Noel Aoun

Vascular manifestations of Behçet’s disease

Abstract Objectives. – To describe the features, prognosis, and treatment of vascular involvement in Behcet’s disease (BD). Patients. – Among 140 patients with BD seen at the Hotel-Dieu Hospital in Beirut between 1980 and 2000, 18 (13%) had vascular involvement and were included in this retrospective study. All these patients fulfilled International Study Group criteria for BD. Results. – Men with BD were more likely to have vascular involvement (13/77, 17%) than women (5/63, 8%) ( P = 0.12) and were younger at diagnosis of vascular disease (32 ± 7 vs. 36 ± 7.5 years; P P P > 0.05). Caval thrombosis and arterial occlusions were the most serious complications. Combined treatment with glucocorticoids, anticoagulants, and immunosuppressants was effective in superior vena cava syndrome and extracranial arterial occlusion. Conclusion. – Vascular manifestations of BD are common in Lebanon, particularly venous lesions. Aneurysms are seen less often than arterial occlusions. Medical treatment may be sufficient in superior vena cava syndrome and arterial occlusion.

Adnexal torsion: magnetic resonance findings in the viable adnexa with emphasis on stromal ovarian appearance.

To evaluate ultrasound (US) and magnetic resonance (MR) findings in the viable twisted adnexa.

Variable MR findings in ovarian functional hemorrhagic cysts.

To describe the magnetic resonance (MR) findings in ovarian functional hemorrhagic cysts (FHC).

Portal and hemiazygos continuation of the inferior vena cava: report of an unusual case

In infrahepatic interruption of the inferior vena cava (IVC), continuation is usually through the azygos or hemiazygos systems (Chuang et al, 1974; Smathers et al, 1982; Mayo et al, 1983). Recently, Bercoff et al (1985) described the first case of portal continuation. We observed such an anomaly in a patient who had a single left-sided IVC with hemiazygos-azygos continuation, and a shunt between the portal and hepatic systems. To our knowledge nosuch complex anomaly has yet been reported.

Spontaneous detorsion of the ovary: Can it be diagnosed by MRI?

To determine whether recent progress in imaging has made it possible to diagnose spontaneous detorsion, which is an accepted concept in the gynecological literature but until now has been a presumptive diagnosis that could not be confirmed because of the lack of imaging proof.

Emergency Arteriography in the Assessment of Penetrating Trauma to the Lower Limbs

One hundred emergency arteriographies (EA) were performed in 87 patients with lower limb trauma due to high-velocity missiles. Thirteen patients had bilateral injuries. In 79 cases, EA findings were positive and led to emergency surgery. In 76 cases an arterial injury was found and treated, a positive predic tive value of 96% (76/79). In the other 3 cases, no arterial lesion was found (3 false positives). Among the 21 patients with normal findings from angiography, 10 had surgical exploration because of high clinical suspicion of vascular injury. Arterial injury was found in 2 cases (2 false negatives). In 8 patients, arteriogra phy modified the surgical procedure. In the 11 remaining patients, clinical and echo Doppler follow-up results were normal, a negative predictive value of 90% (19/21). Sensitivity was 97%, specificity 86%, and accuracy 95%. These data show that arteriography in stable patients is a safe and accurate procedure. It permits avoidance of unnecessary surgical exploration in selected patients and helps modify the surgical procedure.

Pheochromocytoma: a tumour not to be trusted

A 59-year-old male with liver cirrhosis secondary to non-alcoholic steatohepatitis, and prior history of aesophageal variceal bleeding underwent abdominal magnetic resonance imaging (MRI) for increasing a-fetoprotein plasma levels. He was also known to have long-lasting diabetes mellitus. His medication included propranolol for prevention of rebleeding. The examination was performed on a Signa 1.5 Tesla (General Electric, Milwaukee, WI, USA) machine. It showed a dysmorphic but otherwise unremarkable liver, mild splenomegaly, moderate ascitis and a well-circumscribed, heterogeneous, highly enhancing extra-adrenal mass, measuring 5.8 cm, located to the right side of the aorta under the renal hilum (Figs 1–3). Extra-adrenal pheochromocytoma, or paraganglioma, was the first proposed diagnosis. However, because biological markers were normal (serum catecholamines, 24 h urinary catecholamines and urinary vanillylmandelic acid (VMA) levels), other diagnoses were suggested including retroperitoneal sarcoma and adenopathy secondary to hypervascular primary tumour such as neuroendocrine, melanoma, kidney, breast, thyroid or colon. Percutaneous computed tomography (CT)-guided biopsy was performed without premedication and without any side effect. During this procedure carried out without intravenous contrast injection, the highest density in the tumour was 23 Hounsfield units. Histology concluded to a pheochromocytoma. A surgery was planned, and, because the tumour was clinically and biologically silent and because biopsy was not complicated, it was decided not to prepare the patient with a-blockers. Unfortunately the patient developed a hypertensive crisis with a systolic blood pressure reaching 230 mmHg when the surgeon touched the tumour. The blood pressure was rapidly controlled, and the tumour was completely removed. The patient had unremarkable post-operative recovery. Most pheochromocytomas occur in the adrenal gland. However, extra-adrenal or ectopic pheochromocytomas do occur in 15–20% of cases and can be located in any organ containing chromaffin cells, mainly in the abdomen. The diagnosis of pheochromocytoma is easy when clinical signs and biological markers such as elevation of plasmatic concentration of catecholamines and 24-h urinary concentration of VMA are present, and the role of imaging is to localise the tumour prior to surgical removal. However, in about 10% of patients, there may be no or few symptoms and physical signs as in our