Coil embolization of internal mammary artery injured during central vein catheter and cardiac pacemaker lead insertion.

PURPOSE: This study describes several cases of endovascular coil embolization of the proximal internal mammary artery injured by blind approach to the subclavian vein for central venous catheter or pacemaker lead insertion. MATERIALS AND METHODS: We conducted a retrospective analysis of five patients with iatrogenic arterial lesions of the internal mammary artery (IMA). The lesions occurred in three patients from a puncture of the subclavian vein during insertion of a central venous catheter and in two patients from a puncture of the subclavian vein for insertion of a pacemaker lead. Four patients had acute symptoms of bleeding with mediastinal hematoma and hematothorax and one patient was investigated in a chronic stage. A pseudoaneurysm was detected in all five patients. All four acute and hemodynamic unstable patients required hemodynamic support. RESULTS: In all patients, embolization was performed using a coaxial catheter technique, and a long segment of the IMA adjacent distally and proximally to the source of bleeding was occluded with pushable microcoils. In one patient, additional mechanically detachable microcoils were used at the very proximal part of the IMA. Microcoil embolization of the IMA was successful in all patients, and the source of bleeding was eliminated in all patients. CONCLUSION: Transarterial coil embolization is a feasible and efficient method in treating acute bleeding and pseudoaneurysm of the IMA and should be considered if mediastinal hematoma or hemathorax occurs after blind puncture of the subclavian vein.

Complex mincer hand injury in a 4-year-old girl: successful revascularization.

We report on a four-year-old girl who suffered a complex mincer injury to the left hand, resulting in a partial amputation of her hand. To salvage the injured hand, revascularization was performed. The indication, advantages and outcome of the procedure are discussed.

[Possible nerve injuries in ankle dislocations. Trimalleolar fracture including the proximal fibula]. / Mögliche Nervenverletzungen bei Sprunggelenkluxationsverletzungen. Trimalleoläre Fraktur mit Beteiligung der proximalen Fibula.

We present a patient with an exceptional fracture type--a Maisonneuve fracture associated with a lateral ankle fracture--and the therapy of this injury. The Maisonneuve fracture consists of a proximal fibular fracture which is associated with failure of the deltoid ligament or medial malleolus and diastasis of the distal tibiofibular syndesmosis. Diverse nerves of the lower leg can be affected by severe trauma as well as by fracture-associated complications or an operation. Fracture fragments, an excessive distension caused by the trauma, or a fracture-associated hematoma can cause injury to the deep peroneal nerve or the branches of the superficial peroneal nerve at the level of the ankle. We want to point out the possibility of nerve lesions of the lower leg associated with this complex fracture. Additionally the operative access to the ankle in this context is discussed.

Transient global amnesia triggered by the intracarotid amobarbital procedure.

The emergence of a sudden, global, and fully reversible amnestic state during an intracarotid amobarbital procedure (IAP) performed in a patient with a right temporal tumor is described. Forms of amnesia during the IAP are discussed, and it is argued that because of its appearance, the associated behavioral abnormalities, and EEG findings, this state was a transient global amnesia (TGA). In addition to other origins such as bitemporal lesions, increased barbiturate levels, seizures, and epileptic amnesia, TGA may triggered by stress or angiography during the IAP.

The incidence of iliac aneurysms in patients with abdominal aortic aneurysms: comparison of four centers in Europe and the USA.

BACKGROUND: The purpose of this study was to compare the anatomy of the aortoiliac vessels in patients scheduled for infrarenal abdominal aortic aneurysm (AAA) repair in four different countries. MATERIAL AND METHODS: Consecutives series of 100 preoperative CT-scans were evaluated at each center. Diameters of the suprarenal aorta, maximal diameter of the aneurysm, right and left common and external iliac artery as well as the hypogastric arteries were recorded and compared between each center. RESULTS: Configuration of the AAA above bifurcation was similar at each center. The dimensions of the aortic bifurcation and the common iliac arteries were different among the centers. Common iliac arteries with diameters over 25 mm were significantly more common at center 1 (p < 0.001, p = 0.002 and p < 0.001). Among centers 2, 3 and 4 there was no significant difference in common iliac diameters. CONCLUSIONS: Configuration of the iliac arteries in AAA was significantly different for Swiss patients compared to American, Austrian and German patients. Reasons for these differences are unclear, epidemiological or genetic factors may be responsible.

Tumor- and pregnancy-derived isoforms of human chorionic gonadotropin: biological and diagnostic relevance.

OBJECTIVES: Human chorionic gonadotropin (hCG) and hCG variants are of high clinical importance for the diagnosis of pregnancy, monitoring of abnormal and ectopic pregnancies, testing for Down's syndrome or monitoring therapy of hCG-secreting malignancies. In serum and urine, hCG appears in microheterogeneous isoforms with respect to protein backbone structure and the extent of glycosylation. The present study reports on the identification, immunological characterization, biological activity of glycosylation isoforms of pregnancy (preg) and tumor-derived (tu) hCG, and the impact of glycosylation on diagnostic immunoassays. METHODS: Twenty-two urinary preg- and tu-hCG isoforms were separated by preparative isoelectrofocusing (hCG-pI variants) and characterized by Western blot. Number, topography and accessibility pattern of epitopes on their surface was evaluated by two-site radioimmunoassays using 14 different monoclonal antibodies (mabs). Binding of hCG isoforms to four different LH/CG receptors was investigated in radioreceptor assays, and their biological activity determined by measuring cAMP elevation. RESULTS: All 22 hCG glycosylation variants appeared immunologically intact: each isoform, even when highly acidic, expressed all 14 surface epitopes which were arranged in a topographical manner indistinguishable from crude hCG. hCG isoforms were able to bind to four different receptor variants, with slightly varying affinities, but orientations indistinguishable from each other as shown by identical epitope accessibility patterns. Each of the hCG-pI variants was able to activate the LH/CG-Rs, but with varying reactivities. CONCLUSIONS: We conclude that in contrast to deglycosylated hCG, all hCG glycosylation isoforms investigated act as receptor agonists. Moreover, there is no overspecificity of mabs to certain hCG isoforms due to carbohydrate variability that exclude others from diagnostic measurement.

A novel vacuum device for extremity immobilisation during digital angiography: preliminary clinical experiences.

Our objective was to develop and evaluate a non-invasive device for rigid immobilisation during extremity angiography. The patented BodyFix immobilisation device (Medical Intelligence, Schwabmünchen, Germany) consists of a vacuum pump connected to special cushions and a plastic foil that covers the body part to be immobilised. First, the patient's extremity is covered by a thin plastic bag and then wrapped in one of the cushions, placed on the top of the therapy couch, and covered with the plastic foil. The air is evacuated from the cushion under the covering foil by the vacuum pump, resulting a hardening of the cushion and thus immobilisation of the patient's extremity. The rigid immobilisation resulted in a complete absence of motion artefacts in the majority of patients. No pixeling of the images was required in any of the 100 patients vs 32% in the control group. Repetition of series could be avoided in all cases and a substantial increase in the quality of the images was obtained. Setup of the device takes an additional 1-2 min. Vacuum immobilisation allows for comfortable, effective immobilisation during digital subtraction angiography, eliminating motion artefacts. This device has become an indispensable tool in daily clinical routine at our department.

[Radiation exposure in single slice and multi-slice spiral CT (a phantom study)]. / Untersuchungen zur Strahlenexposition bei der Einzelschicht- und Mehrschicht-Spiral-CT (eine Phantom-Studie).

PURPOSE: The purpose of study was to compare patient dose applying singleslice- and multislice-spiral CT. METHODS: The examinations were performed with a singleslice-spiral CT (Highspeed Advantage; GE Medical Systems; Milwaukee, USA) and with a multislice CT systems (LightSpeed QX/i GE Medical Systems; Milwaukee, USA). For the determination of the radiation exposure (absorbed dose) a selection of most executed protocols (thorax-helical, abdomen-helical, petrous bone-axial, head-axial) were simulated using an Alderson Rando Phantom. The dose was determined by means of lithiumfluorid-thermoluminiscence dosimeters (TLD-GR 200). RESULTS: For thorax and abdomen protocols higher energy dose values could be found using a multislice CT. On the average the energy dose values were increased by 2.6 on an average in relation to single slice spiral CT. The energy dose values of the multisclice CT using head protocols could be reduced by 30% in relation to single slice spiral CT due to suitable parameter selections. The energy dose applying a petrous bone protocol resulted in an average increase by a factor 1.5 using a multislice CT. CONCLUSION: Using the new multislice CT technique protocol strategies must be optimized regarding the patient doses. Users can operate critically in the sense of the radiation protection only if they are aware of the occurring dose amounts to the patient.

Can the dimensions of artificial tendon lesions be predicted ultrasonographically? A cadaveric study.

OBJECTIVE: To prove the reliable assessment of artificial partial tendon lesions in cadavers. METHODS: The tendon of the tibialis anterior muscle was cut twice (transversely, not standardized depths) along its dorsal surface. The dimensions were measured by using a 10-MHz linear probe and a gliding caliper. The lesions were classified as type A tears (<60%; n = 15) and type B tears (>60%; n = 28). RESULTS: The depths of type A tears had high correlation (r = 0.827), and those of type B tears had low correlation (r = 0.415). This low correlation was due to subtotal lesions (50%-70%; r = 0.699). High-resolution ultrasonography allowed the correct detection of 14 type A tears and 21 type B tears (kappa = 0.63; accuracy, 81%; type B tears: sensitivity, 75%; specificity, 93%). CONCLUSIONS: High-resolution ultrasonography is able to assess the dimensions of artificial partial tendon lesions in cadavers and would be an accurate tool for determining the lesion percentages in patients with partial tendon tears.

Induction of apoptosis in Kaposi's sarcoma spindle cell cultures by the subunits of human chorionic gonadotropin.

OBJECTIVES: Elucidation of the mechanisms of the previously shown growth-inhibitory action of human chorionic gonadotropin (hCG) on Kaposi's sarcoma (KS) cells and the role of the luteinizing hormone/hCG receptor (hCGR). DESIGN AND METHODS: Analysis of KS tissues and cultured spindle-type KS cells for the presence of the hCGR using 125I-hCG binding and reverse transcriptase-polymerase chain reaction; analysis of several hCG preparations (urinary, recombinant, isolated alpha and beta subunits); analysis of apoptosis mechanisms by several assays including using z-Val-Ala-Asp-fluoromethylketone (zVAD-FMK), a known apoptosis-inhibitory drug. RESULTS: First, we found that some urinary preparations of hCG (e.g., CG-10, Steris Profasi) were indeed KS-killing but others (such as Pregnyl, Choragon, Serono Profasi) were not. Secondly, recombinant subunits (alpha as well as beta) of hCG were KS cell-killing but recombinant intact hCG was not. Thirdly, the hCGR message and protein were undetectable in KS. Fourthly, CG10-induced cell death occurred by apoptosis and KS cells could be rescued by preincubation with zVAD-FMK. Finally, we also found that normal peripheral blood lymphocytes (PBL) were killed by CG-10. CONCLUSION: It is proposed that the action of subunits or subunit fragments of hCG, mediated by a putative orphan receptor (as opposed to the hCGR) and executed by interleukin-1-converting enzyme (ICE)-like protease(s), constitutes a novel apoptosis mechanism effective towards KS cells, but PBLs and possibly other cells as well. These results provide a basis for testing in vitro the therapeutic efficacy of hCG preparations which, in turn, should improve current clinical trials with 'hCG' in patients who have KS.

Number and topography of epitopes of human chorionic gonadotropin (hCG) are shared by desialylated and deglycosylated hCG.

A previously established map of the surface epitopes of human chorionic gonadotropin (hCG) served as template for the present study in which we investigated the antigenic surfaces of two glycosylation variants of hCG, i.e. desialylated hCG (asialo-hCG) and deglycosylated hCG (degly-hCG). This map allocates five epitopes to the alpha subunit, five to the beta subunit and four alpha beta epitopes to structures formed only by the alpha/beta heterodimer holo-hCG (Schwarz et al. (1986) Endocrinology 118, 189-197; Berger et al. (1990) J. Endocrinol. 125, 301-309). Here it is described that both variants complied with this template: each of the 14 distinct monoclonal antibodies with which the epitopes of hCG were defined reacted with radiolabeled asialo-hCG and degly-hCG as well and generally bound degly-hCG with greater affinity than hCG. Moreover, every combination of capture and radiolabeled detection antibody that was either compatible or incompatible on unlabeled hCG was so also on unlabeled asialo-hCG and degly-hCG. It thus appears that alterations of the carbohydrate structure of hCG can be associated with a change in affinity between some antibodies and their respective epitopes but not with a loss of an epitope or with a change in the topographical relationships of the 14 epitopes.

Epitope mapping of the receptor-bound agonistic form of human chorionic gonadotropin (hCG) in comparison to the antagonistic form (deglycosylated hCG).

On the surface of free human chorionic gonadotropin (hCG), we can distinguish with our panel of monoclonal antibodies (MCA) 14 topographically distinct epitopes (designated alpha 1 - alpha 5, beta 1 - beta 5, alpha beta 1 - alpha beta 4, depending on the subunit they are attached to). Only 2, i.e. the adjacent beta 3 and beta 5 epitopes, of these 14 are accessible to 125I-labeled MCA binding, when hCG is first allowed to bind to the rat testis hCG receptor. This result indicates that the agonist hCG assumes a defined orientation in its receptor-bound state and that, except for that small area comprising the beta 3 and beta 5 epitopes, most of its surface is masked by the hCG receptor. We therefore asked whether the competitive antagonist deglycosylated hCG (degly-hCG), which, when free, is antigenically (as to number and topography of epitopes) indistinguishable from native hCG, would interact with the receptor differently, that is, in a way that can be discerned by this epitope accessibility paradigm. Here we describe that on receptor-bound degly-hCG the beta 3 and beta 5 epitopes were concealed as were all other epitopes. This observation, together with finding the receptor affinity of degly-hCG to be 4 times higher than that of native hCG, suggests that degly-hCG assumes a signal transduction-incompetent ligand orientation and at the same time interacts with the receptor more intensively, i.e. establishes additional ("antagonist accessory") protein-protein contacts besides those involved in agonist binding. It thus appears that the carbohydrate moieties function to prevent formation of such accessory contacts.