K. Hachem

Intrathyroid parathyroid adenoma in primary hyperparathyroidism: can it be predicted preoperatively?

IntroductionThe role of cervical ultrasonography (US)-guided surgery for intrathyroid parathyroid adenoma in primary hyperparathyroidism is rarely reported. The aim of this study was to elucidate the role of cervical US in identifying this entity.MethodsFrom 1996 to 2003, cervical explorations were performed in 178 patients (mean age 57 years) with primary hyperparathyroidism. High-resolution cervical US was performed in all of the patients. Patients’ characteristics were reviewed to identify predictive factors for intrathyroid adenoma.ResultsCervical US identified abnormal parathyroid glands in 163 of 178 patients, with a positive predictive value (PPV) of 100%. Six patients (3.4%) were found to have intrathyroid parathyroid adenomas (two in the superior parathyroid and four in the inferior parathyroid). Cervical US predicted this anomaly in four of six patients (67%) in whom the thyroid gland was not nodular and allowed total enucleation of the adenoma to be performed in three and subtotal thyroid loboisthmectomy in three; these operations were performed uneventfully and rapidly. The PPV in this anomaly was 80%. Thirteen patients required postoperative calcium supplementation for 2 to 4 months, and all were normocalcemic at the time of the last clinic visit, with follow-up varying from 12 to 96 months. On multivariable analysis, no factor predicted intrathyroid localization of parathyroid adenoma.ConclusionsThe PPV of high-resolution cervical US for identifying an abnormal parathyroid gland was 100% in this series. It was 80% for predicting intrathyroid localization of the adenoma. This method allows us to shorten the operating time by guiding the exploration immediately toward the thyroid gland.

Ultrasonography : Highly Accuracy Technique for Preoperative Localization of Parathyroid Adenoma

Objectives/Hypothesis: This study evaluates the accuracy of ultrasonography in guided unilateral parathyroidectomy to treat primary hyperparathyroidism.

Intracranial Aneurysm and Recessive Polycystic Kidney Disease: The Third Reported Case

OBJECTIVE To highlight the possible association of intracranial aneurysm with autosomal recessive polycystic kidney disease. DESIGN, SETTING, AND PATIENT To our knowledge, this association has been reported only twice in the medical literature. We herein report the case of a 21-year-old man with autosomal recessive polycystic kidney disease, presenting with subarachnoid hemorrhage secondary to a ruptured intracranial aneurysm, at our institution. RESULTS In the presence of only 3 cases in the medical literature, one might conclude they are a simple coincidence. However, should this association exist, such as with the dominant form, then the neurologic prognosis and even the life of young patients may be at stake. CONCLUSIONS Given the devastating consequences of intracranial bleeding in young patients, early neurologic screening may be warranted.

Imagerie d'une artère occipitale aberrante naissant de l'artère carotide interne à l'étage cervical

Resume Nous rapportons un cas d’occlusion asymptomatique de la carotide interne droite grâce a l’existence d’une variante anatomique rare (artere occipitale naissant de la carotide interne a l’etage cervical). Durant le bilan pre-operatoire d’un pontage aorto-coronarien, une occlusion de la carotide interne droite a ete mise en evidence par echo Doppler chez un patient de 65 ans. En aval de l’occlusion, la carotide etait permeable avec un flux Doppler bien module grâce a un vaisseau parallele ayant un flux circulant dans le sens inverse. L’angio-IRM des vaisseaux du cou et l’arteriographie confirmaient l’occlusion de la carotide interne et sa revascularisation a travers une artere occipitale aberrante, naissant de l’etage sus-bulbaire et s’anastomosant avec l’artere vertebrale droite. Une abstention therapeutique a ete decidee et le patient a ete opere de pontage aorto-coronarien sans complication neurologique. L’artere occipitale naissant de la carotide interne est une anomalie rare. Son association avec une occlusion de la carotide interne peut etre utile car elle permet d’envisager une chirurgie si le patient est symptomatique, meme au stade chronique, ou une abstention therapeutique si le patient est asymptomatique. (J Mal Vasc 2004 ; 29 : 205-209).

Imagerie non invasive d’une agénésie bilatérale des artères vertébrales

Imaging descriptions are lacking for vertebral artery variants reported in the anatomy literature. We report thus a variant of vertebral arteries discovered incidentally in a patient admitted for aortocoronary bypass. Doppler of the supra-aortic arches revealed the absence of cervical segments of both vertebral arteries. Transcranial doppler revealed the presence of intracranial segments of these arteries that continued in a normal basilar trunk. MR-angiography performed on a 3T machine confirmed the bilateral absence of cervical segments and the presence of normal intracranial segments arising from the occipital arteries, branches of the external carotid arteries. Embryologic analysis explains this variant by an involution of cervical segments and persistence of anastomoses between the external carotid system and the vertebrobasilar system that normally regresses during fetal life. This anastomosis enables irrigation of the intracranial vertebrobasilar system by the external carotid artery. The introduction of 3T MR-angiography has enabled better and more precise detection of vascular variants without invasive angiography.

Faux anévrysme de l’aorte abdominale naissant dans un magma ganglionnaire : diagnostic par écho Doppler et traitement par embolisation

OBJECTIVE: To report a case of pseudoaneurysm of the abdominal aorta due to retroperitoneal enlarged lymph nodes. MATERIALS AND METHODS: A 40 years old patient, with known sarcoma and metastatic retroperitoneal lymph nodes was referred for abdominal ultrasound because severe abdominal pain after defecation. RESULTS: The Doppler examination revealed magma of retroperitoneal lymph nodes surrounding the abdominal aorta inside of which a saccular collection of circulating blood, communicating with the aorta, was detected. The spectrum registered in the channel revealed a bidirectional flow compatible with a pseudoaneurysm. MR angiography confirmed the diagnosis. Successful occlusion was done by coil embolization. CONCLUSION: Pseudoaneurysms of the abdominal aorta are very rare. We report the first case of pseudoaneurysm arising in retroperitoneal lymph nodes. Diagnosis by Doppler ultrasound allowed a rapid treatment by embolization.

Rupture of an infected radial artery false aneurysm

A 67-yr-old male obese smoker was admitted to the intensive care unit with respiratory failure due to exacerbation of chronic obstructive pulmonary disease. A 20G, 5-cm catheter (Seldicath; Plastimed , Paris, France) was placed in the right radial artery under aseptic conditions with a single puncture. The catheter was removed on day 5 and its tip sent for routine culture. On day 7, a red, painful, pulsatile mass (Figure A) with purulent discharge appeared at the puncture site. The discharge was sent for culture. Arterial ultrasonography of the lesion revealed a radial artery pseudoaneurysm (Figures B and C). The cultures from both the catheter tip and discharge were positive for methicillin-resistant Staphylococcus aureus. Antibiotic treatment was initiated with teicoplanine on day 9. On day 11, active bleeding at the puncture site developed. A suspected rupture of the

Contributing Factors to Inferior Vena Cava Filter Migration

We read with great interest the study published by Laborda et al. about the relationship between inferior vena cava size and pressure, and filter migration or penetration [1]. We agree completely with their findings concerning the effects of ventilation and valsalva maneuvers on the hemodynamics and anatomy of the inferior vena cava (IVC). These changes may be a risk factor for the migration of a previously inserted IVC filter. We would like to draw attention to an overlooked additional element that may also contribute to IVC filter migration: Prone positioning in association with positive pressure ventilation. We recently experienced an IVC filter migration during spinal surgery in a prone position. The IVC is a dynamic compliant vessel, subject to many physiologic variables that may affect its anatomy and hemodynamics [2]. Bariatric surgery illustrates best the dynamic nature of the vena cava, the vessel being under constant stress from fluid resuscitation and pneumoperitoneum, and acute migration of IVC filters have been reported during surgery [3]. Migrations have also been reported during cardiopulmonary resuscitation, where the IVC takes its maximal diameter as a result of aggressive fluid replacement, pump failure, and positive pressure ventilation [2]. Prone positioning of the patient in the operating room may also acutely modify the pressure in the IVC and contribute to the change in its diameter [4–6]. Prone positioning patients is widely practiced during lumbar spinal surgery, but these positions vary according to the available operating facilities and frames used. A positioning frame allowing the patient’s abdominal viscera to hang freely significantly reduces their inferior vena caval pressure, whereas proning on a conventional pad increases IVC pressure 1.5 times [6]. The patient we hereby describe was positioned on a conventional convex pad. In addition to proning, caval morphology and hemodynamics have probably been also affected by positive pressure ventilation, as demonstrated by Laborda et al. Device migration to the heart chambers is a serious complication, with a potentially fatal outcome. In 3 reviews of filter migrations between 1996 and 2008, we collected 59 cases of devices migrating up to the heart [3, 7, 8]. Four patients (7 %) died from the cardiac complications and half of the patients presented with potentially life-threatening complications including cardiogenic shock, arrhythmias, and acute myocardial infarction. Once again, we congratulate Laborda et al. on their work. We think that anesthesiologists should be aware of the risks related to the sudden increase of IVC pressure in the presence of an indwelling device. The use of proper frames that allow for less abdominal compression, and the avoidance of high positive ventilation pressures should be considered in these patients.

US-WP-2 Atlas d’enseignement en echo-Doppler neurovasculaire

Objectifs pedagogiques Connaitre les differentes pathologies des vaisseaux cervicaux. Connaitre la semiologie en echo-Doppler des differentes pathologies neurovasculaires. Connaitre la traduction en arteriographie, en angio IRM et en angioscanner volumique des anomalies vasculaires des troncs supra-aortiques. Messages a retenir La quantification des stenoses carotidiennes est a la fois morphologique et hemodynamique basee sur les vitesses systolo-diastoliques. Le flux devient resistif en amont d’une occlusion ou d’une stenose tres serree et amorti en aval d’une stenose tres serree. Toute inversion de flux est le temoin d’une pathologie. Une encoche proto-systolique du spectre de l’artere vertebrale peut etre en rapport soit avec une stenose serree de l’ostium de l’A Vert ou un syndrome de pre-vol, la manœuvre d’hyperhemie aide au diagnostic. Une pulsatilite axiale (sequence dynamique) est evocatrice d’une occlusion.

US-WP-11 Aspect echographique des fractures des extremites

Objectifs pedagogiques Connaitre l’aspect echographique des differents types de fractures distales. Connaitre les signes echographiques associes aux fractures. Connaitre les indications de l’echographie en traumatologie. Messages a retenir L’echographie est un examen complementaire non irradiant utile a la radiographie dans les petites fractures distales. L’echographie peut dans certains cas montrer des fractures sans anomalie radiologique visible. L’echographie peut dans certains cas confirmer ou eliminer une fracture douteuse a la radiographie. Un hematome vu en echographie peut etre le seul signe revelateur de fracture notamment physaire.