Silent cerebral infarcts following pulmonary vein isolation with different atrial fibrillation ablation techniques - incidence and risk factors.

Introduction: Silent cerebral infarcts (SCIs) detected by diffusion-weighted magnetic resonance (DW-MRI) following atrial fibrillation (AF) ablation have been reported, with the incidence of 1-38%. We aimed to compare the incidence of SCIs following AF ablation with four different technologies and analyze the risk factors. Material and methods: A total of 104 patients (mean age: 59.9 ±9.5 years, 68 males) with symptomatic AF, referred for ablation, were included in the study. The AF ablation was performed with irrigated radiofrequency point-by-point technique (RF group) in 24 patients, and with 3 different single-shot techniques: phased-RF (PVAC) in 46, second-generation cryoballoon (CB) in 24 and irrigated multipolar RF catheter (nMARQ) in 10 patients. In all patients DW-MRI was performed pre- and post-procedurally to evaluate the incidence of SCIs. Procedural parameters, complication rate and post-procedural SCI incidence were compared between the groups. Results: Procedure (167.1 vs. 110.5 vs. 106.0 vs. 141.5 min, p < 0.001), fluoroscopy (22.7 vs. 15.9 vs. 16.3 vs. 15.3 min, p = 0.048) and LA dwell (101.5 vs. 53.9 vs. 56.0 vs. 97.0 min, p < 0.001) times compared respectively between RF, PVAC, CB and nMARQ groups were significantly shorter with single-shot techniques. The number of new-onset SCIs was 4/24 (16.7%) in RF, 7/46 (15.2%) in PVAC, 1/24 (4.2%) in CB and 1/10 (10%) in the nMARQ group. Univariate analysis identified procedure duration (p = 0.02), lower LV ejection fraction (p = 0.03), persistent form of arrhythmia (p = 0.007) and intraprocedural cardioversion (p = 0.002) as risk factors of new-onset SCIs. Conclusions: Silent cerebral infarcts can be detected following AF ablation regardless of the technology used. Prolonged procedure time, lower ejection fraction, persistent form of arrhythmia and intraprocedural cardioversion increase the risk of SCIs.

Susac syndrome as a multidisciplinary diagnostic challenge.

INTRODUCTION: Susac syndrome (SuS) is a disease manifested as the clinical triad of encephalopathy, branch retinal artery occlusion, and loss of sensory neural hearing. CASE REPORT: The case is presented of a 28-year-old patient hospitalized due to visual impairment of the left eye, and whose hearing and neuropsychiatric disorders had appeared two years earlier. Magnetic resonance imaging demonstrated lesions located in the white matter and along the corpus callosum. An audiogram showed bilateral sensory neural hearing loss. Fluorescein angiography examination revealed branch retinal artery occlusion of the left eye. Based on the clinical picture and results of tests, the diagnosis of SuS was made. Despite the use of steroid and immunosuppression therapy the disease progressed. CONCLUSIONS: The prognosis for SuS depends on the early diagnosis and implementation of treatment. It should be underlined that in case of hearing loss or encephalopathy of unknown cause, SuS should always be excluded.

IFN-γ Correlations with Pain Assessment, Radiological Findings, and Clinical Intercourse in Patient after Lumbar Microdiscectomy: Preliminary Study.

OBJECTIVES: We investigated the influence of pain decrease after lumbar microdiscectomy on the interferon gamma (IFN-γ) serum level in patients with lumbar disc herniations. The study challenges the mechanism of sciatica pain and the role of IFN-γ in radicular pain development. Material and Methods. We performed clinical and immunoenzymatic assessment in a group of 27 patients with lumbar radicular pain due to disc herniations before and 3 months after surgery. Clinical status was assessed with the use of the Numeric Rating Scale (NRS), the Pain Rating Index and Pain Intensity Index of McGill Pain Questionnaire (SF-MPQ), the Oswestry Disability Index (ODI), and Beck Depression Inventory (BDI). The plasma concentrations of IFN-γ were ascertained by an immunoenzymatic method. RESULTS: We observe significant correlations between the results of the pain in the back region assessment NRS back scale after the surgery with the level of IFN-γ before the procedure (r s = 0.528; p = 0.008) and after the procedure (r s = 0.455; p = 0.025). These are moderate and positive correlations-the decrease in pain is correlated with the lower IFN-γ level. Additionally, there are significant correlations between the results of the PRI scale and the IFN-γ level. The PRI score before surgery correlates positively with IFN-γ after surgery (r s = 0.462; p = 0.023), and the PRI score after surgery correlates positively with IFN before surgery (r s = 0.529; p = 0.005) and after surgery (r s = 0.549; p = 0.003). All correlations are moderate in severity-severe pain before surgery correlates with a higher level of IFN-γ after surgery and also higher IFN-γ before surgery. There were significant differences in the IFN-γ level before (Z = -2.733; p = 0.006) and after (Z = -2.391; p = 0.017) surgery in the groups of patients with and without nerve compression. In the group of patients with nerve compression, the level of IFN-γ before and after surgery was lower. CONCLUSIONS: Less pain ratio after operation correlates with the level of IFN-γ. In the group of patients without significant nerve compression confirmed by MRI scans, the level of IFN-γ before and after surgery was higher than that in the group with nerve root compression.

Silent Cerebral Infarcts Following Left-Sided Accessory Pathway Ablation in Wolff-Parkinson-White (WPW) Syndrome: A Preliminary Report.

BACKGROUND Catheter ablation is a routine procedure in patients with WPW syndrome. Silent cerebral infarcts (SCI) detected in magnetic resonance imaging may be a complication of the ablation procedure, but it is well documented only in atrial fibrillation ablation. Ablation of left-sided accessory pathways (L-AP) has a similar target area, but WPW patients differ from those with atrial fibrillation, due to lower initial risk of cerebral embolic events. The aim of this study was to determine whether the ablation of left-sided accessory pathways carries the risk of SCI. MATERIAL AND METHODS Twenty consecutive patients with overt L-AP referred for RF ablation in our center were included in the study. An irrigated ablation catheter was used in 8 patients, and a non-irrigated ablation catheter was used in 12 patients. Diffusion-weighted magnetic resonance imaging was performed pre-procedurally and on the next day after the ablation in all patients. RESULTS Ablation procedures were completed without complications and there were no neurological symptoms following the procedure, although in 2 patients (10%), post-procedural diffusion-weighted magnetic resonance revealed new acute silent cerebral infarcts. Both patients with new cerebral lesions were female, and a non-irrigated catheter was used in both cases. CONCLUSIONS This is the first study documenting the presence of silent cerebral infarcts after WPW ablation. Further investigations are needed to evaluate the risk of silent cerebral infarcts associated with L-AP ablation.

[Diagnosis of benign ovarian lesions using imaging techniques]. / Diagnostyka obrazowa zmian lagodnych w jajnikach.

Benign ovarian focal lesions - such cystic, inflammatory, vascular and metaplastic changes - may occur at any age but they are most commonly observed in girls at puberty and in young women. The most important preliminary procedures in case of suspected adnexal pathologies are interview, physical examination and classical female bimanual pelvic examination which together with imaging techniques allow correct diagnosis. The commonly available and inexpensive method of female reproductive organs imaging is an ultrasonography (USG). Magnetic resonance (MR), computed tomography (CT) and in case of malignant lesions also positron emission tomography (PET) may also be performed. In doubtful cases, when the evaluation of lesions using USG method is difficult MR is recommended. Due to high resolution, it facilitates precise evaluation of the type and size of lesions, allows distinguishing simple and complex fluid collections while fat saturation sequences make it possible to distinguish cysts containing blood and fat. Moreover, the patient is not exposed to ionizing radiation, which is especially important in women in reproductive age and in children. Computed tomography is recommended for preoperative staging and monitoring of treatment of malignant adnexal neoplasms as well as localization of small peritoneal metastases.

Disappearance of white matter lesions on MRI and clinical recovery after initiating antiretroviral therapy in a case of HIV infection presenting as spastic paraparesis.

We present a case of a 30-year-old Polish female who presented with increasing for about 2 years spastic paraparesis and urinary incontinence. She denied any risky sexual behaviors, drug abuse, there was no history of surgery or blood transfusions. MRI of the brain showed diffuse, hyperintensive in T2, poorly defined lesions in the white matter. About 3 months later paraparesis increased and control MRI showed progression of previously described lesions. She was then diagnosed with HIV infection. There was a suspicion of progressive multifocal leucoencephalopathy (PML) or vacuolar myelopathy in the course of HIV infection. Antiretroviral treatment was initiated leading, together with rehabilitation, to a progressive improvement of symptoms. Pathological lesions on brain MRI completely disappeared. In conclusion, HIV test should be done in every patient with neurological signs of unknown cause.

[Evaluation of prostate cancer progression]. / Ocena zaawansowania raka gruczolu krokowego.

Prostate cancer occures in male, especially over 65 year old. It develops usually in the peripheral zone, less commonly in central or transitional ones. The neoplasm screening bases on clinical digital rectal examination and serum level of prostate-specific antigen (PSA). Among patients with increase PSA concentration, transrectal ultrasound usually with multiple core biopsies is performed. The obtained bioptates are histologically evaluated using Gleason's grading system. However, the method of choice to examine the entire pelvis is a magnetic resonance. According to current principles, the obtained images are evaluated using five-step PI-RADS classification based on T2-weithed, diffusion weighted and dynamic contrast enhancement images. Spectroscopy is also suggested especially in case of prostatic carcinoma. Such procedures allow precise evaluation of cancer progression, and is helpful in treatment planning and response monitoring.

Solid-pseudopapillary neoplasm of the pancreas - comparisons between magnetic resonance and histological findings.

Solid-pseudopapillary neoplasm is a rare pancreatic tumor typically observed in young adults. A new case of the tumor was diagnosed in a 22-year-old woman. An abnormal mass connected with the pancreatic body was found on ultrasound and computed tomography. Magnetic resonance revealed weak homogeneous contrast enhancement and a low ADC value (0.824 mm/s2; b1000). Primary radiological diagnosis suggested a solid pancreatic neoplasm, which was confirmed during histopathological assessment after resection of the pancreatic body with preservation of the spleen and normal drainage through the main pancreatic duct. Histological appearance of the solid-pseudopapillary neoplasm corresponded with its radiological morphology.

Incidence of spinal perineurial (Tarlov) cysts among East-European patients.

The spinal perineurial cyst (Tarlov) is a dilatation between the perineurium and endoneurium of spinal nerve roots, located at level of the spinal ganglion and filled with cerebrospinal fluid but without communication with the perineurial subarachnoid space. The aim of the study was to evaluate it incidence among East-European patients. The retrospective data collected during various magnetic resonance spinal examinations and stored on the picture archiving and communication system was analyzed for an incidence of perineurial cysts. From among 842 patients that underwent examination, 75 cases perineurial cysts were revealed. In 22 cases single anomalies were found. In remaining 53 cases, multiple uni- or less frequently bilateral changes were noted. The most common position was the sacral canal, particularly the level of S2 and S3. Occasionally, cysts were also visible on the cervical, thoracic and lumbar level. Incidence of sacral perineurial cysts was significantly higher in females than in males. Similar data was found for single and multiple changes despite of their localization. Insignificant changes were seen for patient age and cyst size. Perineurial spinal cysts were the most frequently observed on the sacral level and such changes were more common in females.

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

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 phospho(181Thr)-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.

Acromegaly in a patient with normal pituitary gland and somatotropic adenoma located in the sphenoid sinus.

Ectopic acromegaly is a very rare clinical entity occurring in less than 1% of acromegalic patients. In most cases it is caused by GHRH or rarely GH-secreting neoplasms. Even rarer are ectopic pituitary adenomas located in the sphenoid sinus or nasopharynx that originate from pituitary remnants in the craniopharyngeal duct. This dissertation presents the difficulties in visualizing GH-secreting adenoma located in the sphenoid sinus. A 55-year-old man had somatic features of acromegaly for several years. MRI imaging revealed a slightly asymmetric pituitary gland (14 yen 4 mm) without focal lesions. Simultaneously, a spherical mass, 10 mm in diameter, corresponding with ectopic microadenoma was demonstrated on the upper wall of the sphenoid sinus. The serum GH level was 4.3 mg/l, IGF-1 = 615 mg/l, and a lack of GH suppression with oral glucose was proven. After preliminary treatment with a long-acting somatostatin analogue, transsphenoidal pituitary tumour removal was performed. Histopathological, electron microscopical and immunohistochemical analysis revealed densely granulated somatotropic pituitary adenoma: GH(+), PRL(-), ACTH(-), TSH(-), FSH(-), LH(-), MIB1 < 1%, SSTR3(+) and SSTR5(+). Post-surgical evaluation showed normal pituitary MRI scans, GH and IGF-1 levels 0.18 mug/l and 140 mg/l, respectively, as well as normal GH suppression with oral glucose. The careful analysis of possible pituitary embryonic malformations points out their significance for proper localization of extrapituitary adenomas.

Tumour-like lesions in multiple sclerosis.

The presence of tumefactive lesions on magnetic resonance imaging (MRI) in multiple sclerosis (MS) patients can cause diagnostic difficulties. It requires differential diagnosis between tumefactive demyelinating lesion (TDL) and the coexistence of neoplasm; it also implies further management. The precise assessment of such lesions at the first clinical manifestation of the disease is particularly important. We present three cases of MS presenting with tumour-like lesions of the brain. Based on serial MRI studies, stereotactic biopsy and the response to treatment with corticosteroids, the diagnosis of TDL was established in every case.

Colour Doppler ultrasound assessment of well-functioning mature arteriovenous fistulas for haemodialysis access.

BACKGROUND: A well-functioning mature arteriovenous fistula is essential for the maintenance of haemodialysis in patients with chronic renal failure. The Brescia-Cimino arteriovenous fistula has the best survival characteristics and low rate of complications. The most common reason of fistula failure is thrombosis caused by stenosis. Colour Doppler ultrasonography has proven to be effective in the assessment of anatomical vascular features. The majority of studies were done in patients with clinically presumed arteriovenous fistula complications. However, only limited data are available about the well-functioning mature arteriovenous fistulas. The purpose of the present study was to evaluate completely asymptomatic, mature arteriovenous fistulas with colour Doppler ultrasound. MATERIALS AND METHODS: From July 2001 to April 2003, we examined 139 patients with the end-stage renal disease. They were in the range of 19-79 years of age (mean, 46.7 years). The study included only the patients who met the following criteria: (1) no difficulties with haemodialysis (as reported by nurses); (2) normal venous diastolic blood pressure (<150 mmHg) at monthly evaluation; (3) normal urea clearance x time/urea volume of distribution; (4) blood cells count, plasma electrolytes, and liver function at monthly evaluation. The mean fistula age was 26 months (S.D.=21.9). The mean time of dialysis therapy was 49 months. Thirty-eight percent patients had primary fistulas, 23%--secondary, 11%--third and 11%--fourth, 4%--fifth, 5%--sixth, and 8% patients had more than sixth. RESULTS: There was no correlation between: (1) patient's age and fistula age; (2) patient's age and number of fistulas in one patient; (3) fistula age and number of fistulas in one patient; (4) localization of fistula and fistula age. There was a strong correlation between dialysis therapy period and number of fistulas in one patient. The mean flow volume was 1204.1 ml/min (S.D.=554). It was significantly higher in the fistulas with aneurysms, calcifications and tortuous vessels and lower in those with stenosis. There was no correlation between the flow volume or presence of stenosis and fistula age. Stenosis was detected in 64% fistulas. Fifty-seven percent of stenoses were located in the anastomotic region, 22% stenoses were in vein junction, 19% were at one or both ends of aneurysm, and 2% in the remaining region of the efferent vein. Perivascular colour artefacts were present at the 94% fistulas with stenosis. Chronic venous occlusion with collateral veins was detected in 6% of fistulas. The aneurysms were observed in 54% fistulas. The mean diameter of aneurysms was 12.4 mm. Ninety-six percent of aneurysms were located at puncture sites. Ten patients had a small thrombus in an aneurysm and at puncture sites. CONCLUSIONS: We conclude that there was a high level of abnormalities present in well-functioning mature arteriovenous fistulas. However, these abnormalities were not sufficient to affect the functioning of the dialysis fistula.

[Submucosal symptomatic leiomyoma treated with transcatheter uterine artery embolisation--case report]. / Opis przypadku chorej z objawowym miesniakiem macicy leczonej metoda embolizacji tetnic macicznych.

The paper describes case of a patient (43 year old) suffering from submucosal symptomatic leiomyoma. She was treated with transcatheter uterine artery embolization. After a 3 month follow-up the patient was asymptomatic and a great reduction of leiomyoma was seen in MR.

[Uterine arteries embolization as a treatment of uterine leiomyoma]. / Zabieg embolizacji tetnic macicznych jako alternatywna metoda leczenia miesniaków macicy.

Uterine artery embolization is a new method of treating uterine leiomyomata, first carried out in France in the early 90s. The procedures involve placing a small catheter into an artery in the groin and directing it to the blood supply of the fibroid. Little plugs of polyvinyl alcohol are injected through the catheter to block these arteries. This cause the fibroid to shrink. Indications for uterine fibroid embolization include menorrhagia, pelvic pain or pressure, other "bulk" syndrome (low-back pain, urinary frequency and constipation. The fluoroscopic-guided procedure is performed under local anesthesia. Most patients are discharged within 72 hours. Post-embolization syndrome including severe pain is managed with morphine via patient-controlled pump. Paper reviews long term outcomes. Uterine artery embolization has several advantages: high efficacy, less invasiveness, ability to treat multifocal changes, uterine preservation, shorter hospitalisation and recovery (low cost) and disadvantages: postembolic syndrome (pain and fever), unknown relations to pregnancy and lack of long term results.

[The use of magnetic resonance imaging for the evaluation of treatment outcome in uterine artery embolisation for fibroids]. / Zastosowanie rezonansu magnetycznego w kwalifikacji i ocenie wyników leczenia objawowych miesniaków macicy metoda embolizacji tetnic macicznych.

THE AIM: Of the study was to evaluate utility of magnetic resonance (MR) in the assessment of the women who fulfilled inclusion criteria for uterine artery embolisation as a symptomatic leiomyoma treatment and outcome of procedures. MATERIALS AND METHODS: MR examination was performed in 220 patients. Uterine artery embolizations were performed in 170 patients. RESULTS: The reasons for disqualification were: no correlation between symptoms and size an position of leiomyoma--61%, adenomyosis--20%. In MR imaging dominant leiomyoma volumes were diminished by 59.6% (p < 0.05) over a period of 3 months. CONCLUSIONS: MR is the method of choice in the assessment of women referred to uterine artery embolisation as a symptomatic leiomyoma treatment. MR imaging is effective and objective method of evaluation outcomes of uterine embolisation.

[Nasopharyngeal angiofibroma images with intracranial extension]. / Problemy w obrazowaniu wypustki wewnatrzczaszkowej naczyniakowlókniaka czesci nosowej gardla.

Nasopharyngeal angiofibroma is a benign, highly vascular, nasopharyngeal tumour. It causes the erosion of bony structures of the skull base and extends into nose, paranasal sinuses, pterygo-pallatine fossa and infratemporal fossa. In some patients intracranial invasion is present. Authors presented three cases of nasopharyngeal angiofibroma with intracranial extension treated in their centre. The clinical details of these cases and discuss the problems related to the diagnosis and management of this pathology were described.

[Fronto-temporal dementia: case report]. / Otepienie czolowo-skroniowe; opis przypadku.

Frontotemporal dementia is a relatively common form of primary dementia. The article presents a case of a female patient with probably inherited frontotemporal dementia, originally diagnosed as Alzheimer's disease.