Increased Intracranial Arterial Pulsatility and Microvascular Brain Damage in Pseudoxanthoma Elasticum

BACKGROUND AND PURPOSE

Carotid siphon calcification might contribute to the high prevalence of cerebrovascular disease in pseudoxanthoma elasticum through increased arterial flow pulsatility. This study aimed to compare intracranial artery flow pulsatility, brain volumes, and small-vessel disease markers between patients with pseudoxanthoma elasticum and controls and the association between arterial calcification and pulsatility in pseudoxanthoma elasticum.

MATERIALS AND METHODS

Fifty patients with pseudoxanthoma elasticum and 40 age- and sex-matched controls underwent 3T MR imaging, including 2D phase-contrast acquisitions for flow pulsatility in the assessment of ICA and MCA and FLAIR acquisitions for brain volumes, white matter lesions, and infarctions. All patients with pseudoxanthoma elasticum underwent CT scanning to measure siphon calcification. Flow pulsatility (2D phase-contrast), brain volumes, white matter lesions, and infarctions (3D T1 and 3D T2 FLAIR) were compared between patients and controls. The association between siphon calcification and pulsatility in pseudoxanthoma elasticum was tested with linear regression models.

RESULTS

Patients with pseudoxanthoma elasticum (mean age, 57 [SD, 12] years; 24 men) had significantly higher pulsatility indexes (1.05; range, 0.94-1.21 versus 0.94; range, 0.82-1.04; P = .02), lower mean GM volumes (597 [SD, 53] mL versus 632 [SD, 53] mL; P < .01), more white matter lesions (2.6; range, 0.5-7.5 versus 1.1; range, 0.5-2.4) mL; P = .05), and more lacunar infarctions (64 versus 8, P = .04) than controls (mean age, 58 [SD, 11] years; 20 men). Carotid siphon calcification was associated with higher pulsatility indexes in patients with pseudoxanthoma elasticum (β = 0.10; 95% CI, 0.01-0.18).

CONCLUSIONS

Patients with pseudoxanthoma elasticum have increased intracranial artery flow pulsatility and measures of small-vessel disease. Carotid siphon calcification might underlie the high prevalence of cerebrovascular disease in pseudoxanthoma elasticum.

Systemic arterial calcium burden in patients with chronic limb-threatening ischemia

INTRODUCTION

5-year mortality of chronic limb-threatening ischemia (CLTI) is 50-60% and coronary artery disease (CAD) is the main cause of death of CLTI patients, followed by stroke. The aim of this study is to quantify and qualify the calcium load in different arterial territories in patients with CLTI.

METHODS

Prospectively, 60 patients with CLTI were included and received a full-body CT scan. 6 patients were excluded. Different arterial territories (the peripheral lower extremity arteries, coronary arteries, extracranial and intracranial carotid arteries, thoracic and abdominal aorta) were analyzed. Analysis and interrelations of both quantitative and semi-quantitative CT measurements was performed.

RESULTS

Mean age was 72 years (range 47-95; SD 11.4). Almost all CLTI patients had calcified arterial beds (femoropopliteal 100%, crural 98.1%, coronary 100%, carotid bifurcation 96.2%, internal carotid artery 98.1%, thoracic aorta 96.2%, abdominal aorta 92.3%). Nearly all arterial territories had severe calcifications. 57% had a very high coronary Agatston score (>1000), and 35% extremely high (>2000). Calcifications in the lower extremity were significantly correlated to CAC score, carotid artery bifurcation calcification score, and to a lesser extent correlated to annular calcifications in the aorta. Very high and extremely high total CAC scores were strongly correlated with severe lower extremity arterial calcifications and severe carotid and intracranial internal carotid artery, thoracic and abdominal aorta calcifications in patients with CLTI patients.

CONCLUSIONS

In CLTI patients nearly all arterial territories are severely calcified, suggesting that systemic calcification plays an important role in the poor outcome of this disease.

Treatment of arterial calcification in patients with chronic limb threatening ischemia with etidronate: protocol of an investigator-initiated multicenter, double blind, placebo-controlled, randomized clinical trial

Background

Pathologic studies have shown that in patients with critical limb threatening ischaemia (CLTI) medial arterial calcifications are frequently found and may be responsible for aggravating the disease. These extensive calcifitcations are found not only in arteries of the leg but also in the coronary arteries and the aorta. The progression of these calcifications is fast and they stiffen the vessel wall and may thus increase the cardiovascular risk.

Reduction of progression of calcification may not only reduce the burden of CLTI but may also reduce the high residual cardiovascular risk. Medial calcifications have been halted by etidronate in other trials. Its potential to reduce the burden from peripheral vascular disease in CLTI and residual cardiovascular risk remains to be established.

Methods

This is an investigator-initiated multicenter, double blind, placebo-controlled, randomized trial comparing the effects of etidronate versus placebo in patients with CLTI.

Subjects will be randomized to either treatment with etidronate for 12 months (cyclical 20 mg/kg for 2 weeks on and 10 weeks off) orally or placebo for 12 months (in a similar routine).

The primary endpoint is the change in arterial calcification as quantified by CT-scan.

Secondary endpoints are the number of amputations above and below the ankle, mortality, number of vascular interventions and quality of life.

Discussion

Up to now, the inert end stage of vascular disease in patients with CLTI, has been considered calcification of vessel walls. We believe there is reason to reverse causation and hypothesize that calcification causes vascular disease. This reversal can be proven in a clinical trial if halting the calcification process improves the outcome of the patient. Therefore we use etidronate, a bisphosphate that has proven to stop the calcification in several rare monogenetic calcifying diseases. We aim to perform this mechanistic proof-of-concept study hopefully leading to a clinical outcome study later on.

Pulsatility Attenuation along the Carotid Siphon in Pseudoxanthoma Elasticum

We compared velocity pulsatility, distensibility, and pulsatility attenuation along the intracranial ICA and MCA between 50 patients with pseudoxanthoma elasticum and 40 controls. Patients with pseudoxanthoma elasticum had higher pulsatility and lower distensibility at all measured locations, except for a similar distensibility at C4. The pulsatility attenuation over the siphon was similar between patients with pseudoxanthoma elasticum and controls. This finding suggests that other disease mechanisms are the main contributors to increased intracranial pulsatility in pseudoxanthoma elasticum.

Diagnostic accuracy of point-of-care ultrasound for evaluation of early blood-induced joint changes: Comparison with MRI

INTRODUCTION

Recurrent joint bleeding is the hallmark of haemophilia. Synovial hypertrophy observed with Magnetic Resonance Imaging (MRI) is associated with an increased risk of future joint bleeding.

AIM

The aim of this study was to investigate whether point-of-care ultrasound (POC-US) is an accurate alternative for MRI for the detection of early joint changes.

METHODS

In this single centre diagnostic accuracy study, bilateral knees and ankles of haemophilia patients with no or minimal arthropathy on X-rays were scanned using POC-US and 3 Tesla MRI. POC-US was performed by 1 medical doctor, blinded for MRI, according to the "Haemophilia Early Arthropathy Detection with Ultrasound" (HEAD-US) protocol. MRIs were independently scored by 2 radiologists, blinded for clinical data and ultrasound results. Diagnostic accuracy parameters were calculated with 95% confidence intervals (CI).

RESULTS

Knees and ankles of 24 haemophilia patients (96 joints), aged 18-34, were studied. Synovial hypertrophy on MRI was observed in 20% of joints. POC-US for synovial tissue was correct (overall accuracy) in 97% (CI: 91-99) with a positive predictive value of 94% (CI: 73-100) and a negative predictive value of 97% (CI: 91-100). The overall accuracy of POC-US for cartilage abnormalities was 91% (CI: 83-96) and for bone surface irregularities 97% (CI: 91-99).

CONCLUSION

POC-US could accurately assess synovial hypertrophy, bone surface irregularities and cartilage abnormalities in haemophilia patients with limited joint disease. As POC-US is an accurate and available alternative for MRI, it can be used for routine evaluation of early joint changes.

Preoperative indication for systemic therapy extended to patients with early-stage breast cancer using multiparametric 7-tesla breast MRI

Purpose

To establish a preoperative decision model for accurate indication of systemic therapy in early-stage breast cancer using multiparametric MRI at 7-tesla field strength.

Materials and methods

Patients eligible for breast-conserving therapy were consecutively included. Patients underwent conventional diagnostic workup and one preoperative multiparametric 7-tesla breast MRI. The postoperative (gold standard) indication for systemic therapy was established from resected tumor and lymph-node tissue, based on 10-year risk-estimates of breast cancer mortality and relapse using Adjuvant! Online. Preoperative indication was estimated using similar guidelines, but from conventional diagnostic workup. Agreement was established between preoperative and postoperative indication, and MRI-characteristics used to improve agreement. MRI-characteristics included phospomonoester/phosphodiester (PME/PDE) ratio on 31-phosphorus spectroscopy (³¹P-MRS), apparent diffusion coefficients on diffusion-weighted imaging, and tumor size on dynamic contrast-enhanced (DCE)-MRI. A decision model was built to estimate the postoperative indication from preoperatively available data.

Results

We included 46 women (age: 43-74yrs) with 48 invasive carcinomas. Postoperatively, 20 patients (43%) had positive, and 26 patients (57%) negative indication for systemic therapy. Using conventional workup, positive preoperative indication agreed excellently with positive postoperative indication (N = 8/8; 100%). Negative preoperative indication was correct in only 26/38 (68%) patients. However, ³¹P-MRS score (p = 0.030) and tumor size (p = 0.002) were associated with the postoperative indication. The decision model shows that negative indication is correct in 21/22 (96%) patients when exempting tumors larger than 2.0cm on DCE-MRI or with PME>PDE ratios at ³¹P-MRS.

Conclusions

Preoperatively, positive indication for systemic therapy is highly accurate. Negative indication is highly accurate (96%) for tumors sized ≤2,0cm on DCE-MRI and with PME≤PDE ratios on ³¹P-MRS.

Spatially regularized region-based perfusion estimation in peripherals using angiographic C-arm systems

The outcome assessment of endovascular revascularization procedures in the lower limbs is currently carried out by x-ray digital subtraction angiography (DSA). Due to the two-dimensional nature of this technique, only visual assessment of arterial blood flow is possible and no tissue blood flow information (i.e. perfusion) is available to assess the effective restoration of blood supply to the tissue. In this work, we propose a method for interventional perfusion estimation in peripherals using C-arms which is based on DSA and two additional 3D images reconstructed from rotational scans. The method assumes spatial homogeneity of contrast within multiple regions identified by segmentation of the reconstructed 3D images. A dedicated segmentation method which relies on local contrast homogeneity and connectivity of anatomical structures is introduced. Region-based perfusion is obtained by mapping the 2D blood flow information from DSA to the 3D segments by solving an inverse problem. Instability of the solution due to the spatial overlap of the regions is addressed by applying spatial and temporal regularizations. The method was evaluated on data simulated from CT perfusion scans of the lower limb. Blood flow values estimated with the optimal number of segmented regions exhibited errors of 1 ± 4  and 2 ± 11 ml/100 ml min(-1) for the two analyzed cases, respectively, which showed to be sufficient to differentiate hypoperfused and normally perfused areas. The use of spatial and temporal regularization proved to be an effective way to limit inaccuracies due to instability in the solution of the inverse problem. Results in general proved the feasibility of C-arm interventional perfusion imaging by a combination of temporal information derived from DSA and spatial information derived from 3D reconstructions.

Excised and irradiated volumes in relation to the tumor size in breast-conserving therapy

In early-stage breast cancer and DCIS patients, breast-conserving therapy is today's standard of care. The purpose of this study was to evaluate the relation between the microscopic tumor diameter (mTD), the excised specimen (ES) volume, and the irradiated postoperative complex (POC) volume, in patients treated with breast-conserving therapy. In 186 patients with pTis-2N0 breast cancer, the mTDs, ES, and POC volumes (as delineated on the radiotherapy-planning CT scan), were retrospectively determined. Linear regression analysis was performed to study the association between the mTD, and the ES and POC volumes. The explained variance (r (2)) was calculated to establish the proportion of variation in the outcome variable that could be explained by the determinant (P ≤ 0.05). Moreover, the influence of tumor characteristics, age, surgical procedures, and breast size was studied. Median mTD was 1.2 cm (range 0.1-3.6 cm), median ES volume was 60 cm(3) (range 6-230 cm(3)) and median POC volume was 15 cm(3) (range 0.5-374 cm(3)). The POC was not clearly visible on the majority of the CT scans, based on a median assigned cavity visualization score of 3 (range 1-5). The explained variance for the mTD on the ES volume was low (r(2) = 0.08, P < 0.001). A slightly stronger association was observed in palpable tumors (r(2) = 0.23, P < 0.001) and invasive lobular carcinomas (r(2) = 0.39, P = 0.01). Furthermore, weak associations were observed between POC volume and mTD (r(2) = 0.04, P = 0.01), and POC and ES volume (r(2) = 0.23, P < 0.001). A weak association was observed between breast volume and ES volume (r(2) = 0.27, P < 0.001). In conclusion, both the excised and the irradiated POC volumes did not show a clinically relevant association with the mTD in women with early-stage breast cancer treated with breast-conserving therapy. Future studies should focus on improvement of surgical localization, development of image-guided, minimally invasive operation techniques, and more accurate image-guided target volume delineation in radiotherapy.

Accuracy of multislice liver CT and MRI for preoperative assessment of colorectal liver metastases after neoadjuvant chemotherapy

INTRODUCTION

To determine the best imaging modality for preoperative detection, characterization and measurement of colorectal liver metastases (CRLM) after neoadjuvant chemotherapy (NAC).

METHODS

A total of 79 lesions in 15 patients with CRLM were included. Following NAC, all patients received multislice liver CT (MSCT) and magnetic resonance imaging (MRI) that were scored by two observers for lesion number, type, diameter (mm) and segmental location. Intraoperative findings, histopathology and follow-up imaging were used as reference standard for surgically treated patients; non-surgical candidates underwent follow-up imaging.

RESULTS

Lesion detection rate was similar for MSCT and MRI (76 and 80%, respectively, p = 0.648). Lesion characterization was significantly superior (p = 0.021) at MRI (89%, κ 0.747, p = 0.001) compared to MSCT (77%, κ 0.235, p = 0.005). Interobserver variability for diameter measurement was not significant at MRI (p = 0.909 [95% CI -1.245 to 1.395]), but significant at MSCT (p = 0.028 [95% CI -3.349 to -2.007]). Differences in diameter measurement were independent of observer (p = 0.131), and no statistical effect from imaging modality on diameter measurement was observed (p = 0.095).

CONCLUSION

MRI is superior to MSCT in preoperative characterization and measurement of CRLM after NAC. Lesion detection rates for both modalities are comparable.

Combined effect of cerebral hypoperfusion and white matter lesions on executive functioning - The SMART-MR study

BACKGROUND/AIMS

It has been hypothesized that cerebral hypoperfusion may contribute to cognitive deterioration. Patients with white matter lesions (WML) may be more vulnerable to a decrease in cerebral blood flow (CBF) due to an impaired autoregulation. We investigated the association between CBF and cognitive performance and whether WML modified this relation.

METHODS

Within the SMART-MR study, a cohort study among patients with manifest arterial disease, cross-sectional analyses were performed in 472 patients (mean age 57 +/- 10 years, 77% male). Total CBF was measured with magnetic resonance angiography in the internal carotid arteries and basilar artery, and was expressed per 100 ml brain volume. Neuropsychological tests assessing executive functioning and memory were performed and composite scores were calculated. We used linear regression analyses, adjusted for age, sex, education and intelligence, to investigate the association between CBF and cognitive performance.

RESULTS

We found that WML modified the association between CBF and executive functioning (p for interaction <0.001); the association between lower CBF and worse performance on executive functioning became stronger and significant with increasing volumes of WML. Lower CBF was not associated with worse memory.

CONCLUSION

Our results suggest that a combination of lower CBF and WML may impair executive functioning but not memory.

Blood pressure and progression of cerebral atrophy in patients with vascular disease

BACKGROUND

Cerebral atrophy on brain magnetic resonance imaging (MRI) has been associated with vascular risk factors including hypertension. Progression of cerebral atrophy and its risk factors have not been studied in vascular disease patients. This study aimed to assess the progression of cerebral atrophy and to evaluate possible associations with blood pressure (BP) in patients with pre-existing vascular disease.

METHODS

A total of 331 patients with manifest vascular disease from the Second Manifestations of ARTerial Disease (SMART) Study underwent baseline and follow-up MRI scanning (mean follow-up 4.1 +/- 0.3 years). The annual change in brain and ventricular volume was calculated with an automated quantitative volumetric method. Associations between BP and change in brain and ventricular volumes and between BP and the occurrence of lacunar infarcts were analyzed.

RESULTS

At baseline mean age was 58 +/- 9 years and mean BP was 138/80 mm Hg. Mean annual decrease in brain tissue volume was 6.5 +/- 3.8 ml and mean annual increase in ventricular volume was 1.0 +/- 1.0 ml. There was no association observed between BP and annual change in brain or ventricular volume, but a clear association was found between BP and incident lacunar infarcts (odds ratio 1.57; 1.11-2.22 per s.d. increase in systolic BP (SBP)).

CONCLUSIONS

The magnitude of changes in brain tissue and ventricular volume in patients with vascular disease was comparable to the physiological changes described in normal people at a much higher age. Progression of cerebral atrophy in this population may be associated with advanced physiological aging, but is probably not caused by elevated BP.

Cerebral perfusion in relation to cognitive function and type 2 diabetes

AIM/HYPOTHESIS

Underlying mechanisms for decreased cognitive functioning in patients with type 2 diabetes are unclear. In the general population, cerebral hypoperfusion is a risk factor for cognitive dysfunction and dementia. Reduced cerebral perfusion may account for cognitive impairments in diabetic patients relative to controls.

METHODS

A total of 98 patients with type 2 diabetes and 47 control participants underwent neuropsychological evaluation. Total cerebral blood flow (CBF) was assessed non-invasively by measuring the volume flow in the internal carotid arteries and basilar artery with two-dimensional phase-contrast magnetic resonance angiography. Relative total CBF, a measure of mean total cerebral perfusion, was obtained by expressing total CBF per 100 ml brain parenchyma volume.

RESULTS

Patients with type 2 diabetes performed worse on neuropsychological tests (p < 0.05). Total CBF per 100 ml brain parenchyma volume did not differ between participants with and without diabetes (difference -2.3 ml min(-1) 100 ml(-1); 95% CI -6.0, 1.3). In the entire group, total CBF per 100 ml brain parenchyma volume was positively associated with cognitive functioning (0.09 SD increase in composite z score per 10 ml min(-1) 100 ml(-1) increase in relative total CBF). This association was not affected by type 2 diabetes.

CONCLUSIONS/INTERPRETATION

Although total CBF per 100 ml brain parenchyma volume was associated with cognitive functioning, it did not explain cognitive impairments in patients with type 2 diabetes relative to controls.

Endovascular Treatment of the Internal Iliac Artery in Peripheral Arterial Disease

In patients with peripheral arterial disease not much is known about the relationship between the localization of the pain and the localization of arterial occlusions in the iliac arteries. Occlusions high in the iliac arteries are assumed to be able to induce pain in the buttocks and upper leg as well as pain in the calves. Several case reports show that the symptoms of arteriosclerotic lesions in the internal iliac artery are often atypical and not easy to diagnose. In this report, 3 patients with internal iliac artery occlusions who were treated with percutaneous transluminal angioplasty (PTA) are described. One patient had isolated pain in the buttock region. In the other 2 patients the initial pain was focused on the buttock region with extension to the calves during exercise. After PTA, 2 patients were free of symptoms, while in the other patient the symptoms improved but did not disappear. Future research should clarify the relation between certain arterial occlusions and the location of the pain.

[Ancillary diagnostic imaging is useful if there is atypical evidence of appendicitis]

Patients with an atypical presentation of acute appendicitis may benefit from ancillary diagnostic imaging, especially CT. The literature shows a decrease of the number of negative appendectomies with this approach, and other causes are diagnosed in about one third of the patients. In addition, costs were reduced. Ultrasonography is a good alternative in pregnant women and in women with suspected gynaecological pathology.

Percutaneous vertebroplasty compared with optimal pain medication treatment: short-term clinical outcome of patients with subacute or chronic painful osteoporotic vertebral compression fractures. The VERTOS study

PURPOSE

To prospectively assess the short-term clinical outcome of patients with subacute or chronic painful osteoporotic vertebral compression fractures (VCF) treated with percutaneous vertebroplasty (PV) compared with optimal pain medication (OPM).

METHODS

Randomization of patients in 2 groups: treatment by PV or OPM. After 2 weeks, patients from the OPM arm could change therapy to PV. Patients were evaluated 1 day and 2 weeks after treatment. Visual analog score (VAS) for pain and analgesic use were assessed before, and 1 day and 2 weeks after start of treatment. Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO) and Roland-Morris Disability (RMD) questionnaire scores were assessed before and 2 weeks after start of treatment. Follow-up scores in patients requesting PV treatment after 2 weeks OPM treatment were compared with scores during their OPM period.

RESULTS

Eighteen patients treated with PV compared with 16 patients treated with OPM had significantly better VAS and used less analgesics 1 day after treatment. Two weeks after treatment, the mean VAS was less but not significantly different in patients treated with OPM, whereas these patients used significantly less analgesics and had better QUALEFFO and RMD scores. Scores in the PV arm were influenced by occurrence of new VCF in 2 patients. After 2 weeks OPM, 14 patients requested PV treatment. All scores, 1 day and 2 weeks after PV, were significantly better compared with scores during conservative treatment.

CONCLUSION

Pain relief and improvement of mobility, function, and stature after PV is immediate and significantly better in the short term compared with OPM treatment.

[A combined protocol using CT, CT perfusion and CT angiography for the evaluation of cerebral ischemia]

Computed tomography (CT) is a widely available, rapid and readily accessible technique for imaging of the brain by means of which other disorders, such as haemorrhage, can be excluded in patients with the signs of an acute cerebral infarction. Recently, CT perfusion and CT angiography have become available for this clinical application. These investigations can be performed in the same session as conventional CT, without significant delay. A combined CT protocol provides information on both cerebral perfusion and the patency of the extra- and intracranial arteries and can therefore yield valuable additional information in the diagnostic work-up and treatment of patients with acute cerebral ischaemia. Current and future research will have to determine the definitive value of these techniques in clinical practice.

Anatomic Variations in the Circle of Willis in Patients with Symptomatic Carotid Artery Stenosis Assessed with Multidetector Row CT Angiography

PURPOSE

To assess the presence of anterior and posterior collateral pathways in the circle of Willis in patients with symptomatic carotid artery stenosis (SCAS) and to compare this to patients without carotid artery stenosis.

MATERIALS AND METHODS

Multislice CT angiography was performed in 91 patients and 91 control subjects. Using consensus reading, 2 observers evaluated the presence and diameter of the anterior communicating artery (AcomA), the A1 segments of the anterior cerebral arteries, the posterior communicating arteries (PcomA) and the P1 segments of the posterior cerebral arteries. Anterior or posterior pathways were assumed to be present if the diameter of continuous arterial segments was >1 mm; both A1 segments and AcomA anterior, and ipsilateral P1 segment and PcomA posterior. Comparison between patients and controls was performed using the chi(2) test.

RESULTS

In the patients we found significantly more hypoplastic (<1 mm) or invisible A1 segments (16 and 14 vs. 4 and 1, respectively, p < 0.01). The AcomA was invisible in 4 patients versus 1 control. An isolated compromised anterior pathway and a combined compromised anterior and posterior pathway occurred more frequently in the patients as compared to the controls; 9 versus 1% (p < 0.01) and 26 versus 4% (p < 0.01).

CONCLUSION

A compromised anterior collateral pathway, usually combined with a compromised posterior pathway, occurs more frequently in patients with SCAS as compared to controls, which suggests a relation between symptomatic carotid stenosis and an incomplete circle of Willis.

A fetal circle of Willis is associated with a decreased deep white matter lesion load

OBJECTIVE

To investigate the relationship between morphologic differences in the circle of Willis and the presence and location of white matter lesions (WMLs).

METHODS

Two hundred forty-three consecutive patients with clinical manifestations of atherosclerotic disease underwent MRI of the brain and MR angiography of the circle of Willis.

RESULTS

Subjects with a fetal configuration of the circle of Willis demonstrated a decreased load of small (p < 0.01) and medium (p < 0.01) deep WMLs compared with subjects with a nonfetal configuration of the posterior part of the circle of Willis.

CONCLUSION

A fetal configuration of the posterior part of the circle of Willis may be an important protecting determinant in the etiology of white matter lesions.

[Women with pelvic complaints and atypical varicose veins, varicose veins of the vulva and insufficiency of the pelvic veins; treatment with embolisation]

In three women, aged 34, 52 and 30 years, respectively, who suffered from chronic pelvic symptoms such as a heavy feeling and abdominal pain, atypical varicose veins were observed on the medial side of the upper thighs together with varicose veins of the vulva; these are indicators of insufficiency of the pelvic veins. The symptoms were reduced following embolisation of the insufficient pelvic veins. These symptoms are also known as the pelvic congestive syndrome. The exact correlation between insufficiency of the pelvic veins and the complaints mentioned above has not yet been determined, but it seems that in most patients the symptoms diminish or disappear following embolisation of the insufficient pelvic veins. When patients complain of chronic pelvic pain of unknown aetiology, one should look for atypical varices and vulval varices and consider pelvic-vein insufficiency as a possible cause.

Cerebral hemodynamics and metabolism in patients with symptomatic occlusion of the internal carotid artery

BACKGROUND AND PURPOSE

The goals of this study were to investigate (1) whether the concentrations of choline, creatine, and N-acetyl aspartate (NAA) in cerebral white matter are changed in patients with symptomatic occlusion of the internal carotid artery (ICA) and (2) whether possible changes in metabolite concentration are related to regional cerebral perfusion or cerebral vasoreactivity.

METHODS

In 19 patients (mean+/-SD age, 60+/-9 years), white matter metabolite concentrations were measured with proton MR spectroscopic imaging on average 4+/-2 months after symptoms occurred. In selected voxels, corresponding cerebral blood flow and volume, mean transit time, and time-to-bolus peak were determined with dynamic susceptibility contrast MRI. Cerebral CO2 reactivity was determined with transcranial Doppler sonography.

RESULTS

No significant changes in choline and creatine concentrations were observed. NAA concentration was significantly reduced in the hemisphere on the side of the symptomatic ICA (9.1+/-1.7 mmol/L) compared with the contralateral hemisphere (10.5+/-1.7 mmol/L, P<0.005) and control subjects (10.5+/-0.9 mmol/L, P<0.01). Although no significant interhemispheric difference in NAA concentration was found in patients who presented with retinal ischemia, patients with cerebral ischemia had a significantly lower NAA concentration in the symptomatic hemisphere (9.0+/-1.7 mmol/L) compared with the asymptomatic hemisphere (10.4+/-1.6 mmol/L, P<0.05). In all patients, NAA concentration was not significantly correlated with quantitative cerebral perfusion parameters or CO2 reactivity.

CONCLUSIONS

Patients with symptomatic ICA occlusion may show chronic neuronal damage in cerebral white matter as evidenced by reduced NAA concentration. This seems to be related to previous symptomatology rather than to the cerebral hemodynamic status in a chronic stage.

MR angiography of the lower extremities with a moving-bed infusion-tracking technique

PURPOSE

To assess the value of MR angiography (MRA) with automatic table movement in a consecutive series of patients with peripheral arterial disease.

METHODS

Seventy-two patients underwent both conventional angiography (CA) and MRA for peripheral arterial occlusive disease. Both techniques were scored in a masked way. Consensus scoring for CA was compared with MRA scoring per observer. If there was a discrepancy in scoring of a segment on MRA and CA, the images were reviewed and a consensus arrived at.

RESULTS

Observer A found 7.4% and observer B found 6.5% of the segments could not be analyzed on MRA. Observer A scored 11.4% dissimilar on MRA and CA, observer B 15.2%. In the aortoiliac arteries, this was mainly caused by stents and overestimation of stenoses; in the crural arteries it resulted from underestimation of the stenoses on MRA. Overall sensitivity and specificity for the aortoiliac, femoropopliteal and crural vessels were respectively 90% and 91%, 90% and 96%, 59% and 96% for observer A, and 85% and 91%, 84% and 89%, 68% and 85% for observer B.

CONCLUSION

Although MRA of the lower extremities is a promising technique, improvements still need to be made. In particular, MRA below the knee is suboptimal for clinical use.