Cerebellar haemorrhage mimicking acute peripheral vestibulopathy: the role of the video head impulse test in differential diagnosis.

Dizziness and vertigo without neurological signs are typically due to a peripheral vestibular disease. Although the most common causes are benign, differential diagnosis must include potentially life-threatening central diseases such as cerebrovascular pathologies. A systemic clinical approach needs a careful work-up, bedside examination and appropriate instrumental investigation. The head impulse test (HIT) allows qualitative clinical assessment of canalar function; it has some limitations such as subjective evaluation, mainly in patients with a spontaneous nystagmus. A new device has been recently developed consisting of an infrared video camera (video-HIT) to provide quantitative instrumental assessment of the high-frequency vestibular-ocular reflex (VOR) gain. By reporting a case of cerebellar haemorrhage mimicking an acute peripheral vestibulopathy, the authors suggest that video-HIT may be considered a useful tool in differential diagnosis between vestibular neuritis and cerebellar vascular disease in patients with severe acute vertigo without central signs.

[Septic thrombophlebitis of the internal jugular vein due to Fusobacterium necrophorum (Lemierre's syndrome): case report and review of literature]. / Tromboflebite settica della vena giugulare interna da "Fusobacterium necrophorum" (sindrome di Lemierre): caso clinico e revisione della letteratura.

Lemierre's syndrome is an uncommon clinical entity. It is characterized by oropharyngeal infection followed by septic thrombophlebitis of the jugular vein with embolization to the lungs and other organs. It is usually due to Fusobacterium necrophorum. Although Lemierre's syndrome is rare, it is potentially fatal. It is important for clinicians to recognize and treat it appropriately. With prompt recognition, abscess drainage with possible ligation of the internal jugular vein and appropriate antibiotic coverage complete recovery can be achieved in most patients.

Recombinant tissue plasminogen activator (rt-PA) as first-line therapy for declotting of haemodialysis access.

One of the most common complication in haemodialysis patients is thrombosis of the arteriovenous fistula (AVF). Thirty-five patients with a total of 42 thromboses of the angioaccess were infused via a small needle: (i) into the feeding artery (50% of the cases); (ii) into a AVF venous segment of the arteriovenous fistula (42.8%); (iii) directly into the thrombus (7.1%), by rt-PA. After an initial pulse of 5-10 mg, according to body weight, the drug was continuously infused by a pump with the speed automatically programmed in 30 Brescia-Cimino autologous AV fistulae and 12 polytetrafluoroethylene (PTFE) grafts. A complete thrombolysis with return of bruit and thrill was obtained in 71.4% of the cases using a mean drug dose of 21 mg and an infusion time of 3.8 h. All the successful cases underwent haemodialysis via AVF on the same day. No bleeding occurred at remote sites. Local bleeding occurred in 16% of the cases; in no case was it so severe as to require the suspension of the therapy or blood transfusions. The median cumulative duration of patency after thrombolysis was 32.4 months. Respectively 21, 12 and two patients had a functioning angioaccess after 3.6, 32.4 and 36 months from the lytic approach. Failure of the treatment was not related to the patients' gender or age, AVF age, route of administration of the drug, type of vessel (natural or artificial), or delay between the discovery of the fistula occlusion and the start of the therapy. In unsuccessful cases an organic lesion of the vessels was documented by angiography or echo colour Doppler. In summary, rt-PA local infusion provides a useful means of preservation of AV fistulae and may be used as the therapy of first choice in dialysis patients without active bleeding or high bleeding risk.

[Color Doppler and phlebography in the Paget-Schroetter syndrome]. / Color Doppler e flebografia nella sindrome di Paget-Schroetter.

The authors compared the adequacy of phlebography and color-Doppler US in the diagnosis of subclavian-axillary thrombosis, or Paget-Schroetter syndrome. Ten patients with subclavian-axillary thrombosis (8 men and 2 women, aged 16 to 55 years, mean age: 30 years) were examined over a two-year period. All of them underwent color-Doppler US and conventional phlebography in the same session. US findings were in agreement with phlebographic results in all cases as to thrombosis presence and site. The thrombosis involved the subclavian-axillary vein in 8 cases, the subclavian-innominate vein in 1 case and both veins in 1 case. Color-Doppler US, however, yielded no information relative to the superior vena cava; these data were always obtained with phlebography even though in 4 cases that segment had to be studied with phlebographic opacification via contralateral route. Furthermore, US failed to clearly demonstrate the thrombosis involving the last axillary valve; preserving this valve is indeed the main aim of fibrinolysis since its integrity, at this level, prevents venous reflux independent of subclavian-axillary trunk recanalization, thus reducing the severe symptomatologic sequelae following postphlebitic damage. Phlebography showed the valve and its possible involvement in all cases. In 4 cases phlebography also demonstrated compressive thoracic inlet syndrome, which had been missed by US, yielding the main anatomic elements for following surgery. To conclude, the authors suggest noninvasive color-Doppler US as the screening method of choice, while phlebography remains the gold-standard technique to be performed in all Doppler positive cases: in fact, the latter method yields more pieces of information and is more panoramic than the former, besides allowing fibrinolysis effects to be studied and the possible presence of an associated thoracic inlet syndrome to be investigated.

[Full computerization of a radiology service. A 5 years' experience at a centralized system]. / Informatizzazione integrale in un servizio di radiologia. Esperienza di 5 anni in un sistema centralizzato.

Even though the problem of collecting and processing information is of paramount importance in any radiology department, the choice of the best information system--as for organization and effectiveness--largely depends on specific and different local situations and is therefore still largely debated. In the ULSS 18 in Veneto (Dolo, Venezia), all patients are referred to the only existing hospital radiology. Therefore, a central computer system has been be realized and used also by the radiology department, for completely computed procedures, since January 1, 1988. We describe the computer configuration of both the ULSS and the radiology department and report on our 5-year experience with full computerization within a central information system. As for department organization, any information system--with appropriate hardware and software--can be equivalent to others, since it largely contributes to both management (programming, booking, filing, accounting) and reporting (automatic reporting with memorized texts and/or voice recognition; reprinting; immediate correction at the video-terminal). Thanks to more rational exploitation of human and technological resources, any information system makes a radiology department more functional and efficient. However, some peculiarities of the central computer system must be stressed, as they allow: 1) to use pre-existing and updated patients files (unequivocal identification in the whole ULSS); 2) to gain access to the databanks of different specialties and to patients' clinical histories (complete data collected from many sources); 3) to intervene in booking and ticket collection centers with none of the relative loads; 4) to have no limits of memory, storage or speed for complex programs (automatic reporting also with the recognition of the dictating voice, accounting and statistical analyses, ecc.); 5) to profit by continually updated and fitted hardware and software, with the relative expenses and benefits shared by the whole ULSS. Within the possibilities given by a double role-ruled password, all different menus and programs are accessible from any video-terminal, even while other programs are running, thus allowing cost-effective hardware to be available in the radiology department.

[Percutaneous neurolysis of the celiac plexus. Description of a new CT-guided technique and preliminary results]. / Neurolisi percutanea del plesso celiaco. Descrizione di una nuova metodica TC-guidata e risultati preliminari.

June 1991 to June 1992, twelve CT-guided percutaneous celiac plexus neurolyses were performed by a new simplified technique with the patient in left-hand side decubitus and a single right lumbar needle access. CT guidance allows the interventional radiologist to locate the best access point on the skin, to give the needle the appropriate depth and inclination to avoid passing through pleura, parenchyma and vessels, and finally to check the correct position of the needle tip and the spread of neurolytic solution. In left-hand side decubitus, fat and loose connective tissue around ganglia and vessels expands much more, thus allowing the alcohol-contrast medium solution to spread easily and evenly getting to both celiac ganglia by gravity. The analgesic value of celiac plexus neurolysis has been proved complete and lasting. The technique is quick and safe (apart from inevitable hypotension due to splanchnic vasodilatation).

[Pre- and postoperative right cardiac insufficiency in patients with mitral or mitral-aortic valve diseases]. / L'insuffisance cardiaque droite pré- et postopératoire des mitraux et mitro-aortiques.

The prognosis of right ventricular failure in patients with mitral valve disease would seem to depend on its chronicity and progression according to the results of a study of 382 cases of mitral valve disease: 231 women, 151 men: average age 55 +/- 13 years, operated between January 1983 and December 1986, most (321) for mitral valve replacement, one third (108) with associated aortic valve replacement. Right ventricular failure was or had been present before surgery in 161 patients: the peri-operative mortality was 11.2% and the secondary mortality 21.7% in these cases, significantly higher than in patients without RVF (respectively 5.0%, p = 0.02, and 8.1%, p < 0.0005). The RVF was present in the immediate post-operative phase in 43 patients, 8 of whom had no signs of this complication beforehand. The cause of this "de novo" early RVF is multifactorial. Ten other patients developed secondary RVF without any obvious cause in 3 cases. The prognosis of "de novo" RVF is very poor (28% survivors at 75 months). At the end of 60.4 +/- 13.6 months 20 patients were lost to follow-up, RVF was present in 60/286 patients followed up. The mortality was high in the patients with residual RVF (38.3% vs 4.0% in patients without: p < 0.0001). This study confirms the poor prognosis of RVF in patients with mitral valve disease whatever the timing with respect to surgery. Right ventricular failure occurring for the first time after surgery is rare (4.7% of cases), of uncertain cause, and carries a particularly poor prognosis.

[Which anti-ischemic treatment can be prescribed during and after the acute phase of myocardial infarction?]. / Quel traitement anti-ischémique prescrire à la phase aiguë de l'infarctus du myocarde et après?

After myocardial infarction, calcium channel blockers are the most prescribed anti-ischemic drugs followed by nitrate derivatives and beta blockers. In order to assess whether this attitude is justified by published data on their efficacy, a meta-analysis of trials of anti-ischemic drugs in myocardial infarction was performed. The early mortality was 13.3% in the group treated by IV nitrates in the acute phase of myocardial infarction and 17.2% in control groups, reducing the risk by a quarter (95% confidence interval of the odds ratio (CI): 0.55-0.95). When all nitrate derivative trials were grouped together, the reduction in the risk of death of 21% was significant (from 15% to 11.8%) (CI: 0.59-0.94). Although oral nitrate derivatives introduced during the acute phase and continued for several weeks induced a non-significant reduction in mortality of 16%, when given intravenously, the benefits on early and longer term mortality were unquestionable. The mortality was 9.8% in the groups treated by calcium channel blockers and 9.3% in control groups (NS); the recurrent infarct rate was 4.8% and 5.4% respectively (NS). In this family of drugs, there was no product which distinguished itself from the others with regard to beneficial or adverse effects. The early mortality decreased from 9.2% to 8.2% in the groups treated by oral beta-blockade--a risk reduction of 10% (NS) and from 4.2% to 3.7% with intravenous beta-blockers--a risk reduction of 12% (p = 0.03). Late mortality decreased from 9.4% to 7.6%, a reduction of 20% (p < 0.00001) in long term trials.2+ contraindication of betablockers in patients without cardiac failure.

[The Duplex system in the follow-up of sclerosing therapy of the greater saphenous vein. First results and considerations]. / Il sistema Duplex nel follow-up della terapia sclerosante della vena grande safena. Primi risultati e considerazioni.

The authors evaluated the long-term results of sclerosing therapy as an alternative to surgery by means of high-resolution US and Doppler dynamic fluximetry (duplex system). Seventy patients (53 females and 17 males) were examined, all of whom fulfilled the clinical criteria of recovery and efficacy of sclerosing therapy. Average follow up was 20 months (range: 6-26). The results, compared with duplex findings before sclerosing therapy, demonstrated: a) persistence of reflux and absence of US signs of sclerosis (9/70 patients); b) evident sclerosis with persistent residual lumen and reflux of variable entity at the thigh (33/70) cases; c) incomplete sclerosis sparing the crosse, with physiological flow and disappearance of reflux (8/70 patients); d) nearly complete sclerosis with vasal lumen obliteration (20/70 cases). No changes were observed in the deep venous system after sclerosing therapy. The authors stress the advantages of the duplex system they employed as an instrumental support to clinics for a complete monitoring of sclerosing therapy.

[Duplex-sonography in the preoperative evaluation of the small saphenous vein]. / L'indagine duplex nello studio preoperatorio della vena piccola safena.

The authors analyze the results obtained by means of Doppler US, duplex examination and venography in the preoperative evaluation of venous vascular anatomy and flow dynamics in the popliteal fossa for short saphenous vein surgery. As a whole, 50 legs were examined in 34 patients who subsequently underwent surgery. The confluence of the short saphenous vein in the deep system proved to be very variable. Doppler results were compared with contrastographic ones: Doppler US had 10% accuracy in locating the confluence of the short saphenous vein and the figure rose to 62% with a +/- 2 cm tolerance. Duplex US had 30% and 98%, respectively. The latter always correctly demonstrated the reflux, while Doppler US in 5 cases (10%) ascribed gastrocnemius vein incompetence (4 cases) and Giacomini vein incompetence (1 case) to the short saphenous vein. The above findings demonstrate the total reliability of duplex US versus Doppler US and venography in recognizing the anatomic confluence and in allowing the fluximetric evaluation in a noninvasive, riskless and inexpensive way.

[First experience with the combination of ultrasonics and pulsed Doppler (Duplex system) in the study of venous pathologies of the legs]. / Prime esperienze di associazione ecotomografia-Doppler pulsato (sistema Duplex) nello studio della patologia venosa negli arti inferiori.

Over a 2-year period the authors examined 400 patients affected with different types of phlebopathies with combined real-time US and pulsed Doppler (Duplex system). Ninety-eight patients had deep phlebothrombosis, 45 had superficial phlebothrombosis, and 110 primitive or secondary vein insufficiency. The obtained data, supported in 171 cases by contrastographic findings, allowed both the semeiological study and the evaluation of the indications for Duplex US in the various phlebopathies. The combination of high-resolution US morphological data, dynamic tests, and the functional data from pulsed Doppler have particular interest in the study of: a) the diagnostics of superficial or deep thrombosis and adhesive or floating thrombi; b) post-thrombotic syndrome; c) primitive or secondary vein insufficiency; d) the ostium of the superficial venous system (location, morphology, functionality). Duplex US is a non-invasive technique for the examination of the superficial and the deep venous systems, which reduces the indications for phlebography, an exam which requires radiation exposure, and is not always safe or possible. Duplex US is however limited by the difficult assessment of the venous system below the knee, because of too many trunks and variants.

[Varicography in the preoperative assessment of primary varices. A study of 100 cases]. / La varicografia nel bilancio preoperatorio delle varici primitive. Studio di 100 casi.

Primary varicose veins in the lower limb are usually well evaluated by the surgeon, who avails himself of tourniquet tests and Doppler US. However, the operation is often followed by failure or recurrence, or else it requires ugly skin dissection to eradicate an unforeseeably complicated varicose vein. We suggest that, whenever the surgeon considers the information obtained with tests and Doppler US inadequate for planning surgery, varicography be performed to get further morphological (and functional) data about the origin of varicose veins, which is of fundamental importance for an accurate surgical planning (cross-section stripping, ligation, sclerosis). Out of 100 varicographies consecutively carried out on patients in whom clinical examination was not conclusive, 62% allowed an already planned surgical approach to be changed. The figure rose to 100% in case of unusual varicose veins. Such a result allowed the needs of both the surgeon (selectivity, effectiveness, radicality) and the patient (narrow scars, absence of relapse) to be respected. Furthermore, it has been pointed out that some vein segments are often only pathological, and they are to be adequately treated, while others can be undamaged, and they are to be preserved for both their function and an eventual by-pass surgery. Varicography is rapidly performed, without complications, and is well accepted by the patient. It is a fundamental help in the preoperative study of primary varicose veins, especially in case of unusual ones, whenever the surgeon is in the slightest diagnostic--and therefore surgical--doubt.