Selective internal carotid artery cross-clamping increases the specificity of cerebral oximetry for indication of shunting during carotid endarterectomy.

BACKGROUND: An indication for selective shunting during carotid endarterectomy (CEA) is based on monitoring during a procedure. Cerebral oximetry (CO) using near-infrared spectroscopy (NIRS) may be a simple technique, but its relevance during CEA, especially with respect to cutoff values indicating shunt implantation, still needs to be elucidated. METHODS: One hundred twenty five patients underwent CEA under local anesthesia (LA) and were monitored clinically throughout the whole procedure. The patients were also monitored using bilateral NIRS probes during surgery. The NIRS values were recorded and evaluated before and after selective cross-clamping, firstly by the external carotid artery (ECA), followed by the internal carotid artery (ICA). The decrease in the ipsilateral CO values, with respect to the indication of shunting, was only analyzed after selective cross-clamping of the ICA. The decision to use an intraluminal shunt was solely based on the neurological status evaluation after ICA cross-clamping. RESULTS: One hundred five patients (85%) were stable throughout the CEA, while 20 patients (15%) clinically deteriorated during surgery. The mean drop in the CO after selective ICA clamping in clinically stable patients was 6%, while in patients with clinical deterioration, the NIRS decreased by 14.5% (p < 0.05). When the cutoff value for selective shunting was set as a 10% decrease of the ipsilateral CO after selective ICA clamping, the sensitivity of the technique was 100% and the specificity 83.0%. CONCLUSIONS: Our study showed that a 10% decrease in the ipsilateral brain tissue oximetry after selective cross-clamping the ICA provides a reliable cutoff value for selective shunting during CEA. Despite the availability of a variety of monitoring tools, the NIRS may be an easy, reliable option, especially in the scenario of acute CEA in general anesthesia.

The masaryk hospital extracranial-intracranial bypass study.

Patients with symptomatic internal carotid artery (ICA) occlusion with haemodynamic impairment are at higher risk of ischaemic stroke, and they require treatment. There are two main options: the best medical treatment and an extracranial-intracranial bypass. The aims of this study are to analyse the 30-day and 2-year risk of stroke and death in patients with extracranial-intracranial bypass performed by our department and to compare our results with major published studies. This retrospective study enrolled patients who underwent surgery from 1998 to 2012. Inclusion criteria were the following: (1) radiological diagnosis of symptomatic atherosclerotic internal carotid artery occlusion (AICAO), (2) less than 50 % stenosis of a contralateral ICA, (3) transient ischaemic attack (TIA) or ischaemic stroke in the hemispheric territory on an occluded side within 120 days and (4) haemodynamic impairment of at least stage I according to transcranial Doppler sonography (TCDS), perfusion CT and SPECT. Patients were followed up in the outpatient department with TCDS and sonography of the contralateral ICA and the anastomosis after 6 weeks and every 12 months after that. All risks of stroke and death from surgery were recorded throughout the 30 days and the following 2 years post surgery. From September 1998 to November 2012, 93 patients were selected for bypass surgery. There were 72 men and 21 women in an age range of 33 to 79 years (mean 58.9 years) and a follow-up range of 13 to 187 months (mean 108 months). The 30-day risk of stroke and death was 7.5 %. It consists of one death, one major ischaemic stroke, two reversible neurological deficits and three TIAs. The 2-year risk of stroke and death was 9.7 %. Extracranial-intracranial bypass is an effective treatment of haemodynamic impairment in patients with internal carotid occlusion. Maintaining low-level morbidity and mortality is possible with a dedicated neurovascular team. This is the only way in which we can reduce the risk of stroke and death in patients with bypass compared to patients treated medically.

[Arthroscopic stabilisation of acute acromioclavicular dislocation using the TighRope device]. / Artroskopická stabilizace akutní akromioklavikulární luxace implantátem TighRope.

PURPOSE OF THE STUDY: To present the TightRope (Arthrex, Naples, FL) technique and its results in the arthroscopic stabilisation of acute acromioclavicular joint (ACJ) dislocation carried out at our department. MATERIAL AND METHODS: From July 2009 till December 2010, arthroscopic stabilisation of acute ACJ dislocation was performed in 22 patients. The group consisted of 18 men and four women with an average age of 37.4 years. The Rockwood type III to type V ACJ dislocations (III, 16; IV, 1; V, 5) were indicated for surgery. The average interval between injury and surgery was 5.4 days. In all cases, a second-generation TightRope implant was inserted by the EndoButton technique joining the distal end of the clavicle and the coracoid process. The results were evaluated using the UCLA Shoulder Scale at 6 months after surgery. RESULTS: All 22 patients returned to their pre-operative activities without any restriction of shoulder motion within 5 months of surgery. The average post-operative UCLA score was 31.2 points (range, 28 to 35). Radiographic evidence of the loss of full reduction, with no effect on the clinical outcome, was recorded in four patients (18%) during post-operative rehabilitation. Of these, one had Rockwood type III, two had type IV and one had type V dislocations. One patient suffered post-operative pull-out of the implant from the coracoid; three patients showed skin wound healing by second intention above the lateral clavicle, with one requiring surgical repair under local anaesthesia. There was no neurovascular complication, intra- or postoperative fracture of the coracoid process or lateral clavicle, or deep wound infection. DISCUSSION: Arthroscopic stabilisation of acute ACJ dislocation is a minimally invasive procedure providing the coracoclavicular ligament complex with dynamic stability. In comparison with open procedures, it is less painful post-operatively, allows the patients to return early to daily activities and has a better cosmetic effect. It eliminates the necessity of removing the osteosynthetic material, as is the case in commonly used techniques such as Bosworth's method, K-wiring, osteorrhaphy or hook plate insertion. The loss of full reduction in four patients, as observed on radiographs during their rehabilitation, was not accompanied by any clinical problems and is in agreement with the findings of other authors. In our group, it occurred in Rockwood grade IV and grade V dislocations. For these, there is a possibility of using two implants in order to increase stability and prevent the loss of full reduction but this involves a higher risk of coracoid fracture, extension of operative time and higher costs. However, a loss of reduction in some patients has also been reported by the authors who have used two implants. Therefore we prefer using a single TightRope implant, particularly in acute grade III ACJ dislocations requiring surgical treatment in patients engaged in repetitive overhead activities related to sports or occupation. CONCLUSIONS: Arthroscopic stabilisation of acute ACJ dislocations using a single TightRope implant is an elegant minimally invasive method with good results in indicated cases. It proves efficient particularly in Rockwood type III injuries in patients who have to do repetitive overhead activities. Acute type IV and type V ACJ dislocations treated by this technique show a loss of full reduction on radiographs more frequently, although no effect on the clinical outcome is evident.

[Treatment for volume upgrading of the low-grade supratentorial glioma after the subtotal neurosurgical resection]. / Lécba nízkostupnového gliomu supratentoriální oblasti mozku po neurochirurgické subtotální resekci s projevy objemového up-gradingu.

BACKGROUND: Low-grade gliomas WHO II (LGG) are mostly detected in patients with neurological symptomatology between 20 and 45 years of age very often as secondary epilepsy. We present two cases in which low-grade gliomas attacked neurological zones. Neurosurgical resection was subtotal because of the risk of the damage in neurocognitive functions in both these patients. After the operation, both patients were followed at neurosurgery department in regular intervals using different imaging methods (MRI, MRS and PET). After resections, the MRI detected the enlargement of the volumes of the tumor residua in both patients. PATIENTS AND METHODS: Owing to the risk of up-grading to high-grades glial tumors (overexpression of EGFR and VEGF), both patients were indicated for curative treatment by external beam radiotherapy combined with chemotherapy (Temodal®) and adjuvant chemotherapy. RESULTS: After the end of this treatment, the MRI proved considerable partial regressions in both patients. Moreover, three months later, the MRI did not prove any residual disease. CONCLUSION: Radiotherapy combined with the administration of Temodal should prolong the OS and TTP in patients with a high risk of up-grading of low-grade gliomas of the brain. Both the patients are in a follow-up program, also because of the risk of duplicite brain tumor.

[Decompressive craniectomy in the treatment of posttraumatic edema and the contribution of new diagnostic methods]. / Dekompresivní kraniektomie v lécbe posttraumatického edému mozku a prínos nových monitorovacích metod.

The authors present a case report of a young male who suffered a brain injury complicated with malignant posttraumatic edema managed with bilateral decompressive craniectomy after conservative treatment failure. They further discuss current surgical approach to posttraumatic brain edema and contribution of new diagnostic methods in secondary brain damage management.

[Results of reinnervation after peripheral nerve repair by a microsurgical technique used in 1996-1998]. / Výsledky reinervace periferních nervu osetrených mikrochirurgickou technikou v letech 1996-1998.

PURPOSE OF THE STUDY: The authors present the results of a retrospective study of reinnervation after peripheal nerve repair by a microsurgical technique between 1996 and 1998. This is a development of a previous study by their colleagues. MATERIAL: Between 1996 and 1998, 113 injured peripheral nerves were treated by epineuroperineural suture (Ethilon; thickness, 8/0-10/0) under a microscope. To achieve a homogeneous group, 12 median and 13 ulnar nerves were included and evaluated in this retrospective study. All nerves studied were completely severed at the distal forearm and had sharply cut ends. METHODS: The results of reinnervation were retrospectively analyzed and classified according to the British Medical Research Council system (Seddon, 1972). The patients were followed up for 3 years. The patient's satisfaction with hand function was rated according our own classification. Tinel's sign and scar tenderness were evaluated. RESULTS: 17 patients (68%) achieved motor function M3 or higher and 16 patients (64%) had sensation S3 or higher. Better motor function was achieved after repair of the median than the ulnar nerve (M3 and higher in 91% and 46%, respectively). Better sensory recovery was achieved after repair of the ulnar than the median nerve (S3 and higher in 77% and 50%, respectively). Tinel's sign was positive in 68% of the patients; 10% of the patients complained of scar tenderness. DISCUSSION: Our results are comparable with the studies published so far. The patients with median nerve lesions showed better improvement after repair than those with ulnar nerve lesions and the outcome was better in hands with injury to only one nerve than in those with both nerves injured. The factors that influence peripheral reinnervation and the recovery of hand function are discussed. The surgical technique used, patient's age, regenerative capacity of the peripheral nerve affected, the interval between injury and the definitive microsurgical procedure and the quality of postoperative care are considered to be most important. CONCLUSIONS: Lesions of the peripheral nerve require special attention by a neurosurgeon competent to provide appropriate microsurgical treatment. The interval between injury and definitive treatment should be as short as possible. Postoperative care (rehabilitation and regular neurological examination) is also an important part of treatment.

Comparative analysis of histologic homologues of endometrial and ovarian carcinoma.

We compared molecular alterations in histologically homologous ovarian and uterine carcinomas, including the prevalence of allelic loss of markers on 17q (within and distal to the familial breast-ovarian cancer gene BRCA1), mutations of codon 12 of Ki-ras and immunohistochemical expression of the p53 and c-erbB2 gene products in endometrioid and papillary serous carcinomas occurring in the uterus and ovary. A total of 86 uterine and 28 ovarian endometrioid carcinomas, as well as 8 uterine and 26 ovarian papillary serous carcinomas, were evaluated. The prevalence of p53 gene product immunoreactivity was similar in papillary serous carcinomas occurring in the uterus (6 of 8, 75%) and ovary (16 of 26, 62%). Allelic loss on 17q also was seen in similarly high proportions of uterine (3 of 7, 43%) and ovarian (16 of 25, 64%) papillary serous carcinomas. In contrast, expression of the p53 gene product was seen in significantly more endometrioid tumors of the ovary (14 of 28, 50%) than in those occurring in the uterus (4 of 86, 5%) (p < 0.0001). Allelic loss on 17q also was present in significantly more ovarian (19 or 27, 70% than in uterine (2 of 72, 3%) endometrioid carcinomas (p < 0.0001). Immunohistochemical expression of c-erbB2 and mutations of codon 12 of Ki-ras were present in a minority of carcinomas. Endometrioid tumors of the ovary and endometrium, although histologically similar, may arise from different genetic events, whereas uterine papillary serous carcinoma shares with its ovarian counterpart several molecular alterations that may account for its aggressive clinical behavior.

Molecular analysis in endometrial cancer.

The molecular events that occur during the development of endometrial carcinoma are largely uncharacterized. Carcinomas of the endometrium are associated as extracolonic malignant tumors in patients with hereditary nonpolyposis colorectal cancer syndrome. Endometrium and ovary may develop histologically homologue cancers especially endometrioid and papillary serous carcinomas. Colon and ovarian carcinoma might serve as model systems for the molecular analysis in endometrial carcinoma. We sought to analyze in endometrial carcinoma frequent molecular mechanisms of colon and ovarian carcinoma, including Ki-ras codon 12 mutations, microsatellite instability, p53 and c-erb B-2 immunohistochemical expression and allelic loss on chromosome 17q. Our results indicate that molecular mechanisms in endometrial carcinoma are different than those responsible for colorectal carcinomas and that uterine papillary serous carcinomas shares with its ovarian counterpart several molecular alterations in contrast to the histologically homologue uterine and ovarian endometrioid carcinoma. Furthermore there is a molecular basis to distinguish uterine endometrioid and papillary serous carcinoma.

Detection and characterization of atypical mycobacteria by the polymerase chain reaction.

The purpose of this study was to develop a simple protocol of nested reamplification polymerase chain reaction (PCR) to detect and characterize diverse mycobacterial species. DNA extracted from 126 pure mycobacterial cultures isolated from clinical specimens was amplified by nested PCR with use of a novel set of oligonucleotide primers specific for the 65-kDa antigen gene of mycobacteria. The PCR products were each digested with three restriction enzymes and electrophoresed on an agarose gel. The observed DNA fragment sizes of the different species with each enzyme were compiled into a simple algorithm. This method can rapidly detect and characterize a wide variety of mycobacterial species, including the most common pathogens Mycobacterium tuberculosis, Mycobacterium avium-intracellulare, and Mycobacterium kansasii, without hybridization to labeled probes. The application of this method to surgical pathology was demonstrated by amplification and identification of atypical mycobacteria, including M. kansasii and Mycobacterium leprae, in formalin-fixed paraffin-embedded tissue. This protocol broadens the diagnostic potential of PCR for rapidly diagnosing mycobacterial infection in clinical samples, particularly in paraffin-embedded tissue sections.

Loss of heterozygosity and overexpression of the p53 gene in ovarian carcinoma.

Mutation and allelic loss of the p53 gene have been demonstrated in a variety of human cancers. In this study, DNA was extracted from formalin-fixed paraffin sections of ovarian carcinoma from 33 patients informative for a restriction fragment length polymorphism (RFLP) for BstU 1 within the 4th exon of the p53 gene. Allelic loss of p53 as indicated by loss of heterozygosity for this RFLP was demonstrated in 16/33 cases (48%). Because immunoreactivity for p53 correlates closely with the presence of mutation in the p53 gene, we performed immunohistochemical staining with the monoclonal antibody PAb1801. Diffuse nuclear p53 immunoreactivity was observed in 16 of the 33 (48%) informative cases used for loss of heterozygosity analysis (37/80 (46%) cases of ovarian carcinoma overall). A significant correlation (Fisher's exact test, P = 0.04) was observed between p53 overexpression and allelic loss. We found no evidence of association of p53 allelic loss or overexpression with advanced stage or other clinical or pathologic prognostic parameters. We conclude that mutation and allelic loss of p53 are common and probably related events in the development of ovarian carcinoma. This study demonstrates the use of paraffin sections in the analysis of p53 alterations in neoplasia.

Hepatitis B and alterations of the p53 tumor suppressor gene in hepatocellular carcinoma.

In areas of the world where hepatitis B and aflatoxin ingestion are common, alterations of the p53 tumor suppressor gene have frequently been reported in hepatocellular carcinoma (HCC). In particular, G-to-T transversions at codon 249 of the p53 gene have been consistently observed in hepatocellular carcinomas in China and sub-Saharan Africa. The goal of this study was to determine the frequency and relationship of p53 gene alterations and hepatitis B in formalin-fixed, paraffin-embedded HCCs resected in the United States. Since immunoreactivity for p53 correlates closely with the presence of missense mutations in the p53 gene, we performed immunohistochemical staining with the monoclonal antibody PAb1801. Only seven of 37 cases (19%) demonstrated nuclear accumulation of p53 gene product, in contrast to 10 of 20 cases (50%) of colon carcinoma metastatic to the liver. Staining was not observed in seven liver cell adenomas, 10 cases of focal nodular hyperplasia, or eight cases of cirrhosis. DNA was extracted from formalin-fixed paraffin sections for additional analysis with use of the polymerase chain reaction (PCR). G-to-T transversions of the third nucleotide of codon 249 were demonstrated in only four of 37 cases (11%), three of which had stained with PAb1801. Of 13 patients for whom there was information about a restriction fragment length polymorphism (RFLP) for BstUI within the fourth exon of the p53 gene, allelic loss of p53 was demonstrated in only two cases (15%), both of which stained with PAb1801. Because of previous reports specifically associating hepatitis B with p53 mutations in HCC, we performed nested PCR for hepatitis B virus DNA. Five of 37 cases (14%) contained hepatitis B virus DNA, two of which stained diffusely for p53 and three of which had codon 249 mutations. Our findings indicate that alterations in the p53 gene, particularly at codon 249, are uncommon in HCCs in the United States, and when present are associated with hepatitis B. Since hepatitis B is infrequently associated with HCC in our patient population, the role of p53 alterations in hepatocellular carcinogenesis may not be as significant as in other parts of the world where hepatitis B and aflatoxin are more prevalent.