Controlled Multicenter Pilot Study of Urokinase – Heparin and Streptokinase in Deep Vein Thrombosis

Thirty-three patients with acute iliofemoral thrombosis were randomly assigned to three treatment groups in a pilot doseranging study of thrombolytic therapy in deep vein thrombosis. One group received tissue culture urokinase in a dose of 2,200 I.U./kg/hr, and a second group in a dose of 1,100 I.U./kg/hr following a loading dose of 4,400 I.U./kg given in ten min. Urokinase was administered for 12 hr periods, alternating with 12 hr periods of heparin. A third group received an initial dose of 250,0001.U. of streptokinase in 20 min, followed by 100,000 I.U./hr. Treatment of all patients continued for three days. At the end of this period little improvement, evaluated by “blinded” interpretation of pre- and post-treatment phlebograms, was found in five out of ten of the higher-dose urokinase patients, seven out of eleven of lower-dosage urokinase patients, and six out of ten of streptokinase patients. Optional treatment for another three days showed little further improvement of urokinase-patients and moderate further improvement in the streptokinase-patients. – Neither of the 2 dosage schemes at intermittent application of urokinase appeared to be advantageous. Urokinase treated patients experienced fewer adverse reactions.

Side Effects of Thrombolytic Treatment with Porcine Plasmin and Low Dose Streptokinase

In the sequential thrombolytic therapy with porcine plasmin and low dose streptokinase side effects are mainly due to bleeding, intolerance reactions are less important. Treatment had to be prematurely stopped in 42 (37%) of 114 DVT cases because of severe bleeding and in 12 (10%) due to intolerance reactions. The corresponding figures for the 45 cases with arterial occlusions are 15 (33%) and 2 (4%) respectively. The intensity of systemic proteolysis as represented by the thromboplastin time is significantly correlated with haemorrhagic manifestations. Macrohaematuria and bleeding from puncture sites are the most frequent haemorrhagic complications followed by spontaneous bleeding into skin and muscles. Non-fatal intracranial bleeding occurred in 1 DVT case (0.9%) and in 2 patients with arterial occlusions (4.4%). The benefit of this potent thrombolytic regimen would greatly improve if a strong reduction of premature treatment stop could be achieved.

Sequential Treatment of Deep Leg Vein Thrombosis with Porcine Plasmin and Low Dose Streptokinase

Sequential treatment of deep leg vein thrombosis with porcine plasmin and low dose streptokinase (10,000-20,000 U/h) produces strong systemic fibrinolysis as demonstrated by the sustained decrease of euglobulin lysis time, of thromboplastin time values in percent, fibrinogen and factor V levels. There is a statistically significant negative correlation between thrombolytic results and euglobulin lysis time. Treatment periods below 3 days are unlikely to give satisfactory results. Occluded vein segments with an apparent median age of 4 days including thrombi older than 10 days (20% of cases) are cleared with an average chance of 50%. Complete dissolution of all thrombi proximal to the crural veins has been demonstrated in 47/114 = 41.2%, some thrombolytic effect in 31/114 = 27.2% and treatment failure in 36/114 = 31.6%. The data favour laboratory monitoring of thrombolytic therapy.

Sequential Treatment of Arterial Occlusions with Porcine Plasmin and Low Dose Streptokinase

Sequential treatment of arterial occlusions of the leg with porcine plasmin and low dose streptokinase results in a strong systemic proteolysis as already seen in deep leg vein thrombosis. In 31 of 45 patients the blood flow through major arterial segments could be restored. Thrombolytic success is possible within the first two treatment days but for the majority of the cases fibrinolytic therapy for 3-6 days is needed. On the average treatment was 1 day shorter than in DVT cases. No statistical relationship between local thrombolysis and systemic proteolysis was detected.

The thrombolytic efficacy of this regimen compares favourably with earlier experience on fibrinolytic therapy in arterial occlusions.

A new rotational thrombectomy catheter: system design and first clinical experiences

PURPOSE

To describe a new catheter for the percutaneous mechanical removal of fresh and organized thrombi, and to assess its efficacy and safety in vitro and in vivo.

METHODS

The catheter consists of a coated stainless steel spiral that rotates at 40,000 rpm over a guidewire inside the whole length of an 8 Fr, single-lumen, polyurethane catheter, driving a dual-blade cutting crown. Abraded occlusion material is sucked into the catheter head through distal side holes and transported by the spiral into a reservoir at the proximal end. The efficacy of the device was tested in arterial models and fresh bovine carotid arteries (n = 72). In a clinical pilot study 10 patients (8 women, 2 men; mean age 70.6 +/- 10.1 years) with occlusions of the superficial femoral artery (2-12 cm, mean 5.8 cm), not older than 4 weeks, underwent thrombectomy with the new catheter.

RESULTS

In arterial models and bovine cadaver arteries the catheter completely removed fresh thrombi. Occlusion material of higher consistency was cut into particles of 100-500 micron and transported outside. Thrombectomy was successful and vessel patency restored in all 10 patients. The ankle/brachial pressure index significantly (p < 0.0005) increased from 0.41 +/- 0. 18 before intervention to 0.88 +/- 0.15 after 48 hr and to 0.84 +/- 0.20 after 3 months. Two reocclusions occurred within 14 days after the intervention.

CONCLUSION

Thrombectomy with the new device appears to be feasible and safe in patients with acute and subacute occlusions of the femoropopliteal artery.

Influence of variability of interpretation of contrast venography for screening of postoperative deep venous thrombosis on the results of a thromboprophylactic study

To assess interobserver variability of venography for screening for postoperative deep venous thrombosis (DVT), we used 185 bilateral ascending contrast venograms (366 lower limbs) which were performed using the long-leg film technique, in the frame of a trial of the efficacy of two low-molecular-weight-heparin fractions (initial evaluation). These venograms were submitted in a multicenter setting to three further readers who performed a serial scoring as DVT, no DVT or non-evaluable. DVTs were diagnosed in 78, 55 and 59/366 limbs (initial evaluation: 58). The proximal locations of DVTs were 16, 9 and 16 (initial evaluation: 15) and the non evaluable limbs 3, 5 and 18 (initial evaluation: 0). Apparent pairwise agreement between the three readers ranged from 87 to 90% (true coefficient of agreement Kappa 0.63-0.70). It ranged from 89 to 93% (Kappa 0.63-0.74) for the comparison between the readers and the initial evaluation. This considerable degree of disagreement among experienced readers should be taken into account in calculating sample sizes in prospective thromboprophylactic studies. Indeed, one of the two prophylactic regimens proved to be significantly (p = 0.012, p = 0.031, p = 0.049) or non-significantly (p = 0.073) superior to the other one depending upon the reading of venograms.

Venography of the lower limbs. Pitfalls of the diagnostic standard. The ETTT Trial Investigators

RATIONALE AND OBJECTIVES

Phlebography is considered the diagnostic standard for suspected deep venous thrombosis. The authors studied the inter-observer variability of phlebogram interpretation in the setting of a multicenter therapeutic trial of the thrombolytic agent alteplase.

METHODS

The interpretation of 31 pairs of venograms (before and after thrombolytic therapy) was studied by comparing the quantitative Marder's scores which were computed by three experts and the qualitative assessment of phlebographic changes induced by thrombolysis by the panel of experts and by the investigators.

RESULTS

Although the scores of the three experts correlated fairly well (r = .67-.82; P < .001), they differed significantly from each other (P < .0001). Substantial differences also were found between local (by investigators) qualitative evaluation of the venographic changes induced by the treatment and central evaluation by the panel of experts (coefficient of agreement kappa = 0.19), local assessment being significantly more optimistic (P = .002) than central judgment.

CONCLUSION

Significant differences were observed between assessment of changes in venographic scores after thrombolytic treatment both among three expert radiologists, and between the panel of experts and the local investigators of the multicenter trial. This observation points to the need for an a priori definition of well-characterized decision criteria to allow a valid interpretation of the effects of the therapeutic intervention.

Thrombosis of the popliteal vein

Among 3,307 consecutive patients (3,556 legs) with deep venous thrombosis, 54 (1.5%) showed an isolated thrombus of the popliteal vein on phlebography. The majority of those had a history of "effort" or long lasting flexion during air or bus travel. Forty-four percent suffered from pulmonary embolism as the first sign of deep venous thrombosis. Functional phlebography demonstrated the primary site of thrombosis at folds forming in the vein wall at flexion. In order to further elucidate the pathogenetic mechanism, 158 popliteal veins were examined phlebographically in different functional states revealing age-related characteristic wall patterns of rings and folds in flexion causing transient impairment of flow. Complementary morphological studies of 120 popliteal veins during autopsy showed a transverse rippling of the vein wall caused by intimal fibrosis and partial atrophy of the media corresponding to the phlebographic findings. It is concluded that microtrauma during effort in combination with impaired venous backflow and fibrotic transformation of the venous wall can lead to thrombus formation in the popliteal vein.

[Percutaneous transluminal coronary angioplasty]

Since its first application in a patient, PTCA has undergone a tremendous evolution: Based on growing experience and due to technical developments, indications have been markedly extended. Despite the fact that PTCA has been used in more risky situations, the primary success rate has risen and the rate of severe complications has dropped. This evolution is shown based on the Basel experience and on data from Switzerland. The problem of restenosis, however, has not been solved and remains the main problem to be looked for during follow-up of these patients.

Prevention of aortocoronary vein bypass graft occlusion: which antithrombotic treatment and for how long?

The effects of 50 mg aspirin combined with 400 mg dipyridamole were compared with those of standard anticoagulant therapy, in the prevention of aortocoronary vein bypass graft occlusion. Early graft occlusion in 249 patients, with 749 distal vein graft anastomoses, were angiographically assessed 11.5 +/- 2 days after surgery and were almost equal in both treatment groups. In half of the patients in each group, active treatment was replaced by placebo after 3 months. Repeat angiography after 1 year (360 +/- 24 days) showed that more new late graft occlusions occurred in patients with only 3 months active medication (either regimen). The incidence of major complications was significantly higher in patients treated with anticoagulants, with minor side-effects more common in the antiplatelet group. Thus, this antiplatelet drug regimen was as effective as standard anticoagulant therapy in the prevention of early and late bypass graft occlusion, but carried a significantly lower risk of severe complications. In addition, as replacement of active treatment by placebo after 3 months resulted in significantly more graft occlusions, antithrombotic treatment should be continued for at least one year after coronary artery bypass graft surgery.

[How long should antithrombotic therapy be continued following aortocoronary bypass surgery?]

In a prospective randomized trial the effect of prolonged antithrombotic treatment with anticoagulants or antiplatelet drugs (50 mg aspirin + 400 mg dipyridamole daily) on late bypass-graft occlusion was studied. After 3 months active treatment was replaced by placebo in half of the patients. Between the angiographic checkups 2 weeks and 12 months postoperatively, 28/330 (8%) new graft occlusions had occurred on continued therapy, versus 44/319 (14%) on placebo (p = 0.03). This difference was most pronounced in individual grafts (6% vs 12%, p = 0.01), so that fewer patients with 12 months' active therapy had at least one occluded graft (22% versus 32%, p = 0.08). These findings suggest that antithrombotic treatment should not be halted 3 months after CABG surgery but should be continued for at least one year and possibly longer.

[Emergency coronary dilatation in acute myocardial infarct with contraindications to thrombolytic therapy: salvage of the myocardium by early intervention]

In 1986/87, emergency-PTCA in acute myocardial infarction was performed in 13 patients in whom thrombolysis was contraindicated. All infarct-related arteries could be opened with PTCA. Patency rate after one week was 94%. Reopening of the vessel resulted in immediate cessation of ischemic chest pain and in stable cardiac rhythm and hemodynamics. Prior cardiopulmonary resuscitation and/or cardiogenic shock did not influence short- or longterm outcome. In nine of eleven patients an improvement of left ventricular function was found after four to six months as compared to one to four weeks after PTCA. The functional result proved to be better if PTCA was performed early; PTCA within 90 minutes was associated with normal left ventricular function. Thus, PTCA is feasible as an emergency procedure in patients with acute myocardial infarction and contraindications to thrombolysis. It can salvage myocardium and improve or prevent severe infarct complications when performed early after onset of pain. Rapid hospital admission through the primary care physician importantly influences the outcome for these patients.

Trial of low-dose aspirin plus dipyridamole versus anticoagulants for prevention of aortocoronary vein graft occlusion

In a prospective randomised trial, 249 patients who had aortocoronary vein bypass surgery were assigned either to a platelet inhibitory drug regimen or to standard anticoagulant therapy. Treatment was replaced by placebo in half of the patients in each group after 3 months. The platelet inhibitory drug regimen--very low-dose aspirin combined with dipyridamole--was as effective as standard anticoagulant therapy to prevent early and late graft occlusion. Death, myocardial infarction, and severe bleeding occurred significantly more often in patients receiving anticoagulants, whereas mild drug-related gastrointestinal and cerebral side-effects were more common in patients taking platelet inhibitory drugs. Antithrombotic treatment should be continued for at least 1 year after coronary artery bypass graft surgery.

[Etiology and long-term course of subclavian vein thrombosis with reference to acute therapy]

Contrary to deep venous thrombosis of the lower extremity, subclavian vein thrombosis (SVT) is rather rare. Although the problem has been known for more than 100 years, the rarity of its incidence accounts for the persistent uncertainty concerning the indication and modalities of acute therapy as well as the long-term course. In the majority of 96 patients observed between 1976 and 1983 SVT was due to central venous catheter, neoplasm and thoracic outlet syndrome. 2 of 96 patients developed pulmonary embolism. 45 patients without malignancy were available for follow-up studies. Acute therapy included anticoagulation in 27, fibrinolysis in 10 and rib resection in 8 cases. The mean follow-up averaged 6.3 years and confirmed a favorable course independent of the acute therapy modality. There were none of the trophic alterations so often found in the lower extremity and no patient was unable to work as a consequence of SVT. However, minor late sequelae occurred quite frequently: slight symptoms in one third, and minor incapacity for sport in 25% of the cases. 75% of the patients showed clinical signs of stasis, such as venous bypass circulation, edema and/or cyanosis. The average post-thrombotic score (1.3 out of a possible 4) confirms the minor significance of the findings. A rather important reduction in venous backflow was found by plethysmography in 4% of the patients. We favor immediate anticoagulation, mainly to cover the risk of pulmonary embolism. This should be continued for at least 3 months in order to prevent early recurrence of thrombosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Deep venous thrombosis of the upper extremities]

Deep vein thrombosis of the upper extremity is rare. While its pathogenesis is not always evident, it often occurs in connection with tumors, thoracic outlet syndrome or intravenous catheter therapy. Acute thrombosis of the subclavian vein usually is a clinical diagnosis, but in doubtful cases diagnostic tests such as Doppler ultrasound and/or plethysmography may be useful. If necessary, verification of subclavian vein thrombosis can be done by phlebography. Considering the incidence of thromboembolic complications such as pulmonary embolism, anticoagulation is indicated in all cases of acute thrombosis. Under standard conservative treatment residual symptoms following the venous occlusion are few and the prognosis is favorable. Therefore, invasive treatment such as thrombectomy or thrombolysis should be considered only in special cases.

[Dipyridamole and low-dose aspirin in patients with aortocoronary bypass--comparison with anticoagulation]

The effects of antiplatelet therapy (AP; dipyridamole 400 mg [beginning 2 days preoperatively] + aspirin 50 mg/day) and anticoagulation (AC) were compared prospectively in 251 patients with coronary artery bypass grafting (CABG). Two weeks postoperatively, 85.2% of AP and 81% of AC patients had all grafts patent with graft patency rates of 93.6% and 91.3% respectively (p = n.s.) Significant differences in favour of AP therapy were found in subgroups with multiple grafts and with low intraoperative graft flow. Up to 3 months postoperatively, severe complications occurred in 22 AC patients (11 bleedings) but only in 9 patients on AP therapy (p less than 0.01). Overall, AP therapy should therefore be preferred to AC in patients with CABG surgery.

Non-invasive grading of aortic regurgitation by Doppler ultrasonography

Doppler ultrasound without concomitant echocardiographic imaging was used to grade isolated aortic regurgitation in 21 patients. The severity of aortic regurgitation was subsequently graded (from 0 to IV) angiographically. A 2 MHz continuous wave Doppler transducer was placed over the apex of the heart and the beam was aimed parallel to the mitral flow by means of acoustic guidance. Mitral pressure half time was calculated from the analogue maximum velocity tracing and it was less than or equal to 60 ms in 10 controls; 50-120 ms in five patients with grade II, 120-160 ms in nine patients with grade III, and greater than or equal to 160 ms in seven patients with grade IV aortic regurgitation. These results indicate that a semi-quantitative grading of aortic regurgitation may be obtained non-invasively with non-imaging Doppler ultrasonography in patients without concomitant mitral valve disease.

[Relation between intraoperative blood flow measurements and graft patency afer aortocoronary bypass surgery]

During aorto-coronary bypass surgery, electromagnetic flow measurements of venous grafts were performed in 50 consecutive patients at rest and after stimulation with papaverine (2 mg) to assess whether early postoperative patency was predictable. The overall patency rate at day 9-11 was 95.4% (145/152 distal grafts; 118 proximal grafts). Flow in all bypass grafts averaged 52.5 +/- 31.4 ml/min and increased after papaverine stimulation by 46.9 +/- 32.2 ml/min (p less than 0.01). 5 of 6 grafts with a flow of less than 30 ml/min and without adequate flow increase after papaverine (less than 80%) were occluded. Grafts with a flow of greater than or equal to 30 ml/min or an increase of greater than or equal to 80% after papaverine, had a high short-time patency rate (98%). Thus, perioperative flow measurements combined with papaverine stimulation predicted early patency of single grafts with an accuracy of 95%.

[The fate of the patient with deep vein thrombosis]

Late results in 278 consecutive patients with unilateral deep vein thrombosis treated with streptokinase or heparin/dicoumarol were analysed as to mortality rate, recurrent thrombo-embolism and incidence of postthrombotic syndrome (PTS). The five-year mortality rate was three times as high as that of the age-matched population. The overall mortality rate was 16%, more than half the patients dying of tumour, males largely of gastric or bronchial carcinoma, females of urogenital carcinoma. Thrombo-embolism had recurred in 14% of 204 patients who had been re-examined, in 9% thrombosis, in 3% pulmonary embolism, and in 2% both. A PTS without ulcer had developed in 16%, an ulcer in 8%. The PTS incidence correlated with the original extent of the thrombosis: no PTS if the thrombosis had been confined to the lower-leg axis, but 34% after four-level thrombosis. The data confirm the importance of thrombo-embolism prophylaxis, early diagnosis and subsequent treatment with anticoagulants and compression.

Traumatic pulmonary pseudocysts and paramediastinal air cyst: two rare complications of blunt chest trauma

Traumatic pulmonary pseudocysts and paramediastinal air cysts due to closed chest trauma are very uncommon. Minor clinical symptoms and major radiologic signs are characteristic of this form of injury to the lung parenchyma. Treatment of combined pseudocysts and pneumatocele in a 17-year-old girl is described. Chest X-ray and computed tomography provided the diagnosis. No surgical treatment was required. Intensive bronchial toilet and PEEP-assisted respiration by mask were followed by recovery. This condition must be differentiated from lung abscesses after infected hematomas, specific cavities, or congenital pulmonary cysts.

Reproducibility of left ventricular volume determinations with use of a semi-automated system

Reliability of a computer-assisted system for determination of left ventricular volumes was judged by multiple measurements of rotation ellipsoids, cadaver hearts, and cineangiograms from patients. The volume measurements in cadaver hearts provided a volume correction factor necessary for reproducible results. Variation coefficient for intraobserver and interobserver variability did not exceed 2.3% when calculated using rotation ellipsoids and was highest at 12.0% for the end-systolic volumes derived from patient films. When appropriate calibration methods are employed, different observers can make reliable left ventricular volume measurements aided by such systems.

Controlled multicenter pilot study of urokinase- heparin and streptokinase in deep vein thrombosis

Thirty-three patients with acute iliofemoral thrombosis were randomly assigned to three treatment groups in a pilot dose-ranging study of thrombolytic therapy in deep vein thrombosis. One group received tissue culture urokinase in a dose of 2,200 I.U./kg/hr, and a second group in a dose of 1,100 I.U./kg/hr following a loading dose of 4,400 I.U./kg given in ten min. Urokinase was administered for 12 hr periods, alternating with 12 hr periods of heparin. A third group received an initial dose of 250,000 I.U. of streptokinase in 20 min, followed by 100,000 I.U./hr. Treatment of all patients continued for three days. At the end of this period little improvement, evaluated by "blinded" interpretation of pre- and post-treatment phlebograms, was found in five out of ten of the higher-dose urokinase patients, seven out of eleven of lower-dosage urokinase patients, and six out of ten of streptokinase patients. Optional treatment for another three days showed little further improvement of urokinase-patients and moderate further improvement in the streptokinase-patients. Neither of the 2 dosage schemes at intermittent application of urokinase appeared to be advantageous. Urokinase treated patients experienced fewer adverse reactions.

[Lymphangioma--a rare cause of a space-occupying lesion at the base of the skull]

A case of an extremely rare lymphangioma of the sphenoid sinus in a 58-year-old woman is described in order to discuss the histogenesis, histopathology, and clinical symptomatology of lymphangiomas located in the base of the skull. The clinically silent course for many years is typical, as is the onset of acute symptoms after bleeding into the tumour. The therapy of choice is to achieve decompression. Prior to this, an aneurysma or a hemangioma should be excluded by fine-needle puncture or by puncture cytology.

Accuracy of serial myocardial perfusion scintigraphy with thallium-201 for prediction of graft patency early and late after coronary artery bypass surgery. A controlled prospective study

To assess the accuracy of serial myocardial perfusion scintigraphy with thallium-201 (201Tl) to predict graft patency early and late coronary artery bypass surgery, rest and exercise 201Tl and coronary arteriography were performed preoperatively and 2 weeks and 1 year after operation. The scintigraphic results were compared with graft patency, symptoms, left ventricular function and physical work capacity in a consecutive series of 55 patients with a total of 154 grafts. Serial 201Tl had an 80% sensitivity, 88% specificity and 86% overall accuracy in detecting or excluding graft occlusion, which was predicted by reversible ischemia as well as persistent "new scar" segments. Occluded grafts were correctly localized by 201Tl scintigraphy in 61%. Postoperative apical 201Tl defects were frequent (two-thirds of cases), and were the result of intraoperative transapical venting of the left ventricle. After coronary bypass graft surgery, ejection fraction at rest was unchanged. Left ventricular end-diastolic pressure and physical work capacity improved significantly. In the presence of new perfusion defects detected postoperatively, physical work capacity was reduced significantly. New 201Tl defects in addition to typical or atypical angina provided a high probability of graft occlusion, while in the absence of new 201Tl defects all grafts were patent in more than 90% of patients, all of whom had no or only atypical chest pain. We conclude that serial 201Tl imaging after coronary artery bypass surgery is an accurate noninvasive method that can be used routinely to assess graft function, to localize spatially occluded grafts and to identify patients with a high likelihood of graft occlusion who may need invasive studies.

Side effects of thrombolytic treatment with porcine plasmin and low dose streptokinase

In the sequential thrombolytic therapy with porcine plasmin and low dose streptokinase side effects are mainly due to bleeding, intolerance reactions are less important. Treatment had to be prematurely stopped in 42 (37%) of 114 DVT cases because of severe bleeding and in 12 (10%) due to intolerance reactions. The corresponding figures for the 45 cases with arterial occlusions are 15 (33%) and 2 (4%) respectively. The intensity of systemic proteolysis as represented by the thromboplastin time is significantly correlated with haemorrhagic manifestations. Macrohematuria and bleeding from puncture sites are the most frequent haemorrhagic complications followed by spontaneous bleeding into skin and muscles. Non-fatal intracranial bleeding occurred in 1 DVT case (0.9%) and in 2 patients with arterial occlusions (4.4%). The benefit of this potent thrombolytic regimen would greatly improve if a strong reduction of premature treatment stop could be achieved.

Sequential treatment of arterial occlusions with porcine plasmin and low dose streptokinase

Sequential treatment of arterial occlusions of the leg with porcine plasmin and low dose streptokinase results in a strong systemic proteolysis as already seen in deep leg vein thrombosis. In 31 of 45 patients the blood flow through major arterial segments could be restored. Thrombolytic success is possible within the first two treatment days but for the majority of the cases fibrinolytic therapy for 3-6 days is needed. On the average treatment was 1 day shorter than in DVT cases. No statistical relationship between local thrombolysis and systemic proteolysis was detected. The thrombolytic efficacy of this regimen compares favourably with earlier experience on fibrinolytic therapy in arterial occlusions.

Sequential treatment of deep leg vein thrombosis with porcine plasmin and low dose streptokinase

Sequential treatment of deep leg vein thrombosis with porcine plasmin and low dose streptokinase (10,000-20,000 U/h) produces strong systemic fibrinolysis as demonstrated by the sustained decrease of euglobulin lysis time, of thromboplastin time values in percent, fibrinogen and factor V levels. There is a statistically significant negative correlation between thrombolytic results and euglobulin lysis time. Treatment period below 3 days are unlikely to give satisfactory results. Occluded vein segments with an apparent median age of 4 days including thrombi older than 10 days (20% of cases) are cleared with an average chance of 50%. Complete dissolution of all thrombi proximal to the crural veins has been demonstrated in 47/114 = 41.2%, some thrombolytic effects in 31/114 = 27.2% and treatment failure in 36/114 = 31.6%. The data favour laboratory monitoring of thrombolytic therapy.

[The ENT specialist's responsibility in the diagnosis of the olfactory meningeoma (author's transl)]

The principal symptoms associate with olfactory groove meningeomas are anosmia and headache which lead the patient to an ENT specialist. Frontal sinusitis, migraine and neuralgia are the most frequent incorrect diagnosis. Positive radiological changes are found frequently on the plain films of patients with these olfactory tumors, even up to 70% according to the literature. It is important to bear this in mind regarding olfactory groove meningeomas to avoid mistakes in diagnosis.

[Can ischemia-induced wall motion abnormalities of the left ventricle be predicted by non-invasive thallium-201 scintigraphy? Comparison with the ventriculography test]

To assess the relation between stress-induced perfusion defects and wall motion abnormalities (WMA), 20 patients were studied by thallium-201 (201Tl) scintigraphy and cineventriculography at rest and during exercise. Of 100 analyzed segments, 63 were normal while 13 showed constant (scar) and 24 reversible (ischemia) perfusion defects. At peak exercise, 85% of the scar and 80% of the ischemic segments corresponded to abnormally contracting wall segments. There was a marked correlation between the extent of ischemia and the degree of WMA. The increase in abnormal scintigraphic and angiographic segments from rest to exercise was parallel by a significant deterioration in left ventricular function. It is concluded that (1) ischemic perfusion defects detected by 201Tl scintigraphy correlate well with exercise induced wall motion abnormalities, and (2) the localization, extent and degree of WMA can be predicted by non-invasive 201Tl scintigraphy.

[Treatment of post-traumatic cerebrospinal fluid rhinorrhea with lumbar drainage (author's transl)]

Three patients with CSF-rhinorrhea following frontobasal skull and brain injury were treated with lumbar CSF drainage. Rhinorrhea was successfully stopped in one patient few hours after onset of the drainage while a pneumatocephalus developed in each of the remaining patients during the first post-trauma week. We believe that this latter occurrence was due to depression of intra-cranial pressure as a result of the drainage. As a further consequence of this, risk of intracranial infection increased in association with a hypoliquorrhea, and led to a tentorial pressure cone in one of the patients.

[An unusual triad: gall bladder agenesis, annular pancreas and portal anomaly]

A 31-year-old female patient with "vesicule exclue" showed at laparotomy agenesia of gallbladder, annular pancreas and a probably congenital anomaly of portal and splenic vein. She had no clinical but angiographical signs of portal hypertension.

[Cerebellar abscess as an intracranial complication of otogenic origin (author's transl)]

Three cases of otogenic cerebellar abscesses, treated between 1976 and 1978, are reviewed. Early diagnosis is the most important factor in the successful management of these lesions. In localising subtentorial intracranial abscesses, computed axial tomography appears superior to other neuroradiological methods. Lumbar puncture is both inaccurate in diagnosis and dangerous to the patient, when increased intracranial pressure exists.

[The ultrasound appearances of thrombosis of the inferior vena cava due to renal tumours (author's transl)]

The findings of ultra-sound in four cases of thrombosis of the inferior vena cava due to malignant renal tumours are described. In three patients the cava was occluded by tumour, twice by infiltration and once by a mobile tumour mass in the vessel. The advantages of rapid imaging of normal and abnormal vascular structures are described. The method can demonstrate the occluding material in the vessel as well as showing the extent of local tumour infiltration around the cava, information which cannot be provided by cavography in the presence of complete occlusion.

[Spontaneous aortic dissection. Diagnostic experience with 32 patients]

Of 48 patients in whom angiography was carried out on the clinical suspicion of spontaneous aortic dissection, the diagnosis could be confirmed in 18 cases only. On the other hand, aortic dissection was discovered incidentally in 14 patients on whom angiography was being carried out for other reasons. The high incidence of incorrect diagnosis is due to the variety of clinical symptoms caused by various types of dissection combined with the non-specific radiological findings on chest radiographs. Unlike plain films, aortography, provided a suitable technique is employed with an understanding of the possible sources of error, gives a high degree of diagnostic certainty with little risk. It is therefore always indicated when the demonstration or exclusion of an aortic dissection is likely to influence treatment.

[Embolisation of the finger arteries in the thoracic outlet syndrome]

Angiographic studies were undertaken in 18 patients with the signs of a thoracic outlet syndrome due to compression of the subclavian artery, associated with Raynaud's phenomenon. They demonstrated occlusion of the digital arteries in more than half the cases, on the side of the subclavian compression. In three patients with ischaemic pain in the fingers of only a few hours' or days' duration arteriography demonstrated fresh embolisation from the compressed subclavian artery.

[The course of postoperative deep vein thrombi as judged by repeated phlebographies]

Phlebography was carried out in a prospective randomised, controlled study during which dextran and small doses of s.c. heparin have been compared in general surgical and urological patients, in 31 persons with proven deep vein thrombois diagnosed with the 125I-fibrinogen test. In 16 out of the 31 patients a second phlebogram coule be performed two weeks later. In this study all thrombi occurred intraoperatively. In 24 of the 31 patients, the appearance of thrombi was multilocular. Independent of the prevention instituted and irrespective of the therapy, the following phenomena could be seen 14 days after the first phlebogram: 9 thrombi retracted, 6 disappeared completely and 1 occluded the vein completely. 2 thrombi disappeared without any therapy whatsoever, the 4 others disappeared in patients receiving heparin and/or coumarin for treatment.

[Trends in the nuclear-medical diagnosis of thrombosis]

Use of the 125I-fibrinogen-uptake test for detection of freshly developing thrombi is well known. The administration of radiofibrinogen to detect preformed thrombus - the retrospective variant of the 125I-fibrinogen-uptake test - allows the diagnosis of established thrombosis. The correlation with ascending phlebography is 90%. 125I-Fibrinogen cannot be used for scanning, due to its low energy, while 131I-fibrinogen if used involves a high radiation dose to the patient. First experiments with new radiopharmaceuticals for detection of deep vein thrombosis are proposed. Indication lists for the retrospective variant of the 125I-fibrinogen-uptake test are given.