Małgorzata Szczerbo-Trojanowska

Changes in cerebral hemodynamics after carotid stenting: evaluation with CT perfusion studies

PURPOSE To determine changes in cerebral perfusion parameters, based on CT perfusion imaging, in patients after unilateral transluminal angioplasty and stent placement. MATERIAL AND METHODS 74 patients with symptomatic high - grade internal carotid artery stenosis (>70%) were studied with CT perfusion imaging before and - on average - 70 hours and 172 days after carotid stent placement. There were 50 patients with unilateral carotid artery stenosis and 24 with stenosis and accompanying contralateral internal carotid artery occlusion. CT examination was performed using a multidetector helical CT scanner (Light Speed Ultra Advantage, GE Healthcare, USA). Maps showing the absolute values of cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) were generated. RESULTS In a group with unilateral carotid artery stenosis perfusion deficits were present in 84% of patients, ipsilaterally to stenosis. MTT elongation was noted (6.2-6.8s) together with decreased values of CBF (40-46ml/100g/min) and slightly increased CBV (3.2ml/100g). In this group, 3 days after stenting, 30% of patients had perfusion deficits, and after 6 months only 6%. In a group with carotid artery stenosis and contralateral artery occlusion severe perfusion deficits were noted in both hemispheres and they were present in 100% of patients. 6 months after stenting hypoperfusion was observed only in 17% of patients. CONCLUSIONS Brain perfusion deficits, observed in a majority of patients with carotid artery stenosis tend to improve considerably after carotid artery stenting, in long - term follow up.

Power Doppler imaging in the evaluation of extracranial vertebral artery compression in patients with vertebrobasilar insufficiency

OBJECTIVE The recent introduction of Power Doppler Imaging (PDI) made a promise for better visualization of blood vessels lying in regions anatomically difficult for ultrasound imaging, i.e. vertebral arteries. The purpose of our study was to assess usefulness of PDI technique in visualization of vertebral artery course and to assess its utility in the detecting spondylotic vertebral artery compression in patients with vertebrobasilar insufficiency (VBI). METHODS A total of 428 patients with VBI symptoms was evaluated. A total of 282 (66%) patients related their symptoms to a specific head position. Thus, all Doppler examinations were performed in four head positions: hyperextension, flexion and right/left rotation and also in a position reported by a patient to produce symptoms. PDI technique was employed as vertebral artery mapping for precise PW-Doppler range gate placing. RESULTS Vertebral artery compression was found in 73 (17%) patients: 65 unilateral and eight bilateral. The diagnosis was based on flow decrease or its absence shown on PW-Doppler scans, after a specific head turning. CONCLUSION Vertebral artery compression, related to a specific head position is relatively frequent in patients with VBI symptoms, especially in an older population commonly suffering from cervical spondylosis. PDI facilitates noninvasive Doppler US diagnosis by showing the real course of vertebral artery, particularly its intertransverse portion.

Total-tau in cerebrospinal fluid of patients with multiple sclerosis decreases in secondary progressive stage of disease and reflects degree of brain atrophy.

Abstract Introduction. Tau protein is a potential marker of neuronal damage. The aim of the study is to investigate its potential role as a marker of brain atrophy in multiple sclerosis (MS). Materials and methods. Cerebrospinal fluid (CSF) and blood samples were collected from 48 patients with multiple sclerosis. Total-tau (t-tau) and phospho181Thr-tau (p-tau) concentrations were assayed with commercially available INNOTEST® hTAU Ag and INNOTEST® phospho181Thr-tau(181P) and correlated with indices of brain atrophy in magnetic resonance imaging (MRI) and clinical characteristics of the study population. Results. T-tau concentration in CSF was significantly higher in relapsing-remitting (RR) compared to secondary progressive (SP) MS patients (P = 0.01). Brain parenchymal fraction (BPF) was significantly decreased in SP patients (P = 0.002). BPF in the whole study population correlated inversely with Expanded Disability Status Scale (EDSS) (r = –0.51, P = 0.0002) and Multiple Sclerosis Severity Score (MSSS) (r = –0.42, P = 0.002). T-tau in CSF in the whole patient group correlated inversely with EDSS (r = –0.58, P = 0.0006). Conclusions. The results of our study suggest that total-tau concentration in CSF in a MS population decreases in the course of disease and reflects degree of parenchymal brain loss.

Extranasopharyngeal angiofibroma: clinical and radiological presentation

Nasopharyngeal angiofibroma (NA) is a rare, vascular tumor affecting adolescent males. Due to aggressive local growth, skull base location and risk of profound hemorrhage, NA is a challenge for surgeons. Angiofibromas have been sporadically described in extanasopharyngeal locations. We review ten cases of extranasopharyngeal angiofibroma (ENA) and discuss the incidence, clinical presentation and management of this pathology. The group consisted of 4 males and 5 females aged 8–49. There were 7 patients with nasal angiofibroma, 1 patient with laryngeal angiofibroma, 1 patient with oral angiofibroma and another patient with infratemporal fossa tumor. In patients with nasal angiofibroma most common presenting symptoms were nasal obstruction and epistaxis. Patients with laryngeal angiofibroma suffered from mild dysphagia and patients with the infratemporal fossa tumor had painless cheek swelling. In four patients with nasal tumor computed tomography (CT) demonstrated mass with strong to intermediate contrast enhancement. In one patient with nasal tumor carotid angiography demonstrated pathological vessels without intensive tumor blush. Infratemporal fossa tumor showed intensive contrast enhancement on CT and magnetic resonance imaging (MRI) scans, and abundant vascularity on angiography. Laryngeal and oral angiofibroma required no radiological imaging. Three nasal tumors were evaluated before introduction of CT to clinical practice. All patients underwent surgery. No recurrences developed. ENAs differ significantly from NAs regarding clinical and radiological presentations. They lack typical clinical and radiological features as they develop in all age groups and in females, may be less vascularised, arise from various sites and produce a variety of symptoms.

Extranasopharyngeal angiofibroma of the infratemporal fossa.

Juvenile angiofibroma (JA) is a benign, vascular neoplasm that accounts for less than 0.5 percent of all head and neck tumors. The characteristic triad of clinical symptoms consists of nasopharyngeal tumor, nasal obstruction, and recurrent epistaxis. JAs of extranasopharyngeal origin have been sporadically reported in the literature. Windfuhr and Remmert in a review of 65 patients with extranasopharyngeal angiofibromas found only one case of tumor located in the infratemporal fossa. We present a rare case of a patient with extensive JA that occupied infratemporal fossa and cheek, without involvement of the nasopharynx. Medical University of Lublin Review Board approved the analysis and description of the patient. A 24-year-old man was referred to our institution in January 2006 with a 9-month history of painless cheek swelling. No signs of infection were present. No lymph nodes were palpated. Biopsy taken previously in another hospital indicated capillary hemangioma. Computed tomography and magnetic resonance revealed an inhomogeneous mass in the left infratemporal fossa that caused displacement of the pterygoid muscles and anterior bowing of the posterior maxillary wall (Fig 1). The tumor spread anteriorly between alveolar process of the maxilla and ramus of the mandible and invaded the cheek. The masseter muscle was displaced posteriorly. The tumor presented intermediate signal intensity on T1and T2-weighted images with focal signal-void areas. After contrast administration, intensive inhomogeneous enhancement of the lesion was visible. There were no signs of bony destruction. A superficial part of the tumor was easily accessible for sonographic evaluation. Color-flow duplex Doppler sonography demonstrated a solid, hypoechoic mass with multiple internal vessels of low-resistance blood flow. Carotid angiography showed abundant vascularity of the tumor with blood supply from the left external carotid artery via internal maxillary artery (Fig 2). Preoperative embolization of the feeding branches with the use of polyvinyl alcohol particles was performed. Final external carotid arteriogram showed occlusion of the feeding vessels. Two days after embolization, the tumor was removed with the use of combined intraoral and infratemporal fossa approach. Apart from cheek hematoma that resolved spontaneously, postoperative course was uneventful. A threeyear follow-up revealed no recurrence and no functional deficits. Histopathologic examination showed findings characteristic for JA: multiple gaping vessels lined by a single layer of endothelial cells embedded in fibrous stroma containing spindle-shaped and stellate cells, collagen fibers, and inflammatory cells (Fig 3, http://www.journal. entnet.org).

Endovascular transcatheter embolization of recurrent postsurgical varicocele: anatomic reasons for surgical failure.

Background Formation or pre-existence of collateral gonadal veins in varicocele patients has been reported as the main cause of surgical treatment failure. Purpose To describe venographic findings in patients with postsurgical recurrent varicoceles and to assess the efficacy of the following minimally invasive endovascular treatment. Material and Methods Thirty-three men with failed surgical treatment of left-sided varicocele were examined between 2006 and 2013, using retrograde venography to assess the anatomy of varicocele draining veins before the attempted transcatheter embolization. Anatomic variants of gonadal veins were categorized according to the classification modified for the purpose of the present study. 3% polidocanol was used as an embolic agent together with pushable fibered coils. Results In 31 (93%) out of 33 patients venography demonstrated incompetence of the gonadal vein or veins draining varicoceles after failed surgical treatment. The most frequent venographic finding was gonadal vein duplication – 66% of cases (39% in its mid-portion). Technical success of embolization was achieved in all 31 patients. No major complications were observed. Conclusion Retrograde varicocele embolization may be superior to surgery because of its ability to detect gonadal vein variants. In our study group, transcatheter embolization with 3% polidocanol and fibered coils allowed successful, minimally invasive treatment of postsurgical varicoceles.

Pregnancy 4 Months After Uterine Artery Embolization

Uterine artery embolization has been used in the treatment of symptomatic uterine leiomyomas since 1995 [1]. The effectiveness of this method in decreasing pain, and hypermenorrheoa has been described in numerous reports [2, 3]. However, the effects of uterine artery embolization on fertility in women remain unclear. Over 50 cases of pregnancy in women subjected to embolization have so far been described and this encourages further studies in order to assess the influence of the embolization procedure on women’s fertility [4–6]. Nevertheless, primary infertility and active desire to become pregnant are considered a contraindication for UFE by many authors. This paper presents a case of a 41-year-old pregnant woman subjected earlier to the procedure of uterine artery embolization.

Onyx(®) in endovascular treatment of cerebral arteriovenous malformations - a review.

Summary Arteriovenous malformation (AVM) is an abnormal connection between arteries and veins, bypassing the capillary system. In most cases, the disorder may be asymptomatic. The objective of endovascular AVM treatment is set individually for each case upon consultations with a neurosurgeon and a neurologist. The endpoint of the treatment should consist in prevention of AVM bleeding in a management procedure characterized by a significantly lower risk of complications as compared to the natural history of AVM. Endovascular interventions within AVM may include curative exclusion of AVM from circulation, embolization adjuvant to resection or radiation therapy, targeted closure of a previously identified bleeding site as well as palliative embolization. Onyx was first described in the 1990s. It is a non-adhesive and radiolucent compound. Onyx-based closure of the lumen of the targeted vessel is obtained by means of precipitation. The process is enhanced peripherally to the main flux of the injected mixture. This facilitates angiographic monitoring of embolization at any stage. The degree of lumen closure is associated with the location of the vessel. Supratentorial and cortical locations are most advantageous. Dense and plexiform structure of AVM nidus as well as a low number of supplying vessels and a single superficial drainage vein are usually advantageous for Onyx administration. Unfavorable factors include nidus drainage into multiple compartments as well as multiarterial supply of the AVM, particularly from meningeal arteries, en-passant arteries or perforating feeders. Onyx appears to be a safe and efficient material for embolization of cerebral AVMs, also in cases of intracranial bleeding associated with AVM. Curative embolization of small cerebral AVMs is an efficient and safe alternative to neurosurgical and radiosurgical methods. Careful angiographic assessment of individual arteriovenous malformations should be performed before each Onyx administration.

Aortic Stiffness, Left Ventricle Hypertrophy, and Homogeneity of Ventricle Repolarization in Adult Dialyzed Patients

Aim. Study was designed to assess relationship between aortic compliance and homogeneity of heart electrical activity in dialysis patients. Methods. Study group was consisted of 120 dialyzed patients; 57 (age 50,7 ± 7,1) were on continuous ambulatory peritoneal dialysis (CAPD) and 73 (age 51,6 ± 7,6) were hemodialyzed (HD). Three-dimensional vectorocardiographic (VCG) monitoring was done to assess: QRS-T angle, T el and T az. Echocardiography was performed to assess: Aomax, Aomin, ASI (aortic siffness index). Results. ASI in HD as well as in CAPD patients was significantly higher compared to controls [resp., 5,51 (±1,32), 5,83 (±1,41), 3,07 (±1,09)]. Cut-off value of ASI was 5,67. In HD patients strong correlations between ASI and QRS-T angle, T el and T az were determined (resp., r = 0,429, P < 0,001; r = 0,432, P ≤ 0,001 and r = 0,387, P = 0,001). In CAPD group were significant association between ASI and QRS-T angle, T el and T az (resp., r = 0,452, P < 0,001; r = 0,417, P < 0,001 and r = 0,390, P = 0,001). ASI was independently and markedly associated with: QRS-T angle, T elev, T az, ADMA, cTnT, CRP, Total-chol, LDL-chol in HD and CAPD patients. Conclusions. ASI and VCG indices are higher in HD and CAPD patients. Correlation between ASI and VCG parameters may reflect unfavourable influence of poor aortic compliance on the electrical activity of the heart in dialyzed patients. Hypertrophy aggravates repolarization disturbances in hemodialyzed patients.

The diagnostic value of levovist in Doppler imaging of visceral arteries in patients with abdominal angina before and after angioplasty.

PURPOSE To assess the diagnostic value of Levovist in the ultrasound imaging of visceral arteries in patients with clinical symptoms of abdominal angina, before and after percutaneous transluminal angioplasty (PTA). MATERIAL AND METHOD During a 12-month period (2000/2001) five patients with visceral arterial stenoses had ultrasound examinations and a subsequent PTA procedure. Indications for ultrasound examination were abdominal angina symptoms persisting for 3-5 years, (postprandial abdominal pain, diarrhea, and vomiting). In all patients ultrasound examinations were performed using color and spectral Doppler before and after Levovist injections. Color Doppler images and maximum blood flow velocity in stenosed visceral arteries were assessed. Patients underwent control Doppler examinations with Levovist injections to assess the effect of PTA. RESULTS In three patients conventional Doppler examination did not allow proper evaluation of visceral arteries, because of weak color and spectral Doppler signal and in two remaining patients visceral arteries were not visualized at all. In all five patients strong enhancement of color and spectral Doppler signal was observed after Levovist administration. In all these cases a hemodynamically significant stenosis was diagnosed: coeliac trunk-2 and superior mesenteric artery-3. PTA was performed successfully in these patients. In one of them ultrasound examination done before Levovist injection allowed good visualization of treated SMA and showed good PTA result. In the remaining four patients Doppler examination with the use of Levovist demonstrated visceral arteries well and confirmed successful PTA procedures. CONCLUSIONS The use of Levovist makes the diagnostic efficiency of Doppler examinations much higher. In most cases it allows an unequivocal diagnosis of visceral artery stenosis in patients with abdominal angina symptoms. The Doppler examination with the use of Levovist is the method of choice in follow-up after PTA.