Bilateral paramedian thalamic and mesencephalic infarcts after basilar tip aneurysm coiling: role of the artery of Percheron.

Aneurysm embolization using Guglielmi detachable coils (GDC) is gaining acceptance as a viable alternative for surgery in the treatment of aneurysms. Recent reports describe a significant rate of thromboembolic complications. Thalamic and midbrain blood supply can arise from complex anatomical variations. The rare variation: "artery of Percheron", is a solitary arterial trunk arising from one of the proximal segments of a posterior cerebral artery and supplies the paramedian thalami and rostral midbrain bilaterally. We describe a patient that underwent elective endovascular treatment for a basilar tip aneurysm using GDC and stents in each PCA; 12 hours later patient was comatose and not following commands. Sequential magnetic resonance imaging (MRI) of brain showed bilateral paramedian thalamic and mesencephalic infarcts presumably secondary to artery of Percheron occlusion. Thromboembolic event related to the use of the GDC embolization and stents is a rare clinical sequelae, but catastrophic. The use of antiplatelets agents should be reinforced in the scenario. When bilateral medial thalamic and midbrain infarcts are found, occlusion of the artery of Percheron should be considered. Angiography may not b helpful and lack of visualization of the artery does not exclude its presence. In this case the MRI findings confirmed the presence of the infarction based on the anatomical distribution.

Multifocal epithelioid glioblastoma mimicking cerebral metastasis: case report.

OBJECTIVE: Epithelioid glioblastoma is a rare morphologic subtype of glioblastoma that closely mimics metastatic carcinoma or metastatic melanoma histologically. All previous case reports of this unusual glioblastoma variant have been solitary lesions. We report here the first case to our knowledge of multifocal epithelioid glioblastoma mimicking cerebral metastasis. CLINICAL PRESENTATION: A 67-year-old man with a prior history of mycosis fungoides, a common form of cutaneous T-cell lymphoma, presented with memory loss and impaired peripheral vision. Two discrete brain lesions highly suspicious for metastases were identified by magnetic resonance imaging (MRI). INTERVENTION: The patient underwent two separate craniotomies; both lesions were successfully resected in toto with an excellent post-surgical outcome. CONCLUSION: Epithelioid glioblastoma is one of the rarest morphologic subtypes of glioblastoma. Here we describe the first case to our knowledge of multifocal epithelioid glioblastoma that convincingly mimicked a secondary metastatic process. Multifocal epithelioid glioblastoma should be included in the differential diagnosis of patients who present with multiple discrete brain lesions. An attempt at gross total resection is recommended when anatomically feasible for definitive histopathological diagnosis and to improve progression free survival of patients who present with similarly ambiguous and potentially misleading multiple lesions.

Hemorrhagic stroke with intraventricular extension in the setting of acute posterior reversible encephalopathy syndrome (PRES): case report.

We report the case of an eighteen year-old pregnant female with preeclampsia and florid signs and symptoms of posterior reversible encephalopathy syndrome (PRES) in whom intracerebral hemorrhage was evidenced following delivery. Management included blood pressure control, external ventricular drainage and lumboperitoneal shunt. To our knowledge this is the first report of intracranial hemorrhage occurring concurrently with peripartum acute PRES. This case was successfully treated with good outcome upon conclusion of management, thus making awareness of this potentially fatal complication and its suggested management for successful outcome necessary for neurosurgeons, neurologists and intensivists alike.

Linear correlation between stable intracranial pressure decrease and regional cerebral oxygenation improvement following mannitol administration in severe acute head injury patients.

OBJECTIVES: We investigated the relationship between stable decrease in intracranial pressure (ICP) following mannitol administration and variations in regional oxygenation (PtiO2) in severe traumatic brain injured (STBI) patients. METHODS: Fourteen STBI patients (Glasgow Coma Scale score < or = 8) admitted to the neurointensive care unit during a 12-month period were studied. Multiparameter data, including parenchymal tissue oxygen (PtiO2) and carbon dioxide tension, cerebral perfusion pressure, mean arterial pressure; temperature, pH and pressure reactivity index were measured. Point values from 53 mannitol administrations were extracted every five seconds and divided into five consecutive 30-minute epochs. Mean values and trends were identified. Postadministration epoch with maximum decrease in ICP was selected along with the means of the corresponding variables. These data were compared with baseline to derive the delta values. Mean deltaICP was then compared with deltaPtiO2 in each patient using linear correlation. FINDINGS: In patients with ICP0 > 20 mmHg (group A), PtiO2 increased in 69.6% of samples, whereas in group B (ICP0 < 20 mmHg), PtiO2 increased in only 50% of the samples. There was a significant negative correlation between mean deltaICP and deltaPtiO2 in both groups; Group A: r = -0.79 (P = 0.01); Group B: r = -0.92 (P = 0.01). CONCLUSIONS: There is a strong negative correlation between stable decrease in ICP following mannitol administration and improvement in regional oxygenation around the peri-contusional area. The data suggest a potentially favourable interaction between mannitol therapy and cerebral internal milieu in STBI patients.

Usefulness of pp65 antigenemia and viremia in the follow-up of renal transplant recipients with cytomegalovirus disease treated with ganciclovir.

We prospectively evaluated the usefulness of the pp65 antigenemia assay (AGA) and viremia (isolation) in the follow-up of 15 renal transplant recipients with a cytomegalovirus disease treated with ganciclovir. The AGA was performed with the extraction of PMNL with saline dextran, and the viremia detected by the inoculation of them in the MRC-5 cell line (shell-vial). Sixty-nine blood samples were studied, and 55 (79.7%) positive AGA and 42 (60.8%) positive viremia detected. The AGA needed a median of 9 days to negativize, and the viremia only 4 days. In eight patients (53%) the AGA and viremia were negative simultaneously. In seven patients (47%) the viremia was negative before the AGA (median 10.7 days). In this group, three patients (43%) presented a paradoxal rising of the AGA values after the negativization of the viremia. For the follow-up of renal transplant recipients treated with ganciclovir, the viremia was the most useful method of control. The viremia was negative before the AGA in many patients, demonstrating the therapeutic efficacy of ganciclovir.

Long-term evolution and growth patterns in a family with Bartter's syndrome.

The five-year evolution of three siblings of a sibship affected by a combined potassium and magnesium wasting abnormality associated with hypocalciuria is presented. Fractional distal chloride reabsorption was low. A number of therapeutic measures were attempted with partial or no success. Consequently, patients were kept on oral potassium and magnesium supplementation only. Special attention was paid to nutritional status. Although the three girls maintained a plasma potassium range of 2.6 to 3 meq/l, sexual and mental maturation were not delayed. Growth remained within the lower limits of normality. Considering the poor results obtained from treatment and the side-effects, we conclude that this long-term approach is sound, at least, in less severe cases of Bartter's syndrome.

Application of adaptive signal processing for determining the limits of P and T waves in an ECG.

A new algorithm for the determination of the limits of P and T waves is proposed, and its foundations are mathematically analyzed. The algorithm performs an adaptive filtering so that the searched point corresponds to a minimum. Crucial properties of its performance are discussed, i.e., immunity to base line drifts and full adaptation to any cardiological criteria. A series of tests are made involving real registers with different morphologies for P and T-waves.

Double patella. A case of duplication in the coronal plane.

A case of duplication of the patella in the coronal plane is reported. Previously reported cases of double patella have shown sagittal or vertical duplication, and some have been associated with multiple epiphyseal dysplasia. In our case, excision of one patella and realignment of the extensor mechanism relieved symptoms of giving-way.

Epidemiologic aspects of pediatric multiple trauma in a Spanish urban population.

BACKGROUND/PURPOSE: Trauma is still the most frequent cause of mortality and disability in childhood and adolescence. An epidemiologic prospective study on children under 16 years of age with multiple trauma (MT) was conducted in a large Spanish urban university hospital over a 6-year period. METHODS: Of 1,937 children admitted at the pediatric trauma unit for musculoskeletal injuries from March 1988 until March 1994, 56 patients including 37 boys and 19 girls had MT. MT was considered when at least 2 long bones were fractured or there was a fracture of 1 long bone combined with an injury of 4 other major anatomic regions (face and neck, thorax, abdomen, or neural system). The severity of injuries was evaluated according to the modified injury severity score (MISS). RESULTS: Injury to pedestrians was the most frequent cause of MT (54%). The overall mortality rate of the series, including those children dying during transport to the hospital was 11.5%. The average MISS for the whole group was 15 (range, 5 to 59). Head trauma was the most frequent associated injury (52%), two thirds of which were considered minor injuries (Glasgow Coma Scale >15). Seventy-seven fractures were registered, 10% of which were open fractures. External fixation was the most common surgical technique among operated fractures. The average hospitalization period was 16 (median, 13; range, 1 to 150) days. Children with a MISS above 18 points showed a significant longer hospitalization period (mean, 31 +/- 45 days) as compared with those with MISS below 18 points (mean, 10 +/- 7 days; P < .05). There was a strong correlation between the MISS and both the period of hospitalization at the pediatric intensive care unit and the total length of hospital stay. CONCLUSIONS: Pedestrian accidents caused by motor vehicles in children playing at the street contributed most significantly to MT in the urban pediatric population. Special care for prevention must be taken in the age group of 6 to 10 years. Head injury was the main cause of death in children with multiple trauma. MISS was found to be a good predictor of survival and duration of hospital stay in pediatric MT.

Bone remodeling in malunited fractures in children. Is it reliable?

Fracture malunion is not a rare phenomenon in children due to the frequent use of closed reduction treatments. In this article, the processes of bone remodeling in cases of angular and rotational deformities, overriding of bone fragments, and overgrowth are addressed. Critical analyses of the mechanisms to correct these deformities, function of the physis and periosteum, and other related factors are given. The acceptable deformities for complete remodeling to be successful vary at different ages and locations.

[Report of a case with skin lesions and calciphylaxis]. / A propósito de un caso de lesiones cutáneas y calcifilaxis.

Calciphylaxis is an unusual complication of chronic renal failure associated with increased morbidity and mortality. This presentation is a clinical case describing a patient parathyreidectomized in 1997, followed by the condition was clinically suspected and then confirmed by skin biopsy. PTHi levels above 400 pg/ml together with scintigraphic images suggesting parathyroid nodules resulted in the decision to try a new surgical procedure, which yielded two nodules of thyroideal tissue. After the surgery and in spite of this pathology result, the patient recovered completely from her symptoms. This corroborates the theory that the etiology of calciphylaxis is multifactorial, acquiring special relevance the use of calcium-containing phosphathe binders (representing a high risk of hypercalcemia) in the treatment of Chronic Renal Disease.

[Virologic analysis of 1,000 blood samples processed for cytomegalovirus isolation (viremia) and pp65 antigenemia in immunodepressed patients]. / Análisis virológico de 1.000 muestras de sangre procesadas para aislamiento (viremia) y antigenemia pp65 de citomegalovirus en pacientes inmunodeprimidos.

BACKGROUND: To study the principal virological aspects of 1,000 blood samples processed for cytomegalovirus (CMV) isolation (viremia) and pp65 antigenemia assay in immunosuppressed patients, and to compare the diagnostic efficacy of both technics. PATIENTS AND METHODS: All the blood samples collected with EDTA, were fraccionated by dextran sedimentation. The polymorfonuclear rich fraction was used for the isolation of CMV by the shell-vial cell culture and the pp65 antigenemia assay. The cell cultures were stained at 18-24 hours with a monoclonal antibody against p72 CMV antigen. RESULTS: The 1,000 blood samples studied belonged to 363 patients (299 infected by the HIV, 49 renal transplant recipients, and 15 patients with haematologic diseases). 78 patients (21.4%) developed a CMV infection and/or disease. The overall results obtained in the comparative study for the CMV detection in peripheral blood were 86.7% for the antigenemia assay and 58.5% for the shell-vial culture (p = 0.0001). Of 49 patients with renal transplant, 20 (40.8%) presented with a CMV infection versus 19.3% in the HIV-positive group. The transplant recipient patients presented most frequently positivity for both diagnostic technics, and the HIV-positive patients a higher percentage of antigenemia-positive with culture negative. The shell-vial culture (viremia) had most diagnostic efficacy in the transplant recipients group. CONCLUSIONS: In the immunosuppressed patients the pp65 antigenemia assay has demonstrated a high diagnostic efficacy for CMV detection in peripheral blood. However because the antigenemia not always correlates with a replicative viral load, it is necessary to routinely perform culture of the blood in a cell culture system, preferently by the shell-vial method, because this system allows to make the diagnosis of CMV infection in a short period of time.

Diagnostic accuracy and inter-rater reliability of 64-multislice 3D-CTA compared to intra-arterial DSA for intracranial aneurysms.

Catheter-based intra-arterial digital subtraction angiography (IADSA) is widely trusted for diagnosing cerebral aneurysms. However, three-dimensional CT angiography (3D-CTA) is evolving. This study compares the diagnostic performance and inter-rater reliability of 64-slice 3D-CTA and IADSA. Nineteen patients with 26 suspected cerebral aneurysms (23 with confirmed aneurysms, three negative controls) underwent both IADSA and 3D-CTA. Two independent reviewers assessed both imaging modalities for the presence of an aneurysm and subsequently described aneurysmal location, size, shape, orientation, and number of emanating arteries. Inter-observer agreement was followed to control for observer bias. The sensitivity of 3D-CTA was 78% and 96%, the negative predictive value (NPV) was 38% and 75%, and the accuracy of 3D-CTA was 81% and 96%. Both reviewers found 100% specificity and 100% positive predictive value (PPV). There was a clear correlation between 3D-CTA and IADSA for describing cerebral aneurysms. The authors conclude that 3D-CTA has equivocal diagnostic advantage but is less reliable for ruling out aneurysm presence. Anatomy, however, is superior with 3D-CTA.

A molecular microbial ecology approach to studying hemodialysis water and fluid.

Bacteria, or bacteria-derived products, might be responsible for deleterious effects in hemodialysis patients. Most microorganisms in hemodialysis water, including potential pathogens, are difficult to isolate and might subsist in a 'viable but not culturable' state or may need specific culture media. A molecular culture-independent approach based on the analysis of the 16S rDNA obtained from total DNA has been used to better know the diversity of bacteria inhabiting hemodialysis water and fluid, and to address the possible health effects associated with their presence. Four clone libraries from 16S rDNA (274 clones) were analyzed to characterize the species or groups of bacteria present, to assess their distribution in the water circuit, and to compare the results with those previously obtained in culture-dependent analysis. One hundred and ninety-seven clones of four gene libraries were analyzed by sequencing, and were identified phylogenetically. Clones affiliated to the Alphaproteobacteria group led the diversity. The presence in several samples of Alpha-4-proteobacteria, recognized as sphingolipids producers, was to be noted. The most abundant clones were affiliated to the Betaproteobacteria branch, closely related to the genus Herbaspirillum. As known, Alphaproteobacteria and Betaproteobacteria genomes might present a manifest excess in CpG sequences and most of them show a lipopolysaccharide-rich outer membrane, both described as inducers of innate immunity responses. Another abundant group, belonging to the Cyanobacteria class, a possible source of cyanotoxins, was not related to any previously cultured bacterium. Possible risk implications for hemodialysis patients of the bacterial community detected are discussed.

[Prenatal diagnosis of cystic fibrosis, using DNA markers, in Spanish families: experience during 1987-1989]. / Diagnóstico prenatal de fibrosis quística en familias españolas utilizando marcadores del DNA: nuestra experiencia en 1987-1989.

Cystic fibrosis (CF) is the most common severe autosomal recessive disease affecting Caucasian population. Genetic linkage studies using DNA markers have allow to map the disease to chromosome 7q31-32. Several of these markers are closely enough to the CF gene, that they can be used for prenatal diagnosis of CF with a high level of confidence. We have studied 100 families with at least one affected individual. Fifteen DNA markers have been used in the present study. 96% of families were fully informatives, and 15 families requested prenatal diagnosis. A total of 17 prenatal diagnosis have been performed in these families between the 8th and the 14th week. Six fetus were diagnosed as affected and eleven as non affected of CF, with a reliability higher than 99% in all cases.