Vittorio Iaccarino

Multiple Sclerosis: Cerebral Circulation Time

PURPOSE To assess cerebral circulation times (CCTs) in patients with multiple sclerosis (MS) and control subjects by using contrast material-enhanced ultrasonography (US) to determine whether vascular abnormalities can be detected in this disease. MATERIALS AND METHODS This study was approved by the local ethics committee, and informed consent was obtained from all subjects. One hundred three patients with MS and 42 control subjects underwent extracranial and transcranial venous echo-color Doppler ultrasonography (US) and contrast-enhanced US. CCT was defined as the difference in arrival time of the US contrast agent bolus between the carotid artery and the internal jugular vein. The presence of chronic cerebrospinal venous insufficiency (CCSVI) was defined according to previously reported criteria for the extracranial and transcranial US techniques. Nonparametric statistics, including the Mann-Whitney U test and the Kruskal-Wallis analysis of variance, were used to compare contrast-enhanced US parameters between groups. RESULTS The longest and average CCTs were substantially prolonged in patients with MS compared with those in control subjects (median longest CCT in patients with MS, 6.47 seconds [range, 3.29-29.24 seconds]; that in control subjects, 5.54 seconds [range, 2.57-7.63 seconds]; P < .001; median average CCT in patients with MS, 5.76 seconds [range, 2.64-17.51 seconds]; that in control subjects, 5.01 seconds [range, 2.57-7.06 seconds]; P < .002). No correlation was found between CCTs and clinical parameters. The prevalence of CCSVI was higher in patients with MS than in control subjects (77% vs 28%, P < .0001). CCT was not significantly different between patients with MS who had CCSVI and patients with MS who did not (P = .182). CONCLUSION These results suggest that contrast-enhanced US with CCT assessment may have a role in the evaluation of cerebral blood flow in patients with MS and that a vascular impairment could be associated with MS. The finding of a prolonged CCT at contrast-enhanced US does not result from outflow impairment. Further studies are required to verify these observations and to clarify if CCT and CCSVI have any physiologic and clinical relevance in MS.

Interventional radiology of male varicocele: current status.

Varicocele is a fairly common condition in male individuals. Although a minor disease, it may cause infertility and testicular pain. Consequently, it has high health and social impact. Here we review the current status of interventional radiology of male varicocele. We describe the radiological anatomy of gonadal veins and the clinical aspects of male varicocele, particularly the physical examination, which includes a new clinical and ultrasound Doppler maneuver. The surgical and radiological treatment options are also described with the focus on retrograde and antegrade sclerotherapy, together with our long experience with these procedures. Last, we compare the outcomes, recurrence and persistence rates, complications, procedure time and cost-effectiveness of each method. It clearly emerges from this analysis that there is a need for randomized multicentre trials designed to compare the various surgical and percutaneous techniques, all of which are aimed at occlusion of the anterior pampiniform plexus.

Endovascular Thrombolysis in Acute Mesenteric Vein Thrombosis: A 3-year follow-up with the rate of short and long-term sequaelae in 32 patients

Mesenteric vein thrombosis (MVT) is a rare, often lethal, entity that accounts for approximately 10-15% of all cases ofmesenteric ischemia. A variety of risk factors have been reported to be associatedwith acute MVT. However, no underlying cause is found in 25-50% of patients diagnosed with MVT [1,2]. Because of the slow onset of symptoms (vague abdominal discomfort thatworsens in 7-10 days in the absence of significant laboratory abnormalities), the clinical diagnosis is difficult. [1–3] In keeping with this, abdominal CT imaging for other indications, has increased awareness on the issue that mesenteric occlusions may be only mildly symptomatic or completely asymptomatic [3,4]. Current indications for surgery in patients with acute MVT include signs of peritonitis, bowel infarction, hemodynamic instability. In all other cases, long-lasting anticoagulation is the strategy of choice [5,6], patients with MVT having a fairly good prognosis and long-term outcomes once achieved appropriate anticoagulation [6,7]. Nevertheless, MVT is still a serious disease, with a highmortality rate (25%-35%), mostly related to transmural necrosis and bowel perforation due to the delay in diagnosis [1,4]. At variance with the slow onset of recanalization that takes place during anticoagulation, thrombolysis leads to a rapid re-opening of a vessel, with immediate tissue reperfusion [6]. Systemic thrombolysis has been used with success in MVT [8,9]. Encouraging results of endovascular thrombo-

Computed tomography findings of pneumatosis and portomesenteric venous gas in acute bowel ischemia

AIM To use more representative sample size to evaluate whether computed tomography (CT) scan evidence of the concomitant presence of pneumatosis and portomesenteric venous gas is a predictor of transmural bowel necrosis. METHODS Data from 208 patients who were referred for a diagnosis of bowel ischemia were retrospectively reviewed. Only patients who underwent a surgical intervention following a diagnosis of bowel ischemia who also had a post-operative histological confirmation of such a diagnosis were included. Patients were split into two groups according to the presence of histological evidence of transmural bowel ischemia (case group) or partial bowel ischemia (control group). CT images were reviewed for findings of ischemia, including mural thickening, pneumatosis, bowel distension, portomesenteric venous gas and arterial or venous thrombi. RESULTS A total of 248 subjects who underwent surgery for bowel ischemia were identified. Among the 208 subjects enrolled in our study, transmural bowel necrosis was identified in 121 subjects (case group), and partial bowel necrosis was identified in 87 subjects (control group). Based on CT findings, including mural thickening, bowel distension, pneumatosis, pneumatosis plus portomesenteric venous gas and presence of thrombi or emboli, there were no significant differences between the case and control groups. The concomitant presence of pneumatosis and porto-mesenteric venous gas showed an odds ratio of 1.95 (95%CI: 0.491-7.775, P = 0.342) for the presence of transmural necrosis. The presence of pneumatosis plus porto-mesenteric venous gas exhibited good specificity (83%) but low sensitivity (17%) in the identification of transmural bowel infarction. Accordingly, the positive and negative predictive values were 60% and 17%, respectively. CONCLUSION Although pneumatosis plus porto-mesenteric venous gas is associated with bowel ischemia, we have demonstrated that their co-occurrence cannot be used as diagnostic signs of transmural necrosis.

Congenital Agenesis/Aplasia of the Internal Carotid Arteries: MRA and SPECT Findings

Single photon emission CT (SPECT) and MRI and MR angiography studies were performed in a patient with right internal carotid artery (ICA) agenesis, left ICA aplasia, and multiple associated vascular abnormalities identified with digital subtraction angiography. Magnetic resonance angiography provided an excellent depiction of the extra- and intracranial vascular abnormalities. No evidence of brain lesions or perfusion defects was demonstrated with MRI and SPECT, despite the markedly altered vascular anatomy.

Embolization of glomus tumors of the carotid: Temporary or definitive?

The authors describe the use of preoperative embolization of glomus tumors in 7 patients. In two cases a nonresorbable substance (IBCA) was used for the embolization, and no subsequent operation was needed. They therefore suggest that embolization could be a definitive treatment and an alternative to surgery.

Sodium Tetradecyl Sulphate Direct Intralesional Sclerotherapy of Venous Malformations of the Vulva and Vagina: Report of Five Cases

We report five cases of female patients affected by symptomatic focal external genital venous malformations treated with percutaneous direct intralesional injection of sodium tetradecyl sulphate (STS). All patients were referred because of discomfort and pain when sexual intercourse was attempted. Direct sclerotherapy with 3% STS was performed on a day-hospital basis with the patient under local anesthesia. Complete resolution of the symptoms was achieved in all cases. No major adverse effects were reported. Direct intralesional sclerotherapy with STS may be considered a safe and effective method for the treatment of female external genital malformation without the necessity of general anesthesia for pain control.

Anticoagulant Therapy in Oncologic Patients Undergoing Venous Stenting for Superior Vena Cava Syndrome and Other Interventional Procedures

To the Editor, We read with interest the recent study by Fagedet et al. [1] and the case report by Sofue et al. [2] on the treatment of venous stents for superior vena cava (SVC) syndrome. Both articles report the utilization of intravenous (i.v.) heparin sodium during and after the endovascular procedure for the treatment of the SVC syndrome. Fagedet et al. also used antiplatelet aggregation treatment (aspirin 75–325 mg/day) for 3–6 months during postprocedural care. Furthermore, they adopted a long-term treatment with vitamin K antagonists in cases of paraneoplastic hypercoagulability. In their series of 164 patients with malignant SVC syndrome treated with self-expandable bare stents, 13 patients (7.9 %) had bleeding complications caused by anticoagulant treatment, with one death by concurrent thrombocytopenia. Sofue et al. after recanalization and restenting of acute occlusion of SVC, administered heparin (15,000 IU) for 7 days, followed by warfarin after discharge from hospital. We think it is important to stress that venous clots are mainly formed by fibrinous material, unlike arterial clots, which have large platelet components. For this reason, in most percutaneous coronary revascularization procedures, strong antiaggregants are provided, such as i.v. abciximab (Reopro, Lilly); likewise, in accelerated peripheral arterial thrombolysis, recombinant tissue plasminogen activator or urokinase are provided along with abciximab or other, similar drugs. We are thus convinced that aspirin was not useful and could be potentially harmful for possible subsequent gastrointestinal bleeding, especially if associated with warfarin. In addition, the utilization of heparin and warfarin in prophylaxis and the treatment of venous thromboembolism in neoplastic patients has been evaluated within the American Society of Clinical Oncology (ASCO) guidelines [3, 4]. ASCO recommends the utilization of only lowmolecular-weight heparin (LMWH), which is associated with decreased severe bleeding risk. In addition, a 2011 Cochrane report [5] confirms the superiority of LMWH in patients with cancer, as demonstrated by several metaanalyses. However, these reports do not provide a clear physiopathologic explanation. It can be hypothesized that LMWH has 90 % effect on Xa factor, which causes the final transformation of fibrinogen into fibrin. Heparin sodium and vitamin K antagonists act on several different coagulation factors to a more limited (40–70 %) extent than Xa factor. On the other hand, pathogenesis of a hypercoagulable state in malignancy is plainly and clearly described by Caine et al. [6], while over 150 years ago, Trousseau [7] noted recurrent migratory thrombosis (thromboembolic disease) in superficial veins, also in uncommon sites; this is one of earliest V. Iaccarino (&) P. Venetucci Radiologia Cardiovascolare ed Interventistica, Policlinico Universitario Federico II, Via Pansini 5, 80131 Naples, Italy e-mail: vittorio.iaccarino@unina.it

Percutaneous intralesional brushing of cystic lesions of bone: a technical improvement of diagnostic cytology

A modified bronchial brush is presented as a new cytologic method to improve the value of fineneedle aspiration biopsy in the diagnosis of cystic lesions of bone. Four female and six male patients ranging in age from 10 to 44 years were studied. In all cases intralesional brushing was percutaneously performed under fluoroscopic control with local anesthesia. Fine-needle aspiration biopsy preceded intralesional brushing and was performed as described elsewhere. The brush was driven into the walls and septa of an osteolytic lesion through a 14-G needle; material obtained was fixed and processed for cytological and/or histological examinations.

Percutaneous cholecystectomy in the human: A technical note

A new procedure-percutaneous ablation of the gallbladder—is reported in 2 patients. In this technique, ethanol is injected into the gallbladder and bucrylate is injected into the cystic duct to produce necrosis of the gallbladder.