 months (range, 9-34 months). One patient who underwent unilateral CAS experienced contralateral transient ischemic attack during the clinical follow-up. There was no restenosis on six-month follow-up angiograms, and all aneurysms were adequately occluded.

CONCLUSION

A single-stage procedure appears to be feasible for treatment of patients with severe extracranial large vessel stenosis and concomitant ipsilateral intracranial aneurysm.

Role of Diffusion and Perfusion-Weighted MR Imaging in Differentiating Meningioma from Solitary Dural Metastasis

In some instances conventional imaging techniques fail to differentiate meningiomas from isolated dural metastasis. This study aimed to evaluate the role of diffusion and perfusion-weighted MRI in differentiating meningiomas and dural metastasis. In this study, 14 metastasis and 26 meningiomas were involved. The imaging characteristics were analyzed using conventional MRI. Diffusion-weighted MRI was performed and ADC values were calculated from the solid components and the peritumoral edema. Perfusion-weighted MRI was performed and relative cerebral blood volume (rCBV) was calculated. Student's t test was used for the statistical analysis. Dural metastasis and meningiomas could not be differentiated by qualitative assessment of conventional and diffusion-weighted MRI. The mean intratumoral and peritumoral ADC values were not statistically significant (p > 0.05). The rCBV ratios for dural metastasis and meningiomas were 4.13 ± 2.32 and 7.32 ± 4.10 respectively and the difference between two was statistically significant (p = 0.003). Peritumoral rCBV ratios for dural metastasis and meningiomas were not statistically significant (p > 0.05). Conventional MRI findings of dural metastasis and meningiomas may overlap in some lesions. In differentiation of these lesions diffusion-weighted MRI yields no further information additional to conventional sequences. Perfusion-weighted MRI can be useful to distinguish these lesions by demonstrating high intratumoral rCBV ratios for meningiomas and low rCBV ratios for metastasis.

Multiple variant type thalamic infarcts: pure and combined types

BACKGROUND AND PURPOSE

Variant topographic patterns of thalamic infarction with distinct manifestations have been classified into three territories: anteromedian, central, and posterolateral. The purpose of this study was to determine clinical, etiological, and radiological features of multiple variant thalamic infarcts.

METHODS

We reviewed 8400 patients with a first clinical stroke included in the Ege Stroke Registry between 2000 and 2013. Among 80 patients with an acute multiple thalamic infarcts confirmed by MRI, we selected all patients with lesions outside the classical territories and studied their clinical, etiological, and radiological features.

RESULTS

Among 8400 patients with first-ever stroke in our registry, 21 patients (26% of all multiple thalamic infarcts) showed infarction outside the classical territories, allowing us to delineate three variant distributions; (i) unilateral multiple variant infarcts [seven patients (9%) in the anteromedian, central, and posterolateral territories] presented with predominantly decreased vigilance (66% with right lesions, 75% with left lesions), cognitive impairment including amnesia (71%), aphasia (57%) in left-sided or bilateral lesions, and executive dysfunction (43%). The most frequent stroke mechanism was cardioembolism (43%). (ii) Bilateral multiple variant infarcts [five patients (6%)], with lesions on the variant territories of the thalamus, resulting in a variety of neurological and neuropsychological signs, consciousness disturbances (80%), sensory-motor deficits (80%). Cardioembolism (60%) was the most frequent etiology. (iii) Combined multiple variant and classical infarcts [nine patients (11%)], characterized by hemihypesthesia (89%) as the most frequent manifestation, followed by hemiataxia (78%), and cognitive deficits. Cardioembolism (56%) and large-artery disease of the vertebrobasilar system (33%) were the main stroke mechanisms.

CONCLUSIONS

We described multiple variant topographic patterns of thalamic infarction with distinct manifestations and etiologies. We thought that multiple variant infarcts are the result of variation in thalamic arterial supply or reflect a source of embolism.

The relationship between perimesencephalic subarachnoid hemorrhage and deep venous system drainage pattern and calibrations

BACKGROUND AND PURPOSE

The purpose of this study is to investigate the relationship between Rosenthal basal vein (BVR) type and diameter and perimesencephalic nonaneurysmal subarachnoid hemorrhage (P-SAH).

MATERIALS AND METHODS

Aneurysmal subarachnoid hemorrhage (A-SAH), P-SAH, and control groups were evaluated, and BVRs were classified by type. BVR diameters in patients were measured.

RESULTS

There was a statistically significant difference of BVR drainage types between groups (P=.002). BVR diameters of patients with normal drainage pattern in P-SAH group were significantly smaller than those in both other groups (P<.001).

CONCLUSION

There is a relationship between P-SAH and BVR primitive drainage type. P-SAH risk increases in parallel with decreasing caliber of BVR in patients with normal drainage pattern.

Efficacy of ultrasonography in lymphatic malformations: diagnosis, treatment and follow-up: a case report

Lymphatic malformation (LM) is a localized and rare benign anomaly of the lymphatic system. Surgery is the primary form of treatment, but total resection is difficult and generally not possible. The least invasive and most effective form of treatment is injection sclerotherapy with sclerosing agents. Here, we report a case of LM in a baby, detected at prenatal ultrasound. The aim of this report is to assess the importance of ultrasonography in the prenatal diagnosis, therapy and follow-up of LM's.

Role of duplex power Doppler ultrasound in differentiation between malignant and benign thyroid nodules

Objective

To evaluate the usage of duplex power Doppler ultrasound (PDUS) for the differentiation of benign and malignant thyroid nodules.

Materials and Methods

We prospectively examined 77 thyroid nodules in 60 patients undergoing ultrasound-guided fine needle aspiration biopsy (FNAB). Each nodule was described according to size, inner structure, borders, parenchymal echogenicity, peripheral halo formation, and the presence of calcification (B-mode ultrasound findings). Vascularity as determined by PDUS imaging was defined as non-vascular, peripheral, central, or of mixed type. For each nodule, the pulsatility index (PI) and resistive index (RI) values were obtained. Results of FNAB and surgical pathological examination (if available) were used as a proof of final diagnosis to categorize all nodules as benign or malignant. A receiver operating characteristic (ROC) curve analysis was performed to establish cut-off, sensitivity, and specificity values associated with RI-PI values.

Results

A significant relationship was observed between malignancy and irregular margins, microcalcifications, and hypoechogenicity on ultrasound examination (p < 0.05). The pattern of vascularity as determined by PDUS analysis was not a statistically significant criterion to suggest benign or malignant disease in this study (p > 0.05). The central, peripheral, and mean RI-PI values were higher in malignant nodules when compared to the other cytologies (p < 0.05).

Conclusion

Vascularity is not a useful parameter for distinguishing malignant from benign thyroid nodules. However, RI and PI values are useful in distinguishing malignant from benign thyroid nodules.

Suspicion of cricohyoidopexy line rupture after supracricoid partial laryngectomy and the value of computed tomography to exclude this complication

We presented a 48-year-old man who underwent supracricoid partial laryngectomy with cricohyoidoepiglottopexy. He developed diffuse subcutaneous emphysema and saliva aspiration on the first postoperative day, arousing suspicion of a pexy line rupture. Palpation of the cricohyoid suture line and a lateral cervical X-ray were not helpful. Laryngeal computed tomography (CT) obtained demonstrated an undisturbed cricohyoidoepiglottopexy suture line. Some of the neck sutures were removed, a drain was placed under the neck flap, a tight dressing was applied, and surgical exploration was not necessary. Subcutaneous emphysema regressed in the following days and no other problem was seen. Subcutaneous emphysema was attributed to the air escape from the cricohyoid approximation line. Following supracricoid partial laryngectomy, rupture of the cricohyoidopexy line is a rare but serious complication that needs urgent exploration. Therefore, when there is suspicion, laryngeal CT is very important to rule out this condition. Moreover, a close cooperation is necessary with the radiologist who may not be familiar with disturbed anatomy by previous surgery.

A New Method in the Treatment of Ear Amputation

There have been plenty of reconstruction methods for ear amputation, and replantation preserves its importance. In situations where replantation is not feasible, various methods were proposed. We indicate an alternative technique for the ear amputation without replantation indication. The method of replacing of a vascular structure into the tunnel formed on the posterior side of the amputated ear was used instead of replacing the ear cartilage into a vascular area that was described in the literature of ear prefabrication. The dorsal fascial flaps which were prepared from the back of 10 New Zealand rabbits were placed into the amputated ear. The 2 groups, control and the experimental, were consequently the ear that was adapted as a composite graft and the ear with the flap inserted. The ears were examined macroscopically and photographed on postoperative days 3, 7, 14, and 21. On the 21st day, the nourishment pattern of the ear, the dorsal fascia, and the dorsal fascia adapted ear were investigated with digital subtraction angiography (DSA). The group that received applied dorsal fascia possessed increased vascularity. The viability was evaluated with the biopsies taken from the control group and the group that received applied dorsal fascial flap on the 21st day. The cartilage and the connective tissue were viable in the flap-applied group, whereas there was necrosis in the control group. The reflection of the experimental study was performed on 2 subtotal and 1 total ear amputation cases, with the utilization of the superficial temporal artery. The nourishment of the flaps was evaluated with postoperative photographs, angiography, and bone scintigraphy.

Meningiomas with conventional MRI findings resembling intraaxial tumors: can perfusion-weighted MRI be helpful in differentiation?

INTRODUCTION

To investigate the contribution of perfusion-weighted MRI to the differentiation of meningiomas with atypical conventional MRI findings from intraaxial tumors.

METHODS

We retrospectively analyzed 54 meningiomas, 12 glioblastomas and 13 solitary metastases. We detected 6 meningiomas with atypical features on conventional MRI resembling intraaxial tumors. The regional cerebral blood flow (rCBV) ratios of all tumors were calculated via perfusion-weighted MRI. The signal intensity-time curves were plotted and three different curve patterns were observed. The type 1 curve resembled normal brain parenchyma or the postenhancement part was minimally below the baseline, the type 2 curve was similar to the type 1 curve but with the postenhancement part above the baseline, and the type 3 curve had the postenhancement part below the baseline accompanied by widening of the curve. Student's t-test was used for statistical analysis.

RESULTS

On CBV images meningiomas were hypervascular and the mean rCBV ratio was 10.58+/-2.00. For glioblastomas and metastatic lesions, the rCBV ratios were 5.02+/-1.40 and 4.68+/-1.54, respectively. There was a statistically significant difference in rCBV ratios between meningiomas and glioblastomas and metastases (P<0.001). Only one of the meningiomas displayed a type 2 curve while five showed a type 3 curve. Glioblastomas and metastases displayed either a type 1 or a type 2 curve. None of the meningiomas showed a type 1 curve and none of the glioblastomas or metastases showed a type 3 curve.

CONCLUSION

Differentiating meningiomas with atypical conventional MRI findings from malignant intraaxial tumors can be difficult. Calculation of rCBV ratios and construction of signal intensity-time curves may contribute to the differentiation of meningiomas from intraaxial tumors.

[Effect of different threshold levels and injection rates on hepatic enhancement by using bolus tracking technique in helical CT]

PURPOSE

To evaluate the influence of different injection rates and different threshold levels on hepatic enhancement using the bolus tracking technique.

MATERIALS AND METHODS

One hundred patients were included in this randomized and prospective study performed on a helical CT. Patients were assigned to one control and four study groups. Each group received 150 ml nonionic contrast medium. In the control group, used delay time and injection rate were 60 sec and 3 ml/sec, respectively. In the study groups, two different injection rates, 3 ml/sec (groups 1 and 2) and 5 mL/sec, respectively. In study groups, two different preselected thresholds, 40 HU (groups 1 and 3) and 50 HU (groups 2 and 4) were used. In these groups, delay times were determined individually by means of the bolus tracking technique. Peak enhancement time (PET), peak enhancement value (PEV), and mean hepatic enhancement (MHE) on CT scans was calculated for each group.

RESULTS

PET was found to be significantly earlier in the study groups in which the injection rates were 5 mL/sec, compared to the other groups (p < 0.001). MHE was significantly higher in all study groups compared to the control group (p < 0.001). PEV was higher in study groups that the preselected threshold was 50 HU compared to only the control group (p < 0.01).

CONCLUSION

Use of a bolus tracking program helps to achieve a greater level of hepatic enhancement. Increasing the injection rate shortens the time to peak hepatic enhancement. The threshold level of 50 HU achieves a great level of hepatic enhancement independent of injection rates in the bolus tracking technique. If the bolus tracking technique is not available, using an injection rate of 3 ml/sec and 70 sec delay time seems to be appropriate.

Arterial lesions in Behçet's disease

BACKGROUND

Arterial involvement is a rare but serious condition in the course of Behçet's disease. We aimed to assess the results of therapeutic approaches in our patients with arterial lesions caused by Behçet's disease.

PATIENTS AND METHODS

The records of 534 patients with Behçet's disease between 1987 and 2002 were retrospectively evaluated for the presence of arterial lesions. All patients were followed up regularly at 3 to 6 months intervals.

RESULTS

Arterial lesions were diagnosed in 21 (3.9%) patients. Eight of these patients had pulmonary artery aneurysms (PAA), and the other 13 patients had non-pulmonary arterial lesions. Urgent surgical intervention was performed in three patients with PAA leading to death in all three. In addition, three other patients died due to massive haemoptysis at home despite to immunosuppressive therapy. Only two out of eight patients with PAA are still alive who were treated with cyclophophamide and corticosteroids. Thirteen operations were performed in 7 out of 13 patients having non-pulmonary arterial lesions. Although ten of the operations were primary operations, three reoperations had to be performed. A stent-graft was applied for the management of an iliac artery aneurysm in one patient. Only one patient died 8 years after the first non-pulmonary arterial involvement following a type IV thoracoabdominal aortic aneurysm repair. Five patients with arterial occlusive lesions were successfully treated by corticosteroids.

CONCLUSIONS

Pulmonary artery aneurysms in Behçet's disease patients have a poor prognosis despite any form of therapy. High dose corticosteroids alone can be successfully used for isolated non-pulmonary arterial occlusive lesions, unless disabling symptoms occur. Surgery or stent-graft insertion is indicated for non-pulmonary arterial aneurysms because these aneurysms entail high risk of complications.

Acute electrophysiological effect of pulsed gallium-arsenide low-energy laser irradiation on isolated frog sciatic nerve

We evaluated the acute electrophysiological effects of low-energy pulsed laser irradiation on isolated frog sciatic nerve measured by extracellular recording technique. A pulsed gallium-arsenide (GaAs) laser (wavelength: 904 nm, pulse duration 220 ns, peak power per pulse: 27W, spot size: 0.28 cm(2), total applied energy density: 0.005-2.5J/cm(2)) was used for the experiment. Sixty isolated nerves were divided into six groups (n=10), each of which received a different laser dose. In each group, action potentials were recorded before laser irradiation which served as the control data. The extracellular action potentials were recorded for each combination of 1, 3, 5, 7, 10, 13 and 15 minutes of irradiation time and 4, 8, 16, 32, 64 and 128 repetition frequency by using a BIOPAC MP 100 Acquisition System Version 3.5.7 (Santa Barbara, USA). Action potential amplitude, area, duration and conduction velocity were measured. Statistical evaluation was performed using repeated measures variance analysis by SPSS 9.0. There were no statistically significant differences for action potential amplitude, area and conduction velocity among the laser groups and control data (p>0.05). The study showed that low-energy GaAs irradiation at 4-128 Hz repetition frequencies administered for irradiation times of 1-15 min generates no effect on action potential amplitude, area, duration and conduction velocity in isolated frog sciatic nerve.

[Endovascular approach in the treatment of traumatic peripheral arterial lesions: report of two cases]

Arterial injuries associated with pseudoaneurysms or arteriovenous fistulas are usually due to penetrating trauma. Endovascular treatment modalities are emerging as an alternative and less invasive method compared to the conventional surgical repair methods. Herein we report our recent experience on with two cases of traumatic arterial injury who were successfully managed by using stent-grafts with endovascular approach. Endovascular treatment options should be remembered as an alternative to the surgical repair for management of penetrating arterial injuries.

Lumbar and femoral bone mineral density in type 2 Turkish diabetic patients

The relationship between type 2 diabetes and osteoporosis has not been well established. We studied a population composed of 161 post-menopausal women with type 2 diabetes and a control group. We examined bone mineral density with the dual-energy X-ray absorptiometry(DXA) technique at the lumbar and femoral regions and in a subgroup of patients, we also measured the levels of markers of bone remodelling. We found significantly higher levels of bone mineral density at the lumbar and femoral levels in the diabetic subjects compared with the control group. Moreover, we found higher level of urinary calcium in the controls. On the basis of these results, we suggest that osteoporosis cannot be considered a complication of type 2 diabetes.

A case of ochronosis: upper extremity involvement

We present an ochronotic patient with spondylosis and upper extremity involvement. We also evaluated radiologic findings of joints that were involved and MRI features of the lumbar spine.

Oxidative protein damage in plasma of type 2 diabetic patients

In this study, we evaluated protein oxidation in 84 patients with Type 2 diabetes with no complications and in 61 healthy volunteers who formed the control group, whose ages matched those of the patients. We determined plasma carbonyl and plasma thiol levels as markers of oxidative protein damage and erythrocyte glutathione, plasma ceruloplasmin and transferrin as markers of free radical scavengers. The concentrations (mean +/- SD) of both of plasma carbonyl (1.24 +/- 0.46 vs. 0.72 +/- 0.17 nmole/mg protein; p < 0.0001) and lipid hydroperoxides (1.8 +/- 0.63 vs. 1.3 +/- 0.21 micromole/l; p < 0.0001) were increased, and the concentration of plasma transferrin (3.85 +/- 0.65 vs. 4.59 +/- 0.79 g/l; p < 0.05) was decreased, respectively, in Type 2 diabetic patients compared with those of the controls. There were no significant differences in the concentrations of plasma thiol (0.0064 +/- 0.001 vs. 0.0068 +/- 0.001 micromole/mg protein), erythrocyte glutathione (2.54 +/- 0.57 vs. 2.65 +/- 0.56 mg/g Hb), plasma ceruloplasmin (548 +/- 107.30 vs. 609 +/- 93.34 mg/l) between the patients and the controls. These changes observed in diabetic patients contribute to the imbalance in the redox status of the plasma. We attribute this imbalance to oxidative protein damage in Type 2 diabetic patients clinically free of complications.

Increased Serum Soluble CD23 and Soluble IL-2R Levels in Haematologic Malignancies

Serum soluble CD23 (sCD23) and soluble IL-2 receptor (sIL-2R) levels increase not only in disorders with immune system activation, but also in hematological malignancies. They have been used as markers of disease progression and/or the response to therapy in lymphoproliferative disorders (LPD). In this study, we investigated the serum sCD23 and sIL-2R levels of 21 patients with different hematological malignancies [10 LPD, 6 multiple myeloma (MM), and 5 myelodysplastic syndrome (MDS)] before treatment, and compared them with 19 age- and sex- matched healthy subjects. Median sIL-2R levels were found to be significantly elevated in both the overall patient group and each of the subgroups. Median sCD23 levels were significantly higher in the overall patient group and in patients with LPD and MM. A positive correlation was found between sIL-2R and sCD23 levels in LPD. Our preliminary findings suggest that elevated serum levels of these soluble factors are not only markers of LPD but might be also used for other hematologic malignancies, except for MDS. Further studies should be designed to find out if it might be the result of an overactive immune system or not.