Pallidoluysian atrophy: dystonia and basal ganglia functional anatomy.

The clinical correlates of "pure" pallidoluysian atrophy are not well described. A 59-year-old man presented with 20 years of progressive generalized dystonia, dysarthria, gait disorder, supranuclear vertical gaze palsy, and bradykinesia. At autopsy there was severe bilateral atrophy of the external pallidum and subthalamic nucleus with neuronal loss and marked gliosis. This syndrome may epitomize the consequences of "pure" pallidoluysian atrophy. In this case, dystonia appears to occur in the setting of decreased excitation (increased inhibition) of medial pallidal neurons, a pathophysiologic condition common to several hyperkinetic states.

Treatment of diffuse coronary artery and vein graft disease with a 60-mm-long balloon: early clinical experience.

OBJECTIVE: To report our preliminary clinical experience with a new 60-mm-long angioplasty balloon. DESIGN: We reviewed the results in patients who underwent this type of angioplasty between May and October 1993 at our institution. MATERIAL AND METHODS: The study group consisted of 14 high-risk patients (57% with rest-related angina) and 19 treated coronary segments--52% in native coronary arteries and 48% in saphenous vein grafts (mean age, 9 years). Often, long balloon angioplasty was used in conjunction with laser or transluminal extraction atherectomy. RESULTS: Angiographic success (40% or more visual reduction in diameter stenosis) was achieved in all patients. Intimal dissection occurred in 4 of the 19 treated segments (21%), but each was less than 50% obstructive. No patient required intracoronary stenting. Clinical success was achieved in 13 patients (93%). The one death that occurred was from vein graft distal embolization. At a mean follow-up of 9 months, three patients had required reinterventional procedures, and one patient had undergone a coronary artery bypass operation. No myocardial infarction or death occurred during this period. CONCLUSION: Preliminary clinical experience with a 60-mm-long angioplasty balloon to treat complicated coronary lesions in high-risk patients suggests that, when used alone or in combination with other devices, this new balloon results in high initial success and low complication rates. A larger clinical experience is necessary for accurate assessment of the role of this new balloon catheter.

Percutaneous transcatheter embolization of coronary arteriovenous fistulas.

Coronary artery fistulas are infrequently encountered vascular communications that are either congenital or due to cardiac trauma. Most patients with these anomalies are asymptomatic, but late complications can occur and include congestive heart failure, myocardial ischemia, arrhythmias, and endocarditis. Therefore, many investigators have recommended surgical repair, even for asymptomatic patients. Although coronary arteriovenous fistulas pose many challenges to interventional cardiologists, early experiences suggest that these abnormal vessels can be successfully obliterated percutaneously; thus, the patient is spared the risks and morbidity associated with cardiac surgical intervention. Herein we present two cases that illustrate many of the technical issues involved in successful transcatheter embolization of coronary artery fistulas.

Use of coronary artery bypass surgical procedure and coronary angioplasty in treatment of coronary artery disease: changes during a 10-year period at Mayo Clinic Rochester.

OBJECTIVE: To compare changing clinical characteristics and early and late outcomes for patients treated with either coronary artery bypass grafting or coronary angioplasty at Mayo Clinic Rochester during a 10-year period. DESIGN: We retrospectively analyzed a series of patients with coronary artery disease who were clinically selected for myocardial revascularization from Jan. 1, 1982, through Dec. 31, 1991. MATERIAL AND METHODS: The study population consisted of 7,099 patients treated with coronary artery bypass grafting and 4,937 who underwent coronary angioplasty. To monitor changes in clinical and procedural outcomes over time, we divided the 10-year period into three equal intervals: period I = Jan. 1, 1982, through Apr. 30, 1985; period II = May 1, 1985, through Aug. 31, 1988; and period III = Sep. 1, 1988, through Dec. 31, 1991. Patients who underwent valve or arrhythmia operations along with coronary bypass were excluded from the study, as were those who were treated with angioplasty technologies other than balloon angioplasty. RESULTS: Throughout the study period, use of coronary angioplasty progressively increased (784 procedures in period I and 3,516 in period III). The number of coronary bypass operations increased from period I to period II but declined in period III. Over time, increasing numbers of elderly patients and women were referred for myocardial revascularization. Use of the internal mammary artery as a bypass conduit increased from 23% of cases in period I to 84% in period III. In surgical patients, perioperative myocardial infarction rates declined significantly from 5.7% to 2.0% from periods I to III. For coronary angioplasty, elderly patients, patients with diabetes, and patients with hypertension progressively increased. Multivessel coronary angioplasty increased from 10% of the cases in period I to 15% in period III. Operative mortality rates for both coronary bypass and angioplasty remained stable throughout the study despite the increasing number of high-risk patients. CONCLUSION: This 10-year experience with coronary bypass and angioplasty at a major referral center reflects the national trend of an aging patient population with coronary artery disease undergoing revascularization procedures.

"Rescue" directional coronary atherectomy after unsuccessful percutaneous transluminal coronary angioplasty.

OBJECTIVE: To evaluate the outcome in patients who underwent directional coronary atherectomy after unsuccessful balloon angioplasty. DESIGN: We conducted a retrospective computerized data bank search of patients in whom unsuccessful balloon angioplasty and subsequent "rescue" coronary atherectomy had been performed at the Mayo Clinic between Nov. 1, 1988, and May 1, 1993. MATERIAL AND METHODS: Among the 336 patients who underwent directional coronary atherectomy during the study period, in 16 the procedure was a rescue attempt. The mean age of these 16 study patients was 67 years. The following vessels were treated: left anterior descending coronary artery, six patients; right coronary artery, six; circumflex artery, two; and saphenous vein graft, two. Coronary angioplasty had failed because of dissection in eight patients, elastic recoil without evident dissection in seven, and recurrent thrombus without evident dissection in one. RESULTS: After coronary atherectomy, the mean stenosis was 41% (in comparison with 90% before coronary angioplasty and 71% after coronary angioplasty). Both angiographic success (20% or more decrease in stenosis after tissue removal and a final stenosis of less than 50%) and clinical success (angiographic success without in-hospital Q-wave myocardial infarction, bypass operation, or death) were achieved in 10 patients. Adventitia was obtained in two patients, both of whom underwent atherectomy for elastic recoil. In six patients, a stenosis of more than 50% remained after atherectomy; one patient suffered a Q-wave myocardial infarction, and one underwent emergent coronary artery bypass grafting. No deaths occurred in the study group. During follow-up (mean, 22 +/- 19 months), one patient suffered a non-Q-wave myocardial infarction, and two others underwent elective coronary artery bypass grafting. Eleven patients were asymptomatic at last contact. Repeated angiography, done in five patients a mean of 3.4 +/- 3.1 months after the procedure, showed restenosis in three. CONCLUSION: Rescue directional coronary atherectomy seems to be safe and effective in achieving angiographic and clinical successes in carefully selected patients after unsuccessful coronary angioplasty.

Contamination of Pantopaque by glass.

Investigation has shown that when ampules containing Pantopaque are opened, a variable amount of fragments of glass may fall into the Pantopaque. When the Pantopaque is injected into the spinal canal these fragments may also be injected. As yet the results of injecting fragments of glass into the spinal subarachnoid space are unknown. The glass can be removed by passing the Pantopaque through a 0.22 micron Millex Filter.

Case report. Computer assisted tomography in syringomyelia.

A case of cervicothoracic syringomyelia shown on computer assisted tomography is presented. Surgical verification was obtained, and the extent of the cord cavitation was also demonstrated.

Intracranial fibromuscular dysplasia: report of two cases, one with autopsy verification.

We report two patients with fibromuscular dysplasia (FMD) involving intracranial arteries. In the first patient the diagnosis was made at autopsy. Both patients were symptomatic from this disease and, in addition, displayed unusual hormonal abnormalities which may well have contributed to the genesis or evolution of FMD.