Stenosi carotidea: Confronto tra angio-RM e angio-TC spirale

A preliminary study comparing three dimensional time of flight (TOF 3D) Magnetic Resonance angiography (MRA) and spiral CT angiography (SCTA) in the detection and evaluation of internal carotid stenosis.

Digital subtraction angiography (DSA) was the gold standard.

Twenty patients with clinical signs of cerebrovascular insufficiency underwent MRA, SCTA and DSA within a three day period. Both internal carotid arteries were evaluated for absence or degree of stenosis.

Sensitivity, specificity, diagnostic accuracy, concordance, overstimation and understimation were assessed. MRA showed a higher sensitivity, specificity, diagnostic accuracy and concordance compared to SCTA (92% versus 80%, 98,2% versus 96,4%, 96,3% versus 88%, respectively). MRA demonstrated a 5% overstimation rate whereas SCTA demonstrated a 7,5% understimation rate. These differences are not statistically significant.

These results suggest that MRA is the more useful, non invasive modality for the detection and evaluation of the internal carotid artery with a greater than 70% stenoses.

Treatment of peripheral arterial disease in diabetes: a consensus of the Italian Societies of Diabetes (SID, AMD), Radiology (SIRM) and Vascular Endovascular Surgery (SICVE)

Diabetic foot (DF) is a chronic and highly disabling complication of diabetes. The prevalence of peripheral arterial disease (PAD) is high in diabetic patients and, associated or not with peripheral neuropathy (PN), can be found in 50% of cases of DF. It is worth pointing out that the number of major amputations in diabetic patients is still very high. Many PAD diabetic patients are not revascularised due to lack of technical expertise or, even worse, negative beliefs because of poor experience. This despite the progress obtained in the techniques of distal revascularisation that nowadays allow to reopen distal arteries of the leg and foot. Italy has one of the lowest prevalence rates of major amputations in Europe, and has a long tradition in the field of limb salvage by means of an aggressive approach in debridement, antibiotic therapy and distal revascularisation. Therefore, we believe it is appropriate to produce a consensus document concerning the treatment of PAD and limb salvage in diabetic patients, based on the Italian experience in this field, to share with the scientific community.

3D angiography in the evaluation of intracranial aneurysms before and after treatment. Initial experience

PURPOSE

The aim of the study is to evaluate the advantages of 3D angiography as compared to 2D angiography in assessing intracranial aneurysms before and after treatment and, in particular, in selecting and planning the correct treatment.

MATERIALS AND METHODS

Thirty intracranial aneurysms were retrospectively reviewed before and after treatment. The study population consisted of 12 men and 18 women (age range: 35-77 years; mean age: 58 years). Eighteen aneurysms were treated surgically, 10 endovascularly and 2 with combined treatment. The 2D and 3D findings before and after treatment were compared, and the pre-treatment angiographic images were compared with surgical findings. The following parameters were assessed and compared: aneurysmal sac and neck size, vascular involvement and evaluation of post-treatment residual mass.

RESULTS

On the 2D DSA images, visualisation of the sac and neck was optimal in 45% and 15% of cases, adequate in 10% and 35% of cases and inadequate in 5% and 50% of cases, respectively. On the 3D DSA images, visualisation of the sac and neck was optimal in 100% of cases. Three-dimensional DSA was able to detect 8 aneurysms with vessel involvement in all cases (100%). Of these, four (50%) went undetected on 2D DSA; in two cases, two-dimensional DSA erroneously detected the presence of vascular involvement (false positive). Three-dimensional angiography proved superior to 2D angiography in the evaluation of the residual aneurysms treated with clipping. Finally, 3D DSA was able to reduce the number of radiographic projections, the quantity of contrast medium, the time and associated risks necessary for a precise evaluation of the aneurysm.

CONCLUSIONS

In our first experience, 3D DSA proved useful in reducing the risks and diagnostic time as well as in selecting and planning the treatment. Moreover, it improved the operating conditions of both surgical and endovascular treatment. Technological advances in this field will enable the optimisation of the technique in terms of anatomical detail and reconstruction time.

A novel zinc finger transcriptional repressor, ZNF224, interacts with the negative regulatory element (AldA-NRE) and inhibits gene expression

The interaction between the negative cis-element (AldA-NRE) and p97 repressor nuclear protein is a key step in modulating transcription of the human and mouse aldolase A (AldA) gene during the cell cycle and differentiation. In an attempt to clarify the role of transcriptional repression in regulating gene expression, we purified, from HeLa cells, the nuclear protein that specifically binds to the AldA negative regulatory element (NRE). Matrix-assisted laser desorption ionization-time of flight analysis and examination of protein profiles from the SwissProt database revealed that the previously defined p97 repressor is ZNF224, a zinc finger protein. We demonstrate that ZNF224, a Kruppel-like zinc finger transcription factor, is the repressor protein that specifically binds to the negative cis-element AldA-NRE and affects the AldA-NRE-mediated transcription.

Transcatheter arterial chemoembolization for hepatocellular carcinoma in patients with cirrhosis: evaluation of damage to nontumorous liver tissue-long-term prospective study

PURPOSE

To evaluate damage to cirrhotic liver tissue after transcatheter arterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

TACE was performed in 111 patients with HCC that involved less than 30% of the liver. Baseline liver function was evaluated with Child-Pugh scores and other indicators. Eighty-two patients had Child-Pugh class A disease, 27 had class B disease, and two had class C disease. All patients underwent chemotherapy followed by gelatin sponge particle embolization in the proper ("complete" embolization; n = 69) or right or left main ("partial" embolization; n = 42) hepatic artery. Liver function was assessed 4 months later, and 95 patients underwent a second TACE (complete embolization in 57, partial in 38). Liver function was again assessed 4 months later in 60 patients.

RESULTS

No patient died. Child-Pugh scores increased in all patients from a mean 5.96 to 6.28 (not significant) and 6.51 (P =. 05) after first and second TACEs, respectively. In patients with class A disease, scores increased from a mean 5.37 to 5.73 (P =.01) and 5.89 (P =.001) after first and second TACEs, respectively; in patients with class B disease, scores changed from a mean of 7.48 to 7.67 and 7.30 after first and second TACEs, respectively (not significant).

CONCLUSION

TACE does not induce significant long-term worsening of liver function in patients with class A or B cirrhosis.

Congenital absence of the internal carotid artery

We report three cases of congenital absence of an internal carotid artery (ICA), diagnosed incidentally by digital subtraction angiography. The analysis of the cases is based on the classification of segmental ICA agenesis proposed by Lasjaunias and Berenstein. Usually the patients with this rare vascular anomaly are asymptomatic; some may have symptoms related to cerebrovascular insufficiency, compression by enlarged intracranial collateral vessels, or complications associated with cerebral aneurysms. Diagnosis of congenital absence of ICA is made by skull base computed tomography (CT) scan, CT and magnetic resonance angiography, and conventional or digital subtraction angiography.

MR angiography in carotid stenosis: a comparison of three techniques

PURPOSE

To compare the accuracy of three different magnetic resonance angiography (MRA) techniques for studying steno-occlusive disease of carotid arteries.

METHODS

64 patients were evaluated with three MRA techniques- three-dimensional (3D) time-of-flight (TOF), two-dimensional (2D) TOF, and 3D Phase-Contrast (PC); the acquisition was in the axial plane, the volume included the carotid bifurcation. Digital subtraction angiography (DSA) was considered the 'gold standard'. The MRA images were reprojected with a maximum intensity pixel ray-tracing (MIP) algorithm. The three MRA techniques were blindly graded as normal, mildly stenotic (0-29%), moderately stenotic (30-49%), severely stenotic (70-99%), or occluded.

RESULTS

DSA provided 128 diagnostic judgments: 92 were negatives and 36 positives. 2D TOF was in agreement with angiography in 116 of 128 cases (90%), but overestimated the results in seven cases and underestimated in five cases. 3D TOF agreed with angiography in 125 of 128 cases (97%), with one overestimation and two under estimations. 3D PC was concordant in 116 of 128 cases (90%), overestimating in six cases, underestimating in six cases. The sensitivity, specificity and diagnostic accuracy for 2D TOF was, respectively 84%, 94%, and 92%, while for 3D TOF was 94%, 100%, and 98%, and for 3D PC 86%, 98%, and 95%. The comparison of the three different MRA techniques provided no statistically significant difference (Friedman test P < 0.05).

CONCLUSION

The high degree of diagnostic accuracy of MRA found in the study of the steno-occlusive disease of the carotid arteries confirms the high degree of reliability of this methodology carried out with the 3D TOF technique, compared to 2D TOF and 3D PC.

Congenital intrahepatic portosystemic shunt

The authors report a congenital intrahepatic portosystemic shunt detected by angiography in a young patient with acute onset of hyperammoniemia and hepatic encephalopathy.

Carotid stenosis: a comparison between MR and spiral CT angiography

We performed a preliminary study comparing three-dimensional time-of-flight (3 D TOF) magnetic resonance angiography (MRA) and spiral CT angiography (SCTA) in the detection and assessment of internal carotid artery stenosis. Digital subtraction angiography (DSA) was the reference examination. We examined 20 patients with signs of cerebrovascular insufficiency, who underwent MRA, SCTA and DSA within a 3 day period. Both internal carotid arteries were assessed by three blinded readers for degree of stenosis at two different levels (bulb and remaining section) giving a total of 80 assessments. Interobserver variability, sensitivity, specificity, diagnostic accuracy, concordance, overestimation and underestimation were assessed. Interobserver variability was not statistically significant. MRA showed higher sensitivity, specificity, diagnostic accuracy and concordance than SCTA (92.0% vs 80.8%, 98.2% vs 96.4%, 96.3% vs 91.3% and 96.0% vs 88.0%, respectively). MRA gave rise to a 5.0% overestimation rate, whereas SCTA occasioned a 7.5% underestimation rate. These differences are not statistically significant. These results suggest that MRA is a more useful, noninvasive modality for assessment of the internal carotid artery with a more than 70% stenosis.

Problems with post-clipping aneurysmal rests

The postclipping aneurysmal rest is a uncommon but sometimes dangerous event, that is generally underestimated. We distinguish the aneurysmal rest on the basis of its morphology in: 1) partial neck, 2) whole neck, 3) partial neck + partial sac, 4) whole neck + partial sac; on the basis of the relationship with the clip in: 1) proximal, 2) distal, 3) proximal + distal; on the basis of its size in: 1) small (< 2 mm), 2) medium (2-4 mm), 3) large (> 4 mm). From the surgical point of view the aneurysmal rests in our opinion can be classified as unavoidable, avoidable and intentional. Then we analyze the literature data in regard to the possible evolution and the risk of the rest and emphasize the importance of intraoperative angiography which has shown itself to be useful in avoiding aneurysmal rests. There is no consensus of opinion with regard to the type of treatment of the aneurysmal rest. In our opinion the factors which must be considered when deciding on the surgical treatment of a rest are: the age of the patient, mode of presentation of the previous aneurysm, the expertise of the surgeon and the approaches and the techniques used in the first operation, clinical presentation of the rest and its evolution, the surgeon's experience and the possibility of endovascular therapy. Finally we analyze some of the technical aspects of re-operation in relation to the anatomical relationship among the parent artery, the rest and the old clip.

[Diagnostic imaging and interventional therapy in hepatocarcinoma. Multicenter study of 290 cases]

We report the results of a multicenter study on the diagnosis and interventional therapy of hepatocellular carcinoma (HCC). The first aim--diagnosis--was to evaluate the sensitivity of 4 imaging techniques, namely ultrasonography (US), Computed Tomography (CT), digital arteriography (DSA) and Lipiodol CT (LCT), in HCC detection. The accuracy of these techniques was also investigated in tumor staging, which is important for treatment planning. Two hundred ninety patients underwent this imaging protocol. The patients were classified by tumor spread into three groups, namely group 1 (single HCCs < 5 cm), group 2 (multifocal HCCs with max. 3 nodules or tumor volume < 80 cc), group 3 (multifocal HCCs with more than 3 nodules and/or tumor volume > 80 cc). US and CT diagnosed more cases as group 1 and fewer cases as group 3 than DSA and LCT; the latter two techniques gave a similar classification. With LCT as the gold standard, US and CT understaged 27.9% and 26.5% of cases, respectively. Even though LCT is known to have 53% sensitivity, it is currently the most sensitive preoperative investigation and therefore the best tool for treatment planning. In surgical patients, however, intraoperative US, with its nearly 100% sensitivity, is suggested. The second aim--treatment--consisted in assessing the therapeutic efficacy of intraarterial chemoembolization (CEAT) versus percutaneous ethanol injection (PEI) in non advanced HCC and of CEAT versus no treatment (NT) in advanced HCC. Treatment efficacy was evaluated with the following randomized protocols: PEI versus CEAT in group 1, PEI versus CEAT in group 2 and CEAT versus NT in group 3. The data were analyzed relative to 215 patients for 6 to 30 months. The Kaplan-Meier method was used to calculate survival rates, which were, at 24 and 30 months, 72% and 72% for PEI and 72% and 52% for CEAT in group 1, 52% and 28% for PEI and 70% and 50% for CEAT in group 2 and finally 30% and 20% for NT and 45% and 30% for CEAT in group 3. In group 1, PEI appeared markedly superior to CEAT. In group 2, the difference between PEI and CEAT was not statistically significant; the results in this group indicate that CEAT should be considered when three nodules are present because of PEI invasiveness in these cases. In group 3, CEAT results were definitely better in the first two years, but there was no difference with NT patients at the end of the third year. Therefore, CEAT is indicated in advanced HCC because it improves the survival rate in the first 24 months. After this period, the survival time is not modified by treatment.

[Magnetic resonance angiography in stenosing-occlusive diseases of the carotid arteries: 3D with time of flight versus 3D with phase contrast]

We assessed the comparative sensitivity, specificity and diagnostic accuracy of 3D time of flight (TOF) versus 3D phase contrast (PC) MRA in the study of stenoses/occlusions of the extracranial carotid artery. Fifty-four patients were submitted to MRA because of their symptoms or of signs of cerebrovascular insufficiency. 3D TOF and 3D PC axial slices were acquired with a high field magnet; digital angiography was the gold standard. The parameters of 3D TOF acquisitions were: TR/TE/FA 50/8/20, 1 NEX, 512 x 256 matrix, 16 x 12 FOV, 1 axial slab of 60 slices, 1 mm slice thickness, superior presaturation band, ramp pulse, TA 10-18 minutes. 3D PC parameters were: TR/TE/ FA 25/9/20, 1 NEX, 256 x 128 matrix, 18 x 13 FOV, 1 axial slab of 60 slices, 1 mm slice thickness, VENC 35 cm/s, TA 10-15 minutes. 3D TOF MRA was in agreement with digital angiography in 95.6% of cases (22/23), overestimating a grade 3 stenosis as grade 4 (one case, 4.3%) and underestimating no stenoses. 3D PC MRA was in agreement with digital angiography in 78.2% of cases (18/23), overestimating three stenoses (13%); one grade 1 as grade 2 and two grade 4 as grade 5; two stenoses were underestimated (8.6%); one grade 4 as grade 3 and one grade 4 as grade 2. Sensitivity, specificity and diagnostic accuracy were 91.4%, 98.9% and 95.7% for 3D TOF, versus 83.2%, 97.2% and 92.3% for 3D PC, respectively. The two MRA techniques had different semiology. In spite of outstanding background noise suppression, 3D PC poorly depicted the turbulent flow at the carotid bifurcation in carotid stenoses. Therefore, 3D TOF appears a better technique to study stenoses/occlusions of the extracranial carotid arteries.

Treatment of hepatocellular carcinoma: a single-center experience

PURPOSE

The comparative efficacy of transcatheter arterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) in the treatment of hepatocellular carcinoma (HCC) was investigated.

METHODS

Two hundred and sixty consecutive patients were retrospectively analyzed: 156 had received between one and six chemoembolization sessions at 3-month intervals, 33 had had PEI, and the remaining 71 patients refused any treatment. The follow-up ranged from 3 to 36 months. Survival rates were statistically analyzed by life-table analysis.

RESULTS

Patients' survival was affected by the number of nodules and by the Child's and Okuda's classes; no relationship was found between survival rates and the histologic grade or vascular supply of the tumor. In the case of a single lesion of Okuda's class I, TACE was more effective than PEI. In multifocal HCC, TACE was better than no treatment in Okuda's class I and Child's class A.

CONCLUSION

We suggest TACE as the treatment of choice in Child A or Okuda I patients with multifocal HCCs; it seems of little help in Child B-C or Okuda II-III patients.

Surgical treatment of a cerebral mycotic aneurysm using the stereo-angiographic localizer

The authors report a case of mycotic aneurysm surgically treated by means of the Suetens-Gybels-Vandermeulen angiographic localizer system. The major advantages of this technique are reported.

[Treatment of primary hepatocarcinoma with chemoembolization and alcohol injection. Personal experience]

The comparative efficacy of transcatheter arterial chemoembolization and percutaneous ethanol injection (PEI) in the treatment of hepatocellular carcinoma (HCC) was investigated in a series of 243 consecutive patients: 146 of them were submitted to 1-6 chemoembolization sessions at 1 and 3 months' intervals and 30 to PEI; the remaining 67 patients refused any treatment. The follow-up ranged 3 to 36 months. Survival rates were statistically analyzed with the life table analysis. Patients' survival was affected by the number of nodules and by Child's and Okuda's classes; no relationship was found between survival rates and histologic grade or nodule vascular feeding. In case of single lesions, chemoembolization was more effective than PEI in Okuda's class I. In case of multifocal HCC, chemoembolization was better than no treatment in Okuda's class I and Child's class A. In conclusion, we suggest chemoembolization as the treatment of choice in Child A or Okuda I patients with multifocal HCCs, while its use seems of little help in Child B-C or Okuda II-III patients. In case of unifocal HCC, PEI or surgical resection should be combined with chemoembolization.

[Primary hepatocarcinoma. Diagnostic imaging and chemoembolization]

The diagnostic and therapeutic approach by means of transcatheter arterial chemoembolization is analyzed in 100 patients affected with hepatocellular carcinoma (HCC): in all patients the HCC had been diagnosed by means of US-guided fine-needle biopsy: 75 of 100 patients were in Child A class, 24 in Child B and 1 in Child C class. The most sensitive imaging technique to identify HCC proved to be angiography (95%); post-Lipiodol CT was also of great value to stage the disease. The authors suggest a diagnostic-therapeutic approach including angiography and simultaneous chemoembolization right after US-guided biopsy, avoiding conventional CT; such a protocol allows high diagnostic accuracy at a lower cost. Chemoembolization proved to be a safe technique, with a low incidence of mortality and complications; the latter were easy to treat by medical therapy. The follow-up data relative to 39 of 100 patients who underwent 2 or more chemoembolization treatments prove the latter to be a valuable technique relative to both the evolution of HCC nodules (in 18/21 patients with single lesions and in 9/18 patients with multiple lesions, lesion size was unchanged or decreased) and to survival rates (70% in 65 patients followed-up 1 year at least); on the whole, 77 of 100 patients are still alive.

[Transluminal therapy of stenosing lesions of the supra-aortic vessels. Personal experience]

Percutaneous transluminal angioplasty (PTA) is commonly used to treat peripheral vascular diseases, but its use has recently spread to the treatment of stenotic lesions involving the supra-aortic vessels. The authors report their initial experience in 10 patients with left subclavian artery stenoses--8 of them treated with PTA and 2 with PTA and vascular stenting--and two more patients with fibromuscular stenosis of the internal carotid artery (ICA), which was treated by means of PTA. In the authors' opinion, PTA can be considered the procedure of choice to treat the stenotic lesions of the supra-aortic vessels. Intravascular stents can be extremely useful to prevent post-PTA restenosis, but further experience and probably further technological refinements are needed. To conclude, PTA of ICA is an effective method in selected cases--e.g., in the patients with symptomatic hemodynamic lesions and low risk of embolism, in the patients with difficult surgical access or in the event of high anesthesiological and/or surgical morbidity.

[Intra-arterial digital angiography using a trans-humeral approach in the assessment of ambulatory patients]

The authors report their experience with intraarterial digital subtraction angiography (DSA) performed on outpatients via brachial artery catheterization. A total of 120 outpatients were studied for cerebral and lower limbs vascular diseases. Transbrachial catheterization was performed with 5F or, preferably, with 4F angiographic catheters. Success rate was high and the transbrachial approach was always easy. In the course of cerebral examination (18/120 cases) the catheter was always easily positioned in the ascending thoracic aorta, through right transbrachial approach. In the course of abdominal aorta and lower extremities examination (102/120 cases), the ideal catheter positioning--in the descending aorta--was performed in 95/102 cases, by left transbrachial approach, while in 7/102 patients the catheter was placed in the ascending aorta. The complication rate was low: 7/120 ecchymosis, 4/120 small hematomas spontaneously resorbed, and 2/120 transient spasms of brachial artery. The authors suggest trasbrachial intraarterial DSA as an alternative to intravenous DSA in outpatients.

[Radiological diagnosis of Meckel's diverticulum]

Seven patients with clinically suspected Meckel's diverticulum were examined. The symptoms of Meckel's diverticulum are variable, ranging from mild recurrent or severe acute gastrointestinal bleeding to intestinal obstruction and acute peritonitis. The authors evaluate the diagnostic results and suggest guidelines to choose the most appropriate radiological procedures, according to the clinical pattern: barium meal, enteroclysis and scintigraphy (99mTc) in patients with mild bleeding; mesenteric angiography in case of severe bleeding. The possibility of false negatives and positives is then discussed.

[Radiological assessment of Crohn disease]

Fifty-eight consecutive cases of patients affected by Crohn's disease, with ileum (23/58), colon (10/58) and ileo-colic (25/58) involvement were studied. A good overall sensitivity was reached by the radiological procedures employed (barium meal, barium enema, enteroclysis). Enteroclysis is proposed as a second-step method for the study of ileum involvement, because it provides a quite precise assessment of disease stage and extent. Some criteria for a rational use of current radiological procedures in the follow-up of both surgically and medically treated patients are proposed. Moreover it is suggested that better coordination of anatomo-radiological and clinical aspects could improve the therapeutic approach and prognostic judgement in such cases.

Radiological aspects of cancer of the esophagus

The role radiology plays in the study of cancer of the esophagus (CE) involves three different diagnostic steps: identification of CE; staging of CE and postoperative follow-up. This study comprises 117 cases of CE, all surgically confirmed: in 57/117 CE, resection of the neoplasm with subsequent reconstruction of the digestive tract proved possible; in the remaining 60/117 non-resectable CE, a Celestin prosthetic tube was positioned. The radiological diagnosis was correct in 92.3% of the cases, the diagnostic error (9/117: 7.7%) being mainly due to under-diagnoses (6/9) rather than false negatives (3/9). Conventional radiology provided satisfactory results in the staging of CE. Among the postoperative complications in the 57 resected patients, fistulae (13/57) and mediastinal abscesses (1/57) were early complications, whereas stenosis of the anastomosis (5/57) and neoplastic recurrences (3/57) were late complications. The possible role of diagnostic delay in the poor prognosis of CE, as well as its possible causes, are discussed in this paper.

[The pathogenesis of inadequate cerebral circulation in the aged]

A physiopathologically oriented classification is proposed for cerebral circulatory insufficiency to cover forms caused by intra- and extracranial vascular disease, and those of cardiac and non-cardiac extravascular origin. The aetiopathogenetic aspects of the matter are discussed, and some clinical pictures of particular geriatric interest are described. Lastly, attention is given to the dysmetabolically induced instances of cerebral distress that are often observed in the aged.

[Changes in the incidence of coronary vasculopathy in the Cosentina hospital population in the 3-year periods of 1950-52, 1956-58, 1963-65, 1966-68, 1969-71]

The incidence of admissions for coronary disease in relation to age, sex, diet, occupation and place of origin was examined for five 3-yr periods ('50-'52, '56-'58, '63-'65, '66-'68, and '69-'71). There was a marked increase in admissions and a greater incidence among middle-aged subjects and males. The percent frequency differences between urban and montane districts noted in the fifties were less apparent later in the last three-year period.