Daniela Benedeto-Stojanov

Gadolinium deposition within the dentate nucleus and globus pallidus after repeated administrations of gadolinium-based contrast agents-current status.

IntroductionGadolinium-based contrast agents (GBCAs) have been used clinically since 1988 for contrast-enhanced magnetic resonance imaging (CE-MRI). Generally, GBCAs are considered to have an excellent safety profile. However, GBCA administration has been associated with increased occurrence of nephrogenic systemic fibrosis (NSF) in patients with severely compromised renal function, and several studies have shown evidence of gadolinium deposition in specific brain structures, the globus pallidus and dentate nucleus, in patients with normal renal function.MethodsGadolinium deposition in the brain following repeated CE-MRI scans has been demonstrated in patients using T1-weighted unenhanced MRI and inductively coupled plasma mass spectroscopy. Additionally, rodent studies with controlled GBCA administration also resulted in neural gadolinium deposits.ResultsRepeated GBCA use is associated with gadolinium deposition in the brain. This is especially true with the use of less-stable, linear GBCAs. In spite of increasing evidence of gadolinium deposits in the brains of patients after multiple GBCA administrations, the clinical significance of these deposits continues to be unclear.ConclusionHere, we discuss the current state of scientific evidence surrounding gadolinium deposition in the brain following GBCA use, and the potential clinical significance of gadolinium deposition. There is considerable need for further research, both to understand the mechanism by which gadolinium deposition in the brain occurs and how it affects the patients in which it occurs.

The model for the end-stage liver disease and Child-Pugh score in predicting prognosis in patients with liver cirrhosis and esophageal variceal bleeding

BACKGROUND/AIM Esophageal variceal bleeding is one of the most frequent and gravest complications of liver cirrhosis, directly life-threatening. By monitoring certain clinical and laboratory hepatocellular insufficiency parameters (Child-Pugh score), it is possible to determine prognosis in patients who are bleeding and evaluate further therapy. Recently, the Model for the End-Stage Liver Disease (MELD) has been proposed as a tool to predict mortality risk in cirrhotic patients. The aim of the study was to evaluate survival prognosis of cirrhotic patients by the MELD and Child-Pugh scores and to analyze the MELD score prognostic value in patients with both liver cirrhosis and variceal bleeding. METHODS We retrospectively evaluated the survival rate of a group of 100 cirrhotic patients of a median age of 57 years. The Child-Pugh score was calculated and the MELD score was computed according to the original formula for each patient. We also analysed clinical and laboratory hepatocellular insufficiency parameters in order to examine their connection with a 15-month survival. The MELD values were correlated with the Child-Pugh scores. The Students t-test was used for statistical analysis. RESULTS Twenty-two patients died within 15-months followup. Age and gender did not affect survival rate. The Child-Pugh and MELD scores, as well as ascites and encephalopathy significantly differed between the patients who survived and those who died (p < 0.0001). The International Normalized Ratio (INR) values, serum creatinine and bilirubin were significantly higher, and albumin significantly lower in the patients who died (p < 0.0001). The MELD score was significantly higher in the group of patients who died due to esophageal variceal bleeding (p < 0.0001). CONCLUSION In cirrhotic patients the MELD score is an excellent survival predictor at least as well as the Child-Pugh score. Increase in the MELD score is associated with decrease in residual liver function. In the group of patients with liver cirrhosis and esophageal variceal bleeding, the MELD score identifies those with a higher intrahospital mortality risk.

ADC is not reliable in determinating subtypes of meningiomas

ObjectiveTo verify the reliability of apparent diffusion coefficient (ADC) measurements in determining subtypes of meningiomas.Material and methodsThirty patients (20 women and 10 men; average age, 53±15 years) with meningiomas were prospectively studied using DWI with b values of 0 and 1000. ADC values of the neoplastic tissue were obtained as the mean of measurements from three regions of interests within the mass and compared with histologic subtypes using ANOVA test (SPSS16).ResultsThe meningothelial subtype was found in 15 (50%) patients, fibroblastic in 10 (33.33%) patients and cystic in 5 (16.67%) patients. All meningiomas belonged to the WHO Grade 1 — benign meningiomas. There was no significant statistical difference between meningothelial, fibroblastic and cystic meningiomas when considering mean ADC values (0.000411+/−0.000066 mm2/s vs. 0.000750+/−0.001045 mm2/s vs. 0.000688+/−0.000063 mm2/s (p>0.05). Perifocal edema was present only with fibroblastic meningioma with mean ADC 0.000683 mm2/s. The ADC of the cystic component was statistically significantly higher in cystic meningeomas (0.001283 mm2/s) compared with fibroblastic (0.000224 mm2/s) and meningothelial meningiomas (0.000088 mm2/s) (p<0.001). The ADC of meningiomas was higher compared with contralateral healthy brain tissue (0.000642 mm2/s vs. 0.000404 mm2/s; n.s).ConclusionADC measurement do not seem reliable in identifying histological subtypes of Grade I meningiomas.

Multichannel fenestration of the petrous and cavernous segments of the internal carotid artery associated with two small carotid canals.

A fenestration is defined as a division of the arterial lumen into distinctly separate channels, each with its own endothelial and muscularis layers, while the adventitia may be shared. Duplication, by contrast, is defined as two distinct arteries with separate origins and no distal arterial convergence. Fenestrations can range from a small focus of divided tissue to long segment duplications. They are the result of partial failure of fusion of paired primitive embryologic vessels or incomplete obliteration of different anastomosis in a primitive vascular network [1]. Fenestration, or duplication, of the internal carotid artery (ICA) is considered as an extremely rare anatomic variant. The prescens of greater than two channels in a long segment of the ICA has not been previously described. We report a case of multichannel fenestrations of the petrous and cavernous segments of the ICA associated with two small carotid canals. A 58-year-old man with no remarkable medical history was admitted to the Department of Neurology for transient ischemic attack involving the right upper extremity. At admission, his general and neurologic examinations were normal. Brain CT findings were unremarkable expect for narrow right carotid canal (Fig. 1). The inferior part of the carotid canal was divided by a bony septum into two smaller canals. CT angiography revealed hypoplastic cervical segment of the right ICA and multiple vessels in the petrous canal, and parasellar area converging to the intradural paraclinoid segment of the ICA (Fig. 2). Digital subtraction angiography (DSA) was performed. Right carotid angiogram (Fig. 3a, b) demonstrated small caliber of ICA, including the first (cervical) and second (ascending petrous) segment. Distally, four tortuous vessels with a diameter of 1–2 mm were found along the course of the third (horizontal intrapetrous), fourth (ascending intrapetrous and in foramen lacerum) and fifth (horizontal segment of the carotid siphon) segments. These vessels converged to the sixth (clinoid) segment. The seventh (supraclinoid) segment of ICA and medial cerebral artery were normal. There was hypoplasia of the A1 segment of the anterior cerebral artery. Selective right external carotid artery showed no abnormalities. Angiograms of the left carotid and both vertebral arteries were normal. Our case describes developmental abnormalities of the petrous and cavernous portion of the ICA, consisted of four channel fenestrations associated with two small carotid canals. Fenestration or segmental duplication of the petrous and the cavernous segment of the ICA is considered an extremely rare anatomic variant. To the best of our knowledge, this is the first report of long-segment multichannel fenestration involving petrous and cavernous segments of the ICA. There is only one case of multichannel fenestrations of the petrous segment of the ICA reported by Mangla and Teitelbaum [2]. They described the shortsegment division of the petrous segment into four channels on DSA. The fenestration was approximately 1-cm long. Uchino et al. [3] have published the only case of intracavernous fenestration diagnosed by MR angiography and DSA. They described duplicate arterial lumens just proximal to the supraclinoid segment. Fenestrations in the supraclinoid and cervical segments are more common. D. Stojanov P. Bosnjakovic D. Benedeto-Stojanov S. Petrovic Faculty of Medicine, University of Nis, Nis, Serbia

Minimal Hepatic Encephalopathy (MHE)

1. Episodic (precipitant-induced) encephalopathy, commonly seen in the hospital setting, where a superimposed event is a key factor. 2. Persistent (chronic) encephalopathy, seen with extensive portal–systemic shunts and after portocaval shunt surgery or placement of transjugular intrahepatic portosystemic shunt (TIPS). 3. Minimal (subclinical) encephalopathy reflects alterations in cognitive function in patients who clinically exhibit a normal mental state.

Bacterial infections in patients with liver cirrhosis and ascites

INTRODUCTION Bacterial infections are common complications and the cause of death in patients with cirrhosis and ascites. There is no standard method for a rapid and low-cost diagnosis, and its prognosis is poor. OBJECTIVE The aim of this study was to determine the etiology and frequency of bacterial infections in patients with liver cirrhosis of different etiology, and the influence of bacterial infections on the prognosis in patients with liver cirrhosis and ascites. METHODS Sixty-four patients with cirrhosis and ascites were included in the study. The diagnosis of spontaneous bacterial peritonitis was established based on the diagnostic abdominal paracentesis and the results of biochemical, cytological and microbiologic analysis of ascitic fluid. The diagnosis of urinary infection and pneumonia were made according to the standard criteria. RESULTS Spontaneous bacterial peritonitis was diagnosed in 23 (35.9%) patients, urinary infections in 16(25%) and pneumonia in 11 (17.2%). Gram positive and gram negative bacteria in spontaneous bacterial peritonitis were etiologically almost equally represented (52%; 48%).The most frequent causes were Escherichia coli and Staphylococcus aureus. In 81% of patients urinary infections were caused by gram negative bacteria (Escherichia coli in 44%). The most frequent cause of pneumonia was Streptococcus pneumoniae (46%). CONCLUSION Spontaneous bacterial peritonitis, urinary infections and bronchopneumonia are the most frequent bacterial infections in patients with liver cirrhosis and ascites. A timely recognition of bacterial infections and the initiation of treatment have a positive effect on the prognosis of such patients.

Metastatic lesions in the gastroduodenum — an unusual manifestation of malignant melanoma and pulmonary adenocarcinoma

The gastrointestinal tract (GIT) is an unusual site for metastasis. The rate of GIT metastases detected clinically is very low because of unspecific symptoms and signs of GIT involvement, which include general weakness, tiredness, weight loss, unspecific abdominal pain, fatigue, and anemia. We report clinical, endoscopic, and pathological patterns of two patients (malignant melanoma and primary lung tumor) with metastatic lesions in the gastroduodenum. The first case is a 59-year-old man with unspecific symptoms as nausea, vomiting and abdominal pain. He underwent resection of skin melanoma on his back one year before. Upper gastrointestinal endoscopy revealed two melanotic polypoid masses with ulcerations at the tip, one in the stomach and one in the duodenal bulb. Endoscopic biopsy of these polypoid masses and immunohistochemical stains confirmed the diagnosis of metastatic malignant melanoma. The second case is a 73-year-old man with a two-day history of melena and unspecific abdominal pain. Three weeks before, the patient was operated on for the adenocarcinoma of the lung. Endoscopy of the upper gastrointestinal tract revealed irregular polypoid mass with ulcerations at the tip: three of the stomach mucosa, two in the duodenal bulb and more than ten hemorrhagic polypoid masses at the desendent duodenum. Biopsies of these lesions confirmed the diagnosis of metastatic lung adenocarcinoma. In patients with a history of malignant melanoma and lung cancer unspecific symptoms, like abdominal pain, anemia, and gastrointestinal bleeding gastroduodenal metastases should be suspected. The diagnosis requires careful endoscopic examinations of the mucosa for metastatic lesions and biopsy with special immunohistochemical stains.

Endovascular treatment of hereditary hemorrhagic telangiectases of the tongue.

Hereditary hemorrhagic telangiectasia, also known as Osler-Weber-Rendu disease, is an autosomal dominant disorder involving vascular abnormalities of various organs. Telangiectases are frequently observed, predominantly on the nasal and oral mucosa. We present a case a of 53-year-old man with the tonge hemorrhagic telangiectases and epistaxis. Selective catheterization and embolization of the right lingual artery led to size redution and no bleeding from tongue telangiectases.