Hematemesis in Alcoholics: Not Always the Same Problem. A Case Report of Successful Percutaneous Arterial Embolization of Spontaneously Ruptured Splenic Artery Aneurysm Causing Hematemesis, Hematochezia and Hemodynamic Instability

The manuscript presents a rare case of overt upper gastrointestinal bleeding initially manifesting as coffee ground vomiting, in a patient who had negative esophagogastroduodenoscopy performed a few hours before. Over the first 30 minutes in the Emergency Department, the patient developed an episode of hematemesis and hematochezia with hemodynamic instability. To identify the source of bleeding, contrast-enhanced computed tomography was performed, which revealed a small aneurysm in the central part of the splenic artery with signs of intrapancreatic rupture. Re-esophagogastroduodenoscopy revealed active bleeding from the papilla of Vater and urgent selective angiography of the celiac trunk confirmed active extravasation of the contrast material into the main pancreatic duct. Successful embolization of the bleeding vessel was obtained by placing two coils in the aneurysm sac and the splenic artery. The presented clinical case draws attention to a rare case of spontaneously ruptured splenic artery aneurysm causing visible only periodically hemosuccus pancreaticus, progressing quickly to a life-threatening condition and requiring firm and fast multi-profile treatment.

Mechanical thrombectomy in acute stroke - Five years of experience in Poland

OBJECTIVES

Mechanical thrombectomy (MT) is not reimbursed by the Polish public health system. We present a description of 5 years of experience with MT in acute stroke in Comprehensive Stroke Centers (CSCs) in Poland.

METHODS AND RESULTS

We retrospectively analyzed the results of a structured questionnaire from 23 out of 25 identified CSCs and 22 data sets that include 61 clinical, radiological and outcome measures.

RESULTS

Most of the CSCs (74%) were founded at University Hospitals and most (65.2%) work round the clock. In 78.3% of them, the working teams are composed of neurologists and neuro-radiologists. All CSCs perform CT and angio-CT before MT. In total 586 patients were subjected to MT and data from 531 of them were analyzed. Mean time laps from stroke onset to groin puncture was 250±99min. 90.3% of the studied patients had MT within 6h from stroke onset; 59.3% of them were treated with IV rt-PA prior to MT; 15.1% had IA rt-PA during MT and 4.7% - emergent stenting of a large vessel. M1 of MCA was occluded in 47.8% of cases. The Solitaire device was used in 53% of cases. Successful recanalization (TICI2b-TICI3) was achieved in 64.6% of cases and 53.4% of patients did not experience hemorrhagic transformation. Clinical improvement on discharge was noticed in 53.7% of cases, futile recanalization - in 30.7%, mRS of 0-2 - in 31.4% and mRS of 6 in 22% of cases.

CONCLUSION

Our results can help harmonize standards for MT in Poland according to international guidelines.

Vertebroplasty of cervical vertebra

BACKGROUND

The first vertebroplasty was performed by Harve Deramond in France in 1984 due to a hemangioma of cervical vertebral body. Procedure technique consisted of inserting a needle through the bony palate of the oral cavity. Bone cement injected under pressure not only fills the areas of bone loss. The heat released in the process of crystallization causes denaturation of pathological tissue proteins (metastasis) and disrupts blood supply (hemangiomas). The aim of this study was to evaluate the method of treatment from anterolateral access.

MATERIAL/METHODS

In the years 2007-2012 the procedure was performed in 6 men and 9 women aged from 42 to 71 years (mean age: 56.3 years). In 10 cases the reason for vertebroplasty was the vertebral hemangioma, in another 4 - pathological vertebral fractures due to metastases, and in one case - multiple myeloma. Procedures were performed from anterolateral access, under local anesthesia, under x-ray guidance (fluoroscopy). Bone needle was inserted into the vertebral body, followed by injection of PMMA cement.

RESULTS

In 100% cases pain relief was observed immediately after the procedure and beneficial therapeutic effect was obtained. No life-threatening complications and clinical symptoms were observed. Average length hospital stay amounted to 2.9 days.

CONCLUSIONS

Cervical spine vertebroplasty from anterolateral access seems to be a safe, effective and beneficial method of treatment. It reduces the risk of infection in comparison to the transoral method.

Postoperative coronary aneurysm treated with endovascular coiling

We present a rare case of aneurysm formation of the circumflex coronary artery after a Bentall procedure. Implantation of a stent graft in the circumflex artery and closure of the aneurysm neck failed. An endovascular procedure was used to coil the aneurysm and prevent rupture. Further recovery was uneventful. Angiography did not reveal flow in the aneurysmal sack 22 months after the procedure. To our knowledge, this is the first described case of coiling a postoperative coronary artery aneurysm with an almost 2-year follow-up.

[Embolization of carotid arteria branch in stanching of nasal bleeding]

BACKGROUND

Epistaxis is a common clinical problem, especially in otolaryngology. This disorder affects equally both genders. Most cases manifest as spontaneous nasal bleeding. It can also appear as a result of trauma, high blood pressure, Osler-Rendu-Weber disease. When the bleeding is massive it can be potentially life-threatening. A great majority of epistaxis can be treated conservatively, if not it sometimes requires endovascular treatment. It is specially reserved for extensive, dangerous epistaxis. Angiography with selective embolization has become an accepted method of treating epistaxis that is not controlled with conservative methods.

MATERIAL AND METHODS

Authors analyzed the efficacy of selective embolization treatment of epistaxis. 61 patients treated in the Department of Otolaryngology in Bialystok in years 1999-2011 were examined. There were 39 men and 22 women aged 24-48 years. Patients were referred for endovascular treatment when primary management was ineffective. Arteries suspected of bleeding were embolized superselectively.

RESULTS

Immediate, complete control of bleeding was achieved in 100% patients. After few hours recurrent nasal bleeding occurred in 4 (7%) patients who underwent successful reembolization. There were no severe complications after procedure. Nine patients experienced few days lasting mild headache which disappeared after medicament treatment. Five patients suffered from unaided removing facial oedema. Out of 61 patients, 56 were available for 12-month follow-up evaluation. No neurological or otolaryngological complications were certified. There was also no relapse of epistaxis.

CONCLUSIONS

Selective angiographic embolization is an effective method that should be considered in the treatment of refractory epistaxis. It is safe and not traumatic for patients.

Assessment of effectiveness of endovascular treatment of common and external iliac artery stenosis/occlusion using self-expanding Jaguar SM stents

The goal of this work was to assess the effectiveness of endovascular treatment of common and external iliac artery stenosis/occlusion classified according to TASC using a self-expanding stent Jaguar SM. The study group included 95 patients (61 men and 34 women) who underwent treatment for stenosis or occlusion of lower limb arteries at the Department of Radiology of the University Hospital in Bialystok and the Diagnostic Radiology Department of the Central Clinical Hospital of the Ministry of Interior (MSWiA) in Warsaw between 2005 and 2007. All arterial lesions were of atherosclerotic etiology. The shortest stenotic fragment was 10 mm long and the longest occluded arterial fragment did not exceed 90 mm. Morphological classification of iliac artery lesions in treated patients was performed according to TASC II classification and included 10 patients with type A, 39 cases of type B, 36 with type C and 10 patients with type D lesions. Endovascular procedure failed to restore flow in five patients with TASC type D lesions, who were later referred for surgery. One patient suffered a complication – vessel perforation during predilatation, and had a stentgraft implanted. In 95% of patients stents were expanded using a balloon after implantation. Good results were achieved in practically all patients who underwent stent implantation. Patients were subjected to follow-up clinical and imaging evaluation during next 1–24 months. Success rate of the performed procedures as well as in a 30-day observation period was 100% in case of stenosis and 80% in case of vessel occlusion. A follow-up after 12 and 24 months showed patency of treated vessels in 84% and 76% of patients, respectively.

Palliative embolization of hemorrhages in extensive head and neck tumors

Background:

A lot has changed in terms of intervention technique, indications and embolic agents since Duggan introduced embolization to management of postraumatic epistaxis in 1970.

Embolization is used in treatment of spontaneous and traumatic epistaxis, palliative tumors and vascular defects, as well as vascularized tumors and juvenile nasopharyngeal angiofibromas. The possibility of simultaneous visualization of pathology and implementation of therapy is one of its greatest advantages.

Material/Methods:

Authors analyzed the efficacy of selective embolization treatment of haemorrhage in advanced head and neck tumors. Seventy-six patients with such tumors treated at the Department of Otolaryngology in Bialystok between1999 and 2011 were examined.

Results:

Embolization of bleeding vessel within the tumor was effective (hemorrhage was stopped) in 65 patients (86%). Although the method is highly efficient, it is still associated with complications. Fourteen patients suffered from headaches that lasted for several days and six from face edema. Rebleeding was rare. Unfortunately, there was one case of hemiparesis.

Conclusions:

We conclude that superselective endovascular treatment deserves to be considered alongside standard options for the palliative or preoperative management of acute hemorrhage from advanced head and neck cancers.

Severe respiratory distress caused by central airway obstruction treated with self-expandable metallic stents

We investigate retrospectively the efficacy of self-expandable metallic stents (SEMS) for severe respiratory distress (SRD) in patients with central airway obstruction (CAO). Thirty three patients with CAO were treated with SEMS using fiberoptic bronchoscopy method. We found an intraluminal obstruction present in 7, extraluminal compression in 10, and combined stenosis in 16 cases. Tumor infiltration occupied more than 90% of the endoluminal diameter in 21, 70% in 9, and 50% in 3 cases. Obstruction was caused by primary cancer of lung in 23, thyroid in 5, and esophagus in 5 patients. Up to 3 stents per patient were placed. Double stenting (esophagus and trachea) was required in five patients. All patients exhibited symptomatic and arterial blood gas improvement. The mean follow-up was 65 (5 to 752) days. SEMS are useful for the treatment of SRD caused by CAO. The overall effect is related to the degree of tumor progression itself.

[Emergency hybrid surgery for ruptured aortic arch aneurysm--a case report]

We describe a case of 67-year-old man suffering from chronic aortic arch aneurysm complicated by rupture and hemorrhage to the left pleural cavity. The patient underwent emergency hybrid operation: extraanatomical transposition of aortic arch branches to ascending aorta and implantation of stentgraft into the arch without the extracorporeal circulation.

The role of magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) in the diagnosis and assessment of resectability of pancreatic tumors

BACKGROUND

Carcinoma of the pancreas is one of the most malignant tumors. Symptoms are usually nonspecific and insidious, such that the cancer is advanced by the time of diagnosis. The aim of the study was to assess the usefulness of MRI and MRCP in the diagnosis of patients suspected of pancreatic carcinoma and to define the role of these methods in the evaluation of resectability of pancreatic cancer in comparison with surgical findings.

MATERIAL/METHODS

Forty-seven patients (32 men and 15 women) aged 46-81 had undergone MRI and MRCP examination of the upper abdomen on a 1.5 T system with a standard flexible surface coil. The results of those tests were compared with surgical and histopathological findings. The capacity of MR and MRCP to detect pathological mass, assess the nature of the disease process, and accurately assess the resectability of the malignant lesion were evaluated. In the statistical analysis the chi-squared and Fisher's precise tests were performed.

RESULTS

Statistical analysis showed 87% sensitivity, 97% specificity, and 95% accuracy of MRI and MRCP in the evaluation of the nature of tumors within the pancreas and 100% sensitivity, 90% specificity, and 93% accuracy in determining the resectability of the lesion. The positive predictive value came to 83%, while the negative predictive value was 100%. The kappa compatibility index in comparison with surgical findings was 0.85714.

CONCLUSIONS

MR and MRCP is an important diagnostic method in assessing pancreatic tumors. It is very useful in differential diagnosis and determination of tumor resectability.

Activity of enzymes with different subcellular localization in the blood plasma of patients with aortic aneurysm

BACKGROUND

The wall of an abdominal aorta aneurysm shows increased activity of metalloproteinases, aspartyl cathepsins and cystein cathepsins, and decreased activity of inhibitors of these enzymes, as compared to the wall of a normal aorta. Parietal thrombi of the aneurysm also show marked proteolytic activity. The aim of our study was to determine the activity of secretory enzymes, membrane enzymes, cytosol enzymes, mitochondrial enzymes and lysosomal enzymes in the blood plasma of patients with abdominal aortic aneurysm.

MATERIAL/METHODS

Blood for examinations was collected from 15 patients with abdominal aorta aneurysm without coexisting diseases, and from the same number of healthy subjects, to determine the activity of lactic acid dehydrogenase (LDH), 5' nucleotidase (5'NT), gamma-glutamyltranspeptidase (GGTP) and cholinesterase (ChE), alanine aminotransferase (ALT), aspartic aminotransferase (AST), cathepsin B (CB), cathepsin D (CD), and cathepsin L (CL).

RESULTS

The plasma activity of ALT, AST and GGTP in the blood of patients with aortic aneurysm is lower than in the plasma of healthy subjects. The activity of LDH, 5'NT and ChE, CB and CL does not significantly differ in the plasma of patients with aortic aneurysm compared to the plasma of healthy subjects. The activity of CD is increased in the plasma of patients with aortic aneurysm.

CONCLUSIONS

Determination of cathepsin D activity may be helpful in the diagnosis of aortic aneurysm.

[Surgical evacuation of an embolization coil from the middle cerebral artery]

We report the case of a 54-year-old woman with a right intracavernous internal carotid artery aneurysm treated endovascularly with MDS coils. During the procedure, one of the coils migrated to the middle cerebral artery (MCA), resulting in left hemiplegia. The attempt to remove the migrated coil endovascularly failed and the patient had emergency front-temporal craniotomy. After the dissection of the Sylvian fissure, the M1 portion of the MCA was exposed with the coil visible through the distended wall of the artery. Because it was feared that the M1 arteriotomy could tear the MCA, the coil was removed through the anterior temporal artery, a small branch of the M2 segment. Hemiplegia gradually resolved and the patient recovered completely. This case depicts an alternative route via a distal arteriotomy to remove the migrating coil. Additionally, it implies that endovascular procedures in neurosurgical patients should be performed by the interventional neurosurgeon (neurosurgeon trained to perform endovascular procedures) or at least with the support of a neurosurgical department for immediate intervention in the case of life-threatening complications.

Contrast-enhanced, wide-band, phase inversion harmonic power Doppler imaging of hepatocellular carcinoma

BACKGROUND

Early diagnosis of hepatocellular carcinoma (HCC) is extremely important because surgical resection and local ablation therapy are undoubtfully the most effective treatment regiment. Recent advances in sonographic techniques have risen the question ofsonography utility. The scope of this investigation was to assess the detection accuracy of tumor vascularity in HCC by contrast-enhanced, wide-band phase inversion (PI) power Doppler sonography.

MATERIAL/METHODS

Twenty-one patients were examined with 21 nodules (16 hypo-, 2 iso-, 3 hyperechoic nodules). The presence of hepatocellular carcinoma was confirmed by fine-needle biopsy results in 16 nodules, and the diagnosis in the remaining tumors was based on imaging findings and tumor markers. All patients, prior to enhanced sonography, had undergone both the native B-mode and tissue harmonic imaging mode sonography, color Doppler, and power Doppler examinations.

RESULTS

Three patients were excluded. 18 nodules evaluation by contrast-enhanced, wide-band PI power Doppler US revealed tumor vessels in 100% cases in arterial phase. The characteristic chaotic pattern of lesions vascularity was evidently pronounced. Rapid increase of enhancement during the arterial and slow decrease of enhancement during the portal phase were the special features of HCCs helping in making the final diagnosis. Power Doppler sonography detection rates were 14 cases (77%).

CONCLUSIONS

Based on our results we can recommend wide-band, phase inversion power Doppler sonography in the differential diagnosis of HCC by visualizing characteristic behavior of enhancement pattern in the most cases.

Hemangiomas and focal nodular hyperplasia images in contrast-enhanced, wide-band phase-inversion harmonic power Doppler imaging

BACKGROUND

Contrast-enhanced, wide-band, phase inversion power Doppler sonography in the depiction of vasculature in hemangioma and focal nodular hyperplasia.

MATERIAL/METHODS

Fifty-one patients with liver lesions (40 FNHs,37 hemangiomas) were prospectively evaluated with conventional, color, power Doppler sonography, tissue harmonic, phase-inversion sonography and helical CT. Levovist was the standard contrast agent used and all examinations were performed on Siemens SONOLINE Elegra equipped with Ensemble Contrast Imaging (ECI) software.

RESULTS

Color and power Doppler scans were frequently not specific for these highly vasularized lesions. Images were not suggestive in 15 out of 40 FNHs and not positive in all of 37 hemangiomas). If peripheral enhancement in form of puddle enhancement, 'bloo pools' or rimlike followed by a slow centripetal fill-in is regarded as a positive finding for hemangiomas all lesions were depicted confidently with wide-band, phase inversion, contrast enhanced power Doppler scans. Moreover, all typical vascularity features of FNHs confluence firstly the feeding artery then centrifugal spread of contrast later forming wheel like pattern was obvious in all cases of diagnosed FNHs.

CONCLUSIONS

Contrast-enhanced, wide-band, PI ,power Doppler imaging is useful method for diagnosing the vascularity of FNHs and hemangiomas. Not only it overcomes the low prediction rate which was the main obstacle for routine use of sonography but it is cheap, portable, and free also from contrast media and radiation.

Carotid artery dissection - an important complication after fine-needle aspiration biopsy

BACKGROUND

Carotid artery dissection (CAD) is a frequent cause of ischemic stroke in patients under 40 years. It happen spontaneously or after various degree of trauma.

CASE REPORT

In this report we present a case of 33 years-old woman with dissection of the common carotid and internal carotid artery after 'blind ' fine-needle aspiration biopsy of the neck lymph node.

CONCLUSIONS

Fine-needle aspiration biopsy of the neck, close to carotid vessels should be always performed under control of imaging techniques.

[Clinically non-symptomatic pulmonary embolism in patients with deep vein thrombosis of the lower limb]

The pulmonary embolism (PE) is the common and severe complication of the deep vein thrombosis of the lower limbs. The lack of accurate diagnosis of PE is a cause of 5-10% of the hospital deaths. The aim of the study was to assess the incidence of the pulmonary embolism in patients with the deep vein thrombosis of the lower limbs with no clinical symptoms of pulmonary embolism. Pulmonary perfusion scintigraphy was performed in 25 patients with angiographic findings confirmative to the deep vein thrombosis of the lower limbs. The results of the study were analysed according to the PIOPED criteria. In the group of patients with common thrombosis of the deep vein a high probability of lung embolism was assessed in 70%, medium and low by 12% in each group, and very low in 6%. In the group of patients with femoral thrombosis of the deep vein a high probability of lung embolism was assessed in 60%, medium in 20% and very low in 20%. In the group of patients with calf thrombosis of the deep vein high, medium and very low probability of lung embolism was assessed by 25% in each group. Results of this study indicate the need of searching the pulmonary embolism in patients with thrombosis of the deep vein of the lower limbs despite the lack of clinical symptoms of the pulmonary embolism.

Changes in the fibrinolytic system during angiography with ionic and with nonionic contrast media

RATIONALE AND OBJECTIVES

The purpose of the study was to evaluate and compare changes in some parameters of the fibrinolytic system caused by the use of ionic and nonionic contrast media during angiography in certain groups of patients.

MATERIALS AND METHODS

Angiographic diagnostic procedures were performed in 126 patients (male and female) clinically suspected of having kidney cancer (38 patients), arteriosclerotic occlusive disease of lower extremities (44 patients), or dissection of cerebral artery (44 patients). The control group included 12 patients with clinical symptoms of the disease in whom angiographic examination excluded the presence of cerebral artery dissection or kidney cancer. Patients were randomly assigned to receive either an ionic (diatrizoate sodium) or a nonionic (iopromide) contrast medium. Immediately before and 30 minutes after administration, venous blood samples were obtained to determine select parameters of the hemostatic system.

RESULTS

There were no significant differences in the fibrinolytic parameters within the control group after contrast medium administration. The nonionic contrast medium (iopromide) caused a decrease in fibrinolytic activity in the patients, unlike the controls, which was particularly pronounced among the patients undergoing renal angiography.

CONCLUSION

The use of contrast media in some groups of patients led to transient changes in the fibrinolytic system. These results indicate that ionic contrast media should be used during angiographic procedures in patients at increased risk for thrombotic complications.

Accuracy of transcranial color Doppler ultrasonography in the diagnosis of middle cerebral artery spasm determined by receiver operating characteristic analysis

OBJECT

The value of transcranial Doppler ultrasonography for the detection of middle cerebral artery (MCA) spasm has been asserted. None of the published studies, however, has adequately scrutinized the overall diagnostic accuracy of this procedure. There are only sporadic reports concerning the utility of transcranial color Doppler (TCCD) ultrasonography, although this method has been proved to be more precise. In this study the authors attempted to estimate the performance of TCCD ultrasonography in detecting MCA narrowing by using receiver operating characteristic (ROC) curve analysis, based on TCCD studies obtained in a relatively large, randomly selected population of patients.

METHODS

Transcranial color Doppler ultrasonography studies were obtained in 100 consecutive patients (54 men and 46 women ages 18-74 years, median age 50 years) routinely referred by neurosurgeons for intraarterial angiography. The M1 segment of the MCA was insonated using a 2.5-MHz probe via a temporal acoustic window, and angle-corrected flow velocities were obtained. Angiographically depicted vasospasm was graded as none, mild (< or = 25% vessel caliber reduction), and moderate to severe (> 25% vessel caliber reduction). The effectiveness of TCCD ultrasonography in diagnosing MCA spasm was evaluated by calculating the areas under the ROC curves (Az). Of the 200 MCAs examined, 173 were successfully visualized with the aid of TCCD ultrasonography. Mild vasospasm was angiographically diagnosed in 15 arteries and moderate-to-severe vasospasm in 28. The best-performing TCCD parameter for the detection of MCA narrowing was revealed to be peak systolic velocity. The Az value for moderate-to-severe vasospasm only was 0.93 and that for all vasospasms was 0.8. The best efficiency, that is, the optimal tradeoff between sensitivity and specificity in diagnosing vasospasms, was associated with a peak systolic velocity of 182 cm/second.

CONCLUSIONS

The performance of TCCD ultrasonography in the diagnosis of advanced MCA narrowing is very good, and is acceptable for all vasospasms. The best-performing parameter was peak systolic velocity.

An assessment of lymphocytic population in peripheral blood of patients with renal cell carcinoma before and after embolization

The immunophenotype of peripheral blood lymphocytes was evaluated in 50 renal cell carcinoma (RCC) patients, before and after embolization. In RCC patients we have observed significant decrease in the total lymphocyte number as well as in T lymphocyte, their subpopulations and B lymphocyte number. Ten to twelve months after the treatment by embolization, significant increase in the total number of not only lymphocytes (p < 0.001), including T lymphocytes (p < 0.001), T-helper lymphocytes (p < 0.05), cytotoxic T lymphocytes (p < 0.05) and B lymphocytes (p < 0.05), but also an increase of NK cells number (p < 0.05) were found, compared to the values obtained before the treatment and reached the level observed in healthy subjects. Cytometric evaluation of peripheral blood lymphocytic phenotype in renal cell carcinoma patients can help evaluate the immune status of RCC patients as well as assess the embolization efficiency.