Preoperative evaluation of hemodynamic factors in cerebral arteriovenous malformations for selection of a radical surgery tactic with special reference to vascular autoregulation disorders.

After reviewing the literature with respect to hemodynamic factors in AVM the authors describe their experience monitoring the blood volume under induced arterial hypotension. They have been able to select cases which presented disorders of the vascular autoregulation of the brain and represent, for this reason, a challenge to a radical excision; in such cases they advise to remove the AVM in several programmed stages. In addition it was possible to predict the efficiency of the hypotension on AVM vessels pressure during operation enabling the surgeon in case of positive effect of the hypotension to realize more securely the haemostasis. Moreover, the authors present the first data regarding the mean circulatory time the knowledge of which seems very promising. The last 33 cases of a series of 179 radical removals have been monitored before and in some cases after operation; the knowledge of these hemodynamic factors allowed the surgical team of La Pitié to extend the surgical indications for radical removal to AVM recently considered as inoperable.

Indium-111 antimyosin scintigraphy before and after coronary bypass surgery: unexpected preoperative myocardial uptakes.

The present study was designed to evaluate 111In-antimyosin scintigraphy in detecting pre- and post-operative myocardial infarction in patients undergoing coronary artery bypass surgery. Fab antimyosin scintigraphy has been shown to be sensitive and specific in detecting myocardial necrosis and to be potentially valuable in situations where other criteria are not reliable. In a previous study, postoperative antimyosin uptakes occurred in 82% of the studied patients. Sixteen consecutive patients with an indication of coronary artery surgery were assessed by preoperative coronary angiography, serial electrocardiograms, and myocardial scanning with 111Indium-labeled antimyosin antibodies performed before and after operation. In four patients, a recent myocardial infarction (1 to 3 months) was detected with an accurate localization when compared to the classic criteria of myocardial infarction. One more patient with a 21-year old myocardial infarction showed an intense uptake whereas there was no recent acute coronary event. Four other patients had an unexpected preoperative uptake, since there were no acute coronary events in their medical history. All preoperative scintigraphic uptakes were still present on the second scan performed postoperatively in these nine patients. Only one patient showed a new postoperative uptake when compared to the preoperative scan which was normal; this postoperative septal infarct was confirmed by a postoperative coronary angiography. Extracardiac uptakes (sternum and ribs) were frequently observed after operation and might hamper the interpretation of postoperative scintigrams. Unexpected preoperative uptakes may be related to non diagnosed small necrosis. A preoperative reference scan is required for an accurate interpretation of a postoperative 111In-antimyosin uptake. Moreover, extracardiac uptakes may limit the interpretation of perioperative cardiac damage.

Diagnosis of cerebral metastases by thallium 201.

We have studied the diagnostic potential of thallium 201 in cerebral metastases. Twenty-five patients with one or several metastases have been investigated with two tracers, 201T1 and sodium pertechnetate (99Tcm). With 201T1, all the cases gave a positive result within ten minutes of injection. In 88%, the definition was better, and in five cases (20%) small metastases which were invisible with 99Tcm could be demonstrated with 201T1. This radiotracer seems to promise greater diagnostic precision with an examination time of only 30 minutes.

[Comparison of SPECT and quantified EEG features in Alzheimer's type dementia]. / Comparaison des aspects SPECT et EEG quantifié dans les démences de type Alzheimer.

Forty-one patients with probable dementia of the Alzheimer type (DAT) have been studied by computerized EEg (C-EEG) and single photon emission tomography (SPECT) using 123-IMP. Four groups have been distinguished according to SPECT hypoperfusion topography: frontal, temporo-parietal, fronto-parietal and fronto-temporo-parietal. C-EEG parameters were much more disturbed in the 2 latter than in the 2 former groups. Thus a normal C-EEG could indicate a dominant frontal or temporo-parietal form of DAT. Therefore some bias due to duration or rate of disease progression cannot be excluded. So far the important finding is that EEG changes are diffuse and do not reflect the topography of SPECT hypoperfusion questioning the value of EEG topographical analysis in DTA.

[Quantified EEG in the diagnosis of Alzheimer's type dementia]. / Apport de l'EEG quantifié au diagnostic de démence de type Alzheimer.

79 subjects (mean age 70.2 ans, 31 males, 48 females) selected as probable dementia of the Alzheimer type, at the early stage of the disease and 17 normal aged people (mean age: 72.2, 5 males, 12 females) were recorded with a 16 channel computerized-EEG (C-EEG) with topographical analysis of the observed changes and with classical visual analysis of the EEG. Quite simple C-EEG parameters as mean dominant frequency (MF) and alpha to theta ratio are able to discriminate patients from normal with a greater accuracy than visual analysis. The values of 8.6 for the MF and 1.3 for the alpha/theta ratio are proposed as cut off values between normal and DAT patients. The topographical analysis appear to be of no additional usefulness in the discrimination of the two groups.

[EEG value for the prediction of the evolution of Alzheimer's type dementia]. / Intérêt de l'EEG pour la prédiction de l'évolution des démences de type Alzheimer.

Twenty patients selected as probable dementia of the Alzheimer type (DAT) have been examined two times during a mean follow-up period of 14.5 months. Two groups have been distinguished at the end of this period: a cognitively impaired one and a stable one. EEG features at T1, at T2 or the difference T1-T2 does not allow an accurate and predictive discrimination between the two groups. But we cannot conclude that EEG is useless for prediction of the rate of progression of the disease in DAT because most of the cognitively stable patients are also stable for mean frequency. So mean frequency could be an interesting marker of evolutivity but this to be tested with more patients including more subjects reaching the severe stage of dementia.

[Diagnostic value of pulsed Doppler in atheromatous renal insufficiency. A study of 32 patients]. / Intérêt diagnostique du Doppler pulsé dans l'insuffisance rénale athéromateuse. Etude de 32 patients.

RATIONALE: atheromatous stenosis of both renal arteries, or of the artery of a functionally solitary kidney is a frequent cause of renal failure in the elderly. Atheromatous Ischemic Renal Insufficiency (AIRI) can be ameliorated by surgery or angioplasty. However, such procedures can be hazardous in a patient with extensive aortic atheromatous plaques. This justified a study of the validity of Pulsed Doppler (PD), a diagnostic procedure less invasive than renal angiography in AIRI. OBJECTIVES: to evaluate the diagnostic interest of PD in AIRI, using renal angiography as a criterion of adequacy. METHODS: renal arteries PD (Ultramak-4, 3.5 and 5 Mhz probes) followed by renal angiography (Seldinger). "Significant" stenosis = 50% on angiography. "Positive" PD = turbulences and/or acceleration. PATIENTS: 32 patients were investigated for suspected AIRI on the grounds of 1) age greater than 50; 2) atheromatous background and 3) renal insufficiency with no other evident etiology, or rapidly declining GFR in such a patient treated with ACE inhibitors. RESULTS: 16/32 angiographies disclosed significant stenosis of at least 1 renal artery. 56 renal arteries were investigated with both angio. and PD. Prevalence of stenoses was 16/56. PD had 93.7% sensitivity and 55% specificity. Positive predictive value was 45.5% and negative predictive value was 95.7%. Specificity was 80% when PD disclosed acceleration. CONCLUSIONS: negative PD is sufficient argument to reconsider the indication of renal angiography in a high risk pt with suspected AIRI.

[Value of antimyosin monoclonal antibody scintigraphy in the diagnosis of acute myocardial infarction]. / Intérêt de la scintigraphie aux anticorps monoclonaux antimyosine dans le diagnostic d'infarctus du myocarde rudimentaire.

A 53 year old woman developed chest pain with transient anterior subepicardial ischaemic ECG changes and a mild increase in serum myocardial enzyme concentrations. She was admitted to hospital some time later but there were no electrocardiographic signs of infarction. Echocardiography was considered to be normal. Coronary angiography showed no significant stenosis and there were no segmental wall motion abnormalities on left ventriculography. The diagnosis of a non-Q wave infarct was confirmed by myocardial scintigraphy using antimyosin monoclonal antibodies labelled with Indium 111. The site and size of the necrosis were also determined by this non-invasive investigation.

[Indium III monoclonal antimyosin antibody scintigraphy for the detection of chronic myocardial infarction apart from the acute phase]. / Scintigraphie aux anticorps monoclonaux antimyosine marqués à l'indium 111 pour la détection de l'infarctus du myocarde en dehors de la phase aiguë.

Fab antimyosin scintigraphy has been shown to be sensitive and specific in detecting acute myocardial necrosis. This study was designed to evaluate the preoperative frequency of Indium-111 (In-111) antimyosin myocardial uptake in patients scheduled for coronary artery bypass surgery. The scintigraphic results were compared with other criteria of myocardial infarction (MI). Sixteen consecutive patients were included. Recent MI (1 to 3 months) were detected in four patients, with an accurate localization in three cases when compared to the classic criteria for MI. Two more patients had old Q wave MI: one did not show any uptake in the territory of MI whereas the second patient with a 21 year old infarct without recent acute coronary events showed an intense uptake consistent with the ECG and angiographic localization. Four other patients with stable angina showed limited uptakes that were unexpected, since there were no acute coronary events in their medical history, and ECG. Their left ventricle angiography were considered as normal. In these four cases, the scintigraphic location corresponded to a territory supplied by an occluded coronary artery (n = 2) or by a coronary artery with a tight stenosis requiring a bypass graft (n = 2). These antimyosin uptakes are probably related to small necroses which did not modify the ECG and did not alter the ventricular segmental wall motion. We conclude: 1) recent MI are detected by In-111 antimyosin scintigraphy; 2) In-111 antimyosin uptake may occur in patients without a diagnosis of recent myocardial infarction and correspond to older MI or limited necroses without detectable changes of the ECG and left ventricle angiography.

[Noninvasive diagnosis of deep venous thromboses by Doppler ultrasound]. / Diagnostic non invasif des thromboses veineuses profondes par écho-Doppler.

A Duplex ultrasound technique combining real time ultrasound B imaging with pulsed Doppler investigation was used for non-invasive exploration of peripheral venous trunks. A series of 72 patients (21 men and 51 women including 26 pregnant women) was investigated by the examination of deep venous trunks of upper limbs (68 cases) and of lower limbs (4 cases). Lesions were identified in 19 cases (26%), including 9 total thrombosis, 6 partial thrombosis, 3 sequelae of a previous thrombosis and 1 case of valve incontinence. Morphologic (caliber, wall, intraluminal echos) and functional (expansion, flow rate, compression) features establishing diagnosis are discussed. Phlebography findings in 8 of the 15 cases of thrombosis (total or partial) provided very satisfactor correlation, clinical correlation being considered sufficient in the other cases. This duplex technique is a reliable, reproducible and non-invasive method for diagnosis and for follow up of medical treatment of thrombophlebitis.

[Study of variations in the regional blood volume in the limbs under effort or thermal stress in arterial conditions (author's transl)]. / Etude des variations du volume sanguin régional au niveau des membres sous stimulus d'effort ou thermique dans les artériopathies.

The method of measuring the regional blood volume by labelling the erythrocytes with Technetium-99m has been applied to two groups of patients suffering either from arteritis of the lower limbs or from Raynaud's syndrome. A reduction in the blood volume during physical effort has been observed in arteritis of the lower limbs, followed by a rise of varying extent depending on the severity of the condition. In some cases surgical treatment has produced a particularly obvious effect on the variations in the blood volume, accompanied by a favourable clinical evolution. It has been found in patients suffering from Raynaud's syndrome that the reduction in the blood volume continues after the end of the exposition of the patients' hands to a temperature of 10 degrees C.

[Variations in local cerebral blood volume depending on the mean arterial blood pressure in man]. / Variations du volume sanguin cérébral local en fonction de la pression artérielle moyenne chez l'homme

A radio isotopic technique is described to measure and monitor the cerebral blood volume during a controlled arterial hypotension induced by sodium nitroprusside in anesthetised patients (neurolepanalgesia) submited to surgery for a ruptured saccular aneurysm. The study was made in 10 cases from 90 mm Hg to 30 mm Hg mean blood pressure monitored from a transducer connected to an intra humeral microcatheter. The figures obtained show an increase of the cerebral blood volume from 90 mm Hg to 50 mm Hg in every patient and a linear correlation when the pressure is lowered under 50 mm Hg level; therefore under a mean arterial pressure of 50 mm Hg the autoregulation arterial mechanism is out of work.

[Measurement of multiregional blood volumes: a cerebral vascular autoregulatory phenomenon (author's transl)]. / Mesure du volume sanguin multi-régional: phénomène d'autorégulation vasculaire cérébral.

The variations in regional cerebral blood volume (RCBV) during controlled severe hypotension induced by sodium nitroprusside were studied in a series of 29 patients with aneurysms (14), meningiomas (6) and arteriovenous malformations. Two characteristic variations were noted. The RCBV and mean blood pressure (MPB) vary inversely, this type of variation being known as "Active variation". When pathological lesions are present the RCBV and MBP are modified in the same direction in the regions affected and this is called "Passive variation". A quantitative study in 21 patients showed that in the healthy regions there was a change from the active to the passive mode of variation for a MBP situated between 44 and 52 mm of mercury.

[Carotido-vertebral study with ultrasonics]. / Exploration carotido-vertébrale par les ultrasons.

Sonotomography, associated with the Doppler test, permits an atraumatic exploration of quite a satisfactory precision of the carotid and vertebral arteries in their cervical portion. This type of exploration was used in patients with parietal lesions of these vessels, arterio-venous malformations or a cerebral arterial spasm. In these lesions of the wall and lumen of the arteries, the problem is to reconsider the place of this examination as compared to arteriography with injection of contrast material, from the diagnostic as well as pre-therapeutic standpoint.

[Instantaneous measurement of blood flow velocity in internal carotid arteries by pulsed Doppler in cerebral arteriovenous malformations]. / Mesure des vitesses sanguines instantanées dans les artères carotides internes par Doppler pulsé dans les malformations artérioveineuses cérébrales.

Hemodynamics (systolic rate: VS and diastolic rate: VD) of internal carotid artery blood flow was determined by pulsed Doppler combined with ultrasound scans to measure instantaneous flow rate in 8 patients with cerebral arteriovenous malformations. Values obtained were compared with those in 10 healthy volunteers. Measurement of the diastolic fraction a = (formula: see text) appears to be a valid method for assessing severity of this malformation and the importance of its output. Repeated tests in one patients operated upon by several stages demonstrated the importance of a blood shunt after ablation of lesions.

[Successful separation in 1974 of craniopagus twins united at the vertex. Indications, technics, follow-up after 14 years]. / Séparation réussie en 1974 de jumelles craniopages unies par le vertrex. Indications, techniques, évolution sur 14 ans.

On July 22, 1974, 55 days after delivery, the separation of female craniopagus twins united at the vertex was performed. This case was very similar to the case published by Voris in 1957 after separation in 1955. Surgery was decided because the neurological examination was normal in both twins, because there was no body malformation, because the angiogram as well as isotopic scintigraphy showed two normal brains, two superior sagittal sinuses and two torcular areas with a short venous union in the middle of the bone defect. In addition, Sophie and Sonia were suffering from respiratory disturbances due to their position. Surgery was easy (90 min) using the operative microscope; intubation and placing intravascular tubes for hemodynamic monitoring were difficult and lasted 4 hours. After all it took 14 years and 23 operations to complete the reconstructive surgery of the bone and skin. Cranioplasty was finally performed using vitallium plates. On their 14th birthday a neuropsychological investigation was performed with an IQ of 94 in Sophie and 76 in Sonia. Both girls are nubile and enjoy a normal school attendance.