Recurrent stenosis following carotid artery stenting treated with a drug-eluting balloon: a single-center retrospective analysis.

PURPOSE: Early in-stent restenosis after stent-protected angioplasty of the carotid artery (SPAC) is an infrequent, but potentially harmful condition for patients with carotid artery disease. METHODS: In our retrospective single-center analysis of 176 patients with carotid artery stenting between 2009 and 2015, using duplex ultrasound, we detected 9 patients with high-grade carotid artery in-stent restenosis. All restenosis patients were treated with a drug-eluting balloon (DEB) to prevent recurrent neointimal hyperplasia. One patient had bilateral carotid artery disease with bilateral in-stent restenosis, and 1 patient needed repeated DEB treatment 19 months after the first DEB intervention, so 11 DEB procedures, in total, were performed. RESULTS: The median time-interval between primary carotid artery stenting and first DEB-treatment was 9 months. In 3 of the 11 interventions, the DEB treatment was assisted by an additional stent. One repeat DEB treatment was necessary, and three DEB treatments were followed by a secondary stent. No peri-interventional complications (TIA, stroke, or death) were observed during or after DEB intervention. Therefore, in the entire group, the 1y event-free survival (EFS) was 100%, and the 2y/3y/5y EFS was 83%. CONCLUSION: DEB intervention seems to be an effective and safe treatment for patients with high-grade in-stent restenosis after SPAC.

Altered skin flowmotion in hypertensive humans.

Essential hypertensive humans exhibit attenuated cutaneous nitric oxide (NO)-dependent vasodilation. Using spectral analysis (fast Fourier transformation) we aimed to characterize the skin flowmotion contained in the laser-Doppler flowmetry recordings during local heating-induced vasodilation before and after concurrent pharmacological inhibition of nitric oxide synthase (NOS) in hypertensive and age-matched normotensive men and women. We hypothesized that hypertensive subjects would have lower total power spectral densities (PSDs), specifically in the frequency intervals associated with intrinsic endothelial and neurogenic control of the microvasculature. Furthermore, we hypothesized that NOS inhibition would attenuate the endothelial frequency interval. Laser-Doppler flowmetry recordings during local heating experiments from 18 hypertensive (MAP: 108±2mmHg) and 18 normotensive (MAP: 88±2mmHg) men and women were analyzed. Within site NO-dependent vasodilation was assessed by perfusion of a non-specific NOS inhibitor (N(G)-nitro-l-arginine methyl ester; l-NAME) through intradermal microdialysis during the heating-induced plateau in skin blood flow. Local heating-induced vasodilation increased total PSD for all frequency intervals (all p<0.001). Hypertensives had a lower total PSD (p=0.03) and absolute neurogenic frequency intervals (p<0.01) compared to the normotensives. When normalized as a percentage of total PSD, hypertensives had reduced neurogenic (p<0.001) and augmented myogenic contributions (p=0.04) to the total spectrum. NOS inhibition decreased total PSD (p<0.001) for both groups, but hypertensives exhibited lower absolute endothelial (p<0.01), neurogenic (p<0.05), and total PSD (p<0.001) frequency intervals compared to normotensives. These data suggest that essential hypertension results in altered neurogenic and NOS-dependent control of skin flowmotion and support the use of spectral analysis as a non-invasive technique to study vasoreactivity.

Predictive Parameters in Patients Undergoing Percutaneous Hepatic Perfusion with Melphalan for Unresectable Liver Metastases from Uveal Melanoma: A Retrospective Pooled Analysis.

PURPOSE: The aim of this study was to identify positive predictors for survival in uveal melanoma (UM) patients treated with percutaneous hepatic perfusion with melphalan (M-PHP), by retrospectively pooling data from three centers. MATERIALS AND METHODS: Retrospective analysis including patients ([Formula: see text] 18 years) treated with M-PHP between February 2014 and December 2019 for unresectable liver-dominant or liver-only metastases from UM. Predictors for OS were assessed using uni- and multivariate analyses. Other study outcome measures were response rate, progression-free survival (PFS), liver progression-free survival (LPFS), overall survival (OS) and complications according to CTCAEv5.0. RESULTS: In total, 101 patients (47.5% males; median age 59.0 years) completed a minimum of one M-PHP. At a median follow-up time of 15.0 months, complete response (CR), partial response (PR), stable disease (SD) and progressive disease were seen in five (5.0%), 55 (54.5%), 30 (29.7%) and 11 (10.9%) patients, respectively, leading to a 89.1% disease control rate. Median PFS, LPFS and OS were 9.0, 11.0 and 20.0 months, respectively. Survival analyses stratified for radiological response demonstrated significant improved survival in patients with CR or PR and SD category. Treatment of the primary tumor with radiotherapy, ≥ 2 M-PHP and lactate dehydrogenase (LDH) < 248 U/L were correlated with improved OS. Thirty-day mortality was 1.1% (n = 2). Most common complication was hematological toxicity (self-limiting in most cases). CONCLUSION: M-PHP is safe and effective in patients with UM liver metastases. Achieving CR, PR or SD is associated with improved survival. Primary tumor treatment with radiotherapy, normal baseline LDH and > 1 M-PHP cycles are associated with improved OS.

Management of renal artery pseudoaneurysm after partial nephrectomy.

PURPOSE: Nephron sparing surgery has been established as a standard treatment for renal masses smaller than 4 cm in diameter. The benefit of nephron sparing surgery may be hampered by new types of complications. In particular, postoperative gross hematuria due to the formation of renal artery pseudoaneurysm (RAP) can lead to clinical significant hemorrhage. We retrospectively investigated the occurrence of postoperative RAP in our own consecutive series of open/laparoscopic partial nephrectomies requiring transarterial angioembolization. METHODS: Open partial nephrectomy (OPN) was performed in 289 patients, and laparoscopic partial nephrectomy (LPN) in 40 patients. Six patients (1.82%) developed postoperative clinical symptomatic, persistent gross hematuria from RAP. Patient files were evaluated for preoperative, operative and postoperative data. RESULTS: First symptom presentation was observed at a median of 12.5 days (range 6-36) after surgery. Symptoms were flank pain, gross hematuria, dizziness/syncope and/or fever. Median postoperative blood transfusion rate was 3 units (range 0-8). RAP was proven with angiography in all patients. RAP was sufficiently occluded in all patients by using microcoils in a supraselective approach. Median follow-up was 23 months (range 10-37) without any episodes of hemorrhage/flank pain in each patient. CONCLUSIONS: RAP is a rare, but typical complication after partial nephrectomy. The clinical symptoms present with delay. Angiography identifies the origin of the bleeding and provides successful minimally invasive treatment.

Unresectable Hepatic Metastasis of Uveal Melanoma: Hepatic Chemosaturation with High-Dose Melphalan-Long-Term Overall Survival Negatively Correlates with Tumor Burden.

INTRODUCTION: Percutaneous hepatic perfusion with melphalan (PHP-M) for hepatic metastasis of uveal melanoma (LMUM) achieves high local response rates, but the individual clinical benefit is poorly defined. We aimed to determine cofactors of response and clinical outcomes including the probability of long-term (5-years) overall survival (OS) in PHP-M-treated patients with LMUM. Patients and Methods. We retrospectively reviewed clinicopathological, radiological, and outcome data of 19 patients with unresectable LMUM treated with 43 PHP-M (median 2 PHP-M) between 2014 and 2019. Tumor response and adverse events were evaluated using RECIST 1.1 and the Clavien-Dindo classification. Kaplan-Meier methods and Cox regression hazard proportional models were used. RESULTS: Of 19 patients, 10 (53%) achieved a partial response (PR) and 9 (47%) had stable disease (SD). There was no progressive disease (PD) and no adverse events exceeding Clavien-Dindo grade IV. Median OS was 16.7 months after the first PHP-M treatment and 26.4 months after initial diagnosis. Low hepatic tumor volume (median of 10 mL vs. 150 mL) was an independent predictor of favorable OS (hazard ratio (95% confidence interval): 0.190 (0.041, 0.893); p < 0.05), and female patients were at a lower risk compared with males (0.146 (0.017, 1.240)). Estimates of the overall survival were 0.213 (0.0449, 1) from first imaging (95% confidence interval) to 5 years and 0.793 (0.609, 1) and 0.604 (0.380, 0.960) for 1 and 2 years after chemosaturation, respectively. Discussion. PHP-M for nonresectable LMUV provides a safe and locally efficient liver-directed procedure that offers patients a chance for long-term OS, especially for patients with a low hepatic tumor burden.

[Central positional vertigo due to cerebellar nodular infarction]. / Lagerungsschwindel bei zerebellärem Nodulusinfarkt.

Nodular infarctions are a rare cause of vertigo and may imitate vestibular neuritis. We report on two patients with acute positional vertigo due to nodular infarction, a clinical presentation is not reported so far. High-resolution MR imaging using thin slices is required to identify isolated nodular infarctions.

Diagnostic value of multidetector-row CT angiography in the evaluation of thrombosis of the cerebral venous sinuses.

BACKGROUND AND PURPOSE: The diagnosis of cerebral venous and sinus thrombosis (CVST) as a rare but important cause of stroke is challenging. We aimed to investigate the diagnostic value of multidetector-row CT angiography (MDCTA) as a fast and cost-effective imaging tool in diagnosing CVST. MATERIALS AND METHODS: Nineteen patients who presented with clinical symptoms of a possible CVST were included. All patients had received both MDCTA and MR imaging with venous MR-angiography. Three blinded readers were asked to identify the cerebral sinuses and veins in MDCTA and to evaluate the presence of CVST in MDCTA. Consensus reading with interpretation of the MR imaging served to establish the definite diagnosis. RESULTS: The consensus reading revealed CVST in 10 of the 19 patients. With MDCTA, the venous sinuses could be identified in 99.2% and the cerebral veins in 87.6% of cases. The sensitivity and specificity of MDCTA for the diagnosis of CVST were 100%. CONCLUSION: Our study demonstrates that MDCTA provides excellent sensitivity and specificity for the diagnosis of CVST. Further studies are needed to evaluate the diagnostic potential of MDCTA in specific subsets of the general entity of CVST such as cortical venous thrombosis, thrombosis of the cavernous sinus, and thrombosis of the internal cerebral veins.

Micro-Raman spectroscopy study of colloidal crystal films of polystyrene-gold composites.

Monolayers and multilayers of polystyrene (PS)-gold composite films prepared by two different deposition methods have been investigated by atomic force microscopy (AFM), scanning electron microscopy (SEM), X-ray diffraction (XRD), and confocal Raman microspectroscopy. The intensity of the 1001 cm(-1) ring breathing mode of PS is used to evaluate the degree of ordering of monolayers and multilayers within a colloidal crystal. The depth profiling capability of confocal Raman microscopy is used to probe the regions inside the fractures in multilayered films. The intensity profile of the 1001 cm(-1) peak revealed the presence of fractures of different shapes with some PS microspheres at the bottom of the fracture. A strong increase in the Raman intensity (by 10(3) times) has been observed when probing the regions where Au nanoparticles are concentrated in aggregates of different shapes. This enhancement is attributed to the surface plasmons generated by the periodic structure of the gold nanoparticles.

Correlation of coronary calcification and angiographically documented stenoses in patients with suspected coronary artery disease: results of 1,764 patients.

OBJECTIVES: This study correlated the electron beam computed tomographic (EBCT) calcium scores with the results of coronary angiography in symptomatic patients in order to assess its value to predict or exclude significant coronary artery disease (CAD). BACKGROUND: Electron beam computed tomography is a sensitive method to detect coronary calcium. However, it is unclear whether it may play a role as a filter before invasive procedures in symptomatic patients. METHODS: A total of 1,764 patients (1,225 men and 539 women) with suspected CAD from a single center were included in our study. All patients underwent calcium screening with EBCT (C150XP Imatron) and conventional coronary angiography. RESULTS: Fifty-six percent of men and 47% of women revealed significant coronary stenoses (> or =50%). Total exclusion of coronary calcium (14% of the study group) was associated with an extremely low probability of stenosis (<1%). With calcium scores > or =20th, > or =100th or > or =75th percentile of age groups, the sensitivity to detect stenoses decreased to 97%, 93% and 81%, respectively, in men and to 98%, 82% and 76%, respectively, in women. At the same time, the specificity increased up to 77% in men and women. There was a significant difference in coronary calcium between men and women in all age groups; however, receiver-operating characteristic curves indicated that the test can be performed with equal accuracy in all of these subgroups. CONCLUSIONS: Calcium screening with EBCT is a highly sensitive and moderately specific test to predict stenotic disease. Exclusion of coronary calcium defines a substantial subgroup of patients, albeit symptomatic, with a very low probability of significant stenoses.

[Gadolinium enhancement of the cauda equina following ischemia of the lumbar cord]. / Kontrastmittelaufnahme der Cauda equina nach Ischämie im Conus medullaris.

Enhancement of the cauda equina is a well-recognized finding, in particular in patients with inflammatory diseases of the peripheral nervous system. However, we report an unusual case of a woman with an ischemic lesion in the lumbar intumescence who developed enhancement of the cauda equina 18 days after disease onset. Seventy-six days after the onset of illness, contrast uptake was no longer detectable. Severe injury to the motor neurons in the lumbar intumescence was evident clinically and electromyographically. We propose that the enhancement of the cauda equina was due to blood-nerve barrier disruption during Wallerian degeneration following ischemic injury to the motor neurons of the lumbar cord.

Mechanical Recanalization following i.v. Thrombolysis: A Retrospective Analysis regarding Secondary Hemorrhagic Infarctions and Parenchymal Hematomas.

Introduction. In acute stroke by occlusion of the proximal medial cerebral artery (MCA) or the distal internal carotid artery, intravenous thrombolysis is an established treatment. Another option is mechanical recanalization. It remains unclear if the combination of both methods poses an additional bleeding risk. The aim of this retrospective analysis is to determine the proportion of hemorrhagic infarctions and parenchymal hematomas. Methods. Inclusion criteria were an occlusion of the carotid T or proximal MCA treated with full dose thrombolysis and mechanical recanalization. 31 patients were selected. Devices used were Trevo, Penumbra Aspiration system, Penumbra 3D Retriever, and Revive. The initial control by computed tomography was carried out with a mean delay to intervention of 10.9 hours (SD: 8.5 hours). Results. A slight hemorrhagic infarction (HI1) was observed in 2/31 patients, and a more severe HI2 occurred in two cases. A smaller parenchymal hematoma (PH1) was not seen and a space-occupying PH2 was seen in 2/31 cases. There was no significant difference in the probability of intracranial bleeding after successful (thrombolysis in cerebral infarctions 2b and 3) or unsuccessful recanalization. Conclusion. The proportion of intracranial bleeding using mechanical recanalization following intravenous thrombolysis appears comparable with reports using thrombolysis alone.

Correlations between clinical findings and magnetization transfer imaging metrics of tissue damage in individuals with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy.

BACKGROUND AND PURPOSE: We obtained magnetization transfer imaging (MTI) scans from individuals with cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) (1) to investigate the presence, extent, and nature of pathology in white and gray matter outside proton density (PD)-visible lesions; (2) to quantify the degree of tissue damage occurring in lesions seen on PD-weighted scans; and (3) to correlate MTI-derived measures of disease burden with age, physical disability, and cognitive performance. METHODS: Dual-echo, T1-weighted, and MTI scans of the brain were obtained from 33 individuals with CADASIL and 12 control subjects. Magnetization transfer ratio (MTR) values from PD-visible lesions, normal-appearing white matter (NAWM), and normal-appearing gray matter (NAGM) were measured. Histograms of MTR from the whole brain and normal-appearing brain tissue were also produced. RESULTS: All MTR values from NAWM and NAGM regions studied were significantly lower for individuals with CADASIL than for control subjects, with the exception of those obtained from the NAWM of the infratentorial structures and the NAGM of the occipital cortex. The average MTR from PD lesions in individuals with CADASIL was significantly lower than that from all the NAWM regions. Average MTR and peak location from whole-brain and normal-appearing brain tissue histograms were significantly lower for individuals with CADASIL than for control subjects. MTR values from NAWM were strongly correlated with the extent of macroscopic lesions and their average MTR. Apart from NAGM, average MTR from all other tissues studied significantly decreased with increasing age, physical disability, and cognitive impairment. CONCLUSIONS: PD lesions of individuals with CADASIL have variable degrees of tissue damage. Brain tissue outside PD abnormalities is also damaged. This study suggests that the extent and the severity of the brain tissue damage are critical factors in determining clinical status in CADASIL.

Quantitative MRI in CADASIL: correlation with disability and cognitive performance.

OBJECTIVE: To study correlations between total lesion load on brain MRI and clinical features, and to evaluate the influence of demographic variables on quantitative MRI variables in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). BACKGROUND: CADASIL is a hereditary form of small-vessel disease caused by mutations within the Notch3 gene. MRI abnormalities have been found both in asymptomatic and symptomatic CADASIL individuals. METHODS: Quantitative measurements on cerebral MRI were performed in 64 CADASIL individuals. MRI lesions were quantified using a semi-automated segmentation technique based on local thresholds. RESULTS: MRI total lesion volume correlated significantly with disability (Rankin Scale) on both T1- and proton density (PD)-weighted images. There was a significant inverse correlation between total lesion volume and overall cognitive performance as determined by the Mini-Mental State Examination. Age but not sex was correlated with lesion load both on T1- and PD-weighted images. There was no detectable influence of the Notch3 genotype on quantitative MRI variables. CONCLUSIONS: This study demonstrates correlations between MRI lesion volume and clinical characteristics in CADASIL. Longitudinal studies are now warranted to investigate whether quantitative MRI could be used as an adjunct outcome measure in future therapeutic trials in CADASIL.

Diffusion measurements in the ischemic human brain with a steady-state sequence.

RATIONALE AND OBJECTIVES: The authors evaluate the clinical usefulness of a diffusion-weighted steady-state free-precession (SSFP) sequence to detect acute and subacute ischemic changes. METHODS: Twenty-four patients were examined on a 1.5-tesla scanner, using a SSFP-sequence (repetition time [TR]/ echo time [TE] = 22/3-8 mseconds). The slice thickness was 5 mm, 10 averages, 57 seconds per slice. The diffusion gradient strength was 23 millitesla/m, with b-values from 165 to 598 seconds/mm2. Diffusion-weighted images (DWI) were compared with T2-weighted images. RESULTS: The diffusion-weighted SSFP sequence produced diagnostic quality images in 23 of 24 patients. Diffusion depicted (group 1: 0-12 hours) more acute lesions (3 of 6) than T2-weighted images (2 of 6); the mean lesion diameter depicted by diffusion was 10.9 mm (standard deviation [SD], 12.3) and in T2-weighted images was 4.7 mm (SD 6.8). A significant correlation (P < 0.017) in subacute lesions was found when diffusion was compared with turbo spin echo (mean size difference/T2 = 18.5/17.5 mm, SD 13.2/12.2). CONCLUSIONS: The diffusion-weighted SSFP-sequence is more sensitive in acute ischemia and delineates likewise in subacute ischemia, when compared with T2-weighted imaging.

Intercalation of a pendant-arm tetraazamacrocycle into molybdenum disulfide.

A novel macrocycle-MoS2 nanocomposite has been synthesized and characterized using the exfoliation/restacking properties of LiMoS2, providing the first of a new family of intercalation compounds.

Characteristic MR lesion pattern and correlation of T1 and T2 lesion volume with neurologic and neuropsychological findings in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL).

BACKGROUND AND PURPOSE: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is an arteriopathy related to a genetic defect of the notch 3 gene on chromosome 19. The purpose of this study was to evaluate lesion distribution and volume using MR imaging and to correlate the lesion volume with the neurologic and neuropsychological findings. METHODS: Twenty members of two families (14 with CADASIL as determined by linkage analysis, six healthy) were studied with MR imaging. Two observers evaluated the MR findings semiquantitatively and quantitatively. MR results were then correlated with neurologic and neuropsychological findings. RESULTS: A typical pattern of lesion distribution in patients with CADASIL was found: the frontal lobe was the site with the highest lesion load, followed by the temporal lobe and the insula. The total lesion volume on T1-weighted MR images correlated significantly with the degree of disability and the degree of impairment in neuropsychological functions (including attention, memory, and conceptual and visuospatial functions). CONCLUSION: In CADASIL patients, a common pattern of cerebral lesion distribution is found. The total T1 lesion volume is an important parameter to correlate with disability, as it may prove to be helpful in predicting the natural history of the disease.

[3-D CT reconstruction of fractures of the skull base and the facial skeleton]. / 3-D-CT-Rekonstruktion bei Frakturen der Schädelbasis und des Gesichtsschädels.

3-D reconstructions of the skull base, temporal bone, and skull fractures were compared to 2-D- CT to evaluate the diagnostic value in traumatized patients. 38 patients with 22 fractures of the facial skeleton (orbita, zygomatic, Le Fort), 12 temporal bone, and 4 skull fractures were investigated. Subjective grading was performed by two physicians (ENT/RAD) in respect of quality diagnostic validity and estimated clinical impact. The average image validity and quality were graded good. In the temporal bone the average information supplied by 3-D was of inferior value; here, the lack of information regarding the inner ear structures was responsible for the lack of clinical impact. In fractures of the facial skeleton and the skull base a good to very good image quality was seen and clinical relevance was high. 3-D CT is capable of demonstrating fractures, which is of little value in the temporal bone, but of high value in the skull base and the facial skeleton, especially if surfaces are involved or fragments are displaced.

[Magnetic resonance tomographic studies of paragangliomas of the glomus caroticum and glomus jugulare using Gd-DTPA]. / Kernspintomographische Untersuchungen von Paragangliomen des Glomus caroticum und Glomus jugulare mit Gd-DTPA.

The value of magnetic resonance tomography in the diagnosis of paragangliomas in the head and neck has been studied and compared with CT and angiography. Magnetic resonance tomography on its own equals the accuracy of CT, but the use of Gd-DTPA improves diagnostic accuracy. In 19 patients with a glomus jugulare tumour, MR tomography with Gd-DTPA accurately diagnosed all tumours larger than 5 mm. In seven patients with a carotid body tumour, it was possible to arrive at an exact differential diagnosis. Sensitivity was better than that of CT or of sonography. Where there is clinical suspicion of a glomus tumour, magnetic resonance tomography with Gd-DTPA should be the first investigation; if there is a positive finding, angiography should be carried out to demonstrate the circle of Willis.