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.

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.

Multifocal epithelioid glioblastoma mimicking cerebral metastasis: case report

Objective. Epithelioid glioblastoma is a rare morphologicsubtype of glioblastoma that closely mimicsmetastatic carcinoma or metastatic melanoma histologically.All previous case reports of this unusualglioblastoma variant have been solitary lesions.We report here the first case to our knowledge ofmultifocal epithelioid glioblastoma mimicking cerebralmetastasis.Clinical presentation. A 67-year-old man with aprior history of mycosis fungoides, a common form ofcutaneous T-cell lymphoma, presented with memoryloss and impaired peripheral vision. Two discretebrain lesions highly suspicious for metastases wereidentified by magnetic resonance imaging (MRI).Intervention. The patient underwent two separatecraniotomies; both lesions were successfully resectedin toto with an excellent post-surgical outcome.Conclusion. Epithelioid glioblastoma is one of therarest morphologic subtypes of glioblastoma. Here wedescribe the first case to our knowledge of multifocalepithelioid glioblastoma that convincingly mimicked asecondary metastatic process. Multifocal epithelioidglioblastoma should be included in the differentialdiagnosis of patients who present with multiple discretebrain lesions. An attempt at gross total resectionis recommended when anatomically feasible fordefinitive histopathological diagnosis and to improveprogression free survival of patients who present withsimilarly ambiguous and potentially misleading multiplelesions (AU)

Objetivo. El glioblastoma epiteloide es un subtipomorfológico poco común del glioblastoma que puedeimitar al carcinoma o melanoma metastásico histológicamente.Todos los casos reportados de esta varianteinusual de glioblastoma han sido lesiones solitarias.Presentamos el primer caso de glioblastoma multifocalepiteloide imitando metástasis cerebral.Presentación clínica. Varón de 67 años con historiaprevia de micosis fungoide, una forma común de linfomacutáneo de células T, cuyos síntomas fueron pérdida dememoria y alteraciones del campo visual periférico. Doslesiones sospechosas de metástasis fueron identificadaspor resonancia magnética.Intervención. Mediante dos craneotomías independientes,ambas lesiones se resecaron in toto con buenresultado post-quirúrgico.Conclusión. El glioblastoma epiteloide es uno de lossubtipos morfológicos mas raros de glioblastoma. Losautores describen aquí el primer caso de glioblastomaepiteloide multifocal con apariencia de metástasissecundaria. Este diagnóstico debe ser incluido en eldiferencial de pacientes con lesiones multifocales. Elintento de resección total se recomienda cuando éste seaviable para obtener un diagnóstico definitivo así comopara mejorar la supervivencia libre de enfermedad enpacientes cuya presentación incluya lesiones múltiplesque puedan dirigir a un tratamiento inadecuado (AU)

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.

Bilateral paramedian thalamic and mesencephalic infarcts after basilar tipaneurysm 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. Recentreports describe a significant rate of thromboembolic complications. Thalamic and midbrain blood supplycan arise from complex anatomical variations. The rarevariation: "artery of Percheron", is a solitary arterialtrunk arising from one of the proximal segments of aposterior cerebral artery and supplies the paramedianthalami and rostral midbrain bilaterally. We describe apatient that underwent elective endovascular treatment for a basilar tip aneurysm using GDC and stents ineach PCA; 12 hours later patient was comatose and notfollowing commands. Sequential magnetic resonance imaging (MRI) of brain showed bilateral paramedian thalamic and mesencephalic infarcts presumably secondaryto artery of Percheron occlusion. Thromboembolic event related to the use of the GDC embolization and stents is a rare clinical sequelae, but catastrophic. Theuse of antiplatelets agents should be reinforced in the scenario. When bilateral medial thalamic and midbraininfarcts are found, occlusion of the artery of Percheron should be considered. Angiography may not b help fuland lack of visualization of the artery does not excludeits presence. In this case the MRI findings confirmedthe presence of the infarction based on the anatomical distribution (AU)

La técnica endovascular para el manejo de aneurismas está ganando auge como una alternativa a la cirugía abierta. Sin embargo, se han descrito diferentes complicaciones tromboembólicas relacionadas con esta modalidad. El flujo sanguíneo al tálamo y almesencéfalo puede surgir de variaciones anatómicas complejas. La variación infrecuente: "arteria de Percheron", es una rama arterial solitaria que se originadel segmento proximal de una de la arterias cerebralesposteriores.Presentamos un paciente que tuvo un procedimiento endovascular electivo para el tratamiento de un aneurisma de la punta de la arteria basilar; 12 horas después del procedimiento, el paciente estaba clínicamente encoma profundo. La resonancia magnética (RM) cerebral mostró infartos talámicos paramediales bilaterales y mesencefálicos, compatible con la oclusión de la arteriade Percheron.Los eventos tromboembólicos relacionados con eluso de embolización con coil y stents es una rara pero catastrófica secuela. El uso de agentes antiplaquetarios se debe de recomendar en este tipo de situaciones. Cuando existen infartos talámicos paramediales bilaterales y mesencefálicos, la oclusión de la arteria de Percheron sedebe de tener en mente. La angiografía puede no ser demucha utilidad y la falta de visualización de la arteria no excluye su presencia. En este caso los hallazgos en la RM cerebral confirman la presencia de un infarto basado en la distribución anatómica de la arteria de Percheron (AU)

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.

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

We report the case of an eighteen year-old pregnantfemale with preeclampsia and florid signs andsymptoms of posterior reversible encephalopathy syndrome(PRES) in whom intracerebral hemorrhage wasevidenced following delivery. Management includedblood pressure control, external ventricular drainageand lumboperitoneal shunt. To our knowledge this isthe first report of intracranial hemorrhage occurringconcurrently with peripartum acute PRES. This casewas successfully treated with good outcome upon conclusionof management, thus making awareness of thispotentially fatal complication and its suggested managementfor successful outcome necessary for neurosurgeons,neurologists and intensivists alike (AU)

Describimos el caso de una mujer embarazada de18 años con preeclampsia y signos y síntomas floridosde leucoencefalopatía posterior reversible (LPR) en laque se evidenció la presencia de hemorragia cerebraltras el parto. El tratamiento de la enferma incluyó elcontrol de la presión arterial, la utilización de drenajeventricular externo y la colocación de una válvulalumboperitoneal. En nuestro conocimiento esta es laprimera descripción en la literatura de la concurrenciade hemorragia intracraneal con la LPR. Este casofue satisfactoriamente tratado con un buen resultado,haciendo que la sospecha y el conocimiento de esta posible fatal complicación y su correcto tratamientosea importante para neurocirujanos, neurólogos eintensivistas (AU)

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.

Fracturas de rótula en niños. Nuestra experiencia / Fractures of the patella in children. Our experience

Las fracturas de rótula son poco frecuentes enla infancia y la adolescencia. Estas se producen enniños tras un traumatismo directo, tras un mecanismoindirecto por contracción brusca del aparatoextensor, o tras una luxación rotuliana. Estosmecanismos lesionales tienen lugar con frecuenciadurante la práctica deportiva habitual de los escolaresy adolescentes. Se ha realizado un estudio retrospectivode las fracturas de rótula en pacientesmenores de 16 años tratadas en el Hospital ClínicoUniversitario, relacionando los tipos de traumatismo,los diferentes patrones de fractura y tratamientosrealizados. Los resultados obtenidos sonbuenos como en el resto de las series si se siguenlas indicaciones correctas diagnósticas y terapéuticas.Es importante conocer este infrecuente tipode fracturas para los médicos que tratan lesionesdeportivas en niños, pues el conocimiento de éstasasegura un correcto diagnóstico y tratamiento

Fractures of the patella are rare injuries in childrenand adolescents. These injuries may arrive asthe result of a direct trauma blow on the front ofthe knee, by a sudden and violent flexión of theknee or after patella dislocation. These situationsare relativelt common in sporting activity in thatrange of age. We have reviewed retrospectivelyfractures of the patella in patients younger than 16years attented in Hospital Clínico Universitario,comparing the mechanism of production, with thedifferent patterns of fractures and treatment. Theresults obteined were good, as in the rest of literatureif correct diagnosis and treatment are weredone. It´s important to be aware of these rare fracturesthe doctors who attend sport injuries in children,because its knowledge warrant a good prognosis

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.

A propósito de un caso de lesiones cutáneas y calcifilaxis / No disponible

La calcifilaxis es una inusual complicación de la insuficiencia renal crónica asociada a una elevada morbi-mortalidad. El caso clínico que presentamos, describeuna paciente paratiroidectomizada en 1997, que en abril de 1999 es diagnosticada de calcifilaxis tras sospecha clínica y confirmación mediante biopsia cutánea. La persistencia de niveles de PTH superiores a 400 pg/mI, junto con unas imágenes gammagráficas sospechosas de nódulos paratiroideos, determinan una nueva intervención quirúrgica (extirpándose dos nódulos), tras la cual, remite por completo la sintomatología, a pesar de que los nódulos extraídos fueron identificados como tejido tiroideo. Corroboramos el hecho de que la patogenia de la calcifilaxis es multifactorial, adquiriendo especial relevancia el uso de quelantes cálcicos (con un riesgo elevado de presentar hipercalcemia) en el tratamiento de la insuficiencia renal crónica (AU)

Calciphylaxis is an unusual complication of chronic renal failure associted with increased morbidity and mortality. This presentation is a clinical case describinga 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 scintigraphyc 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 phospa ¡the binders (representing a high risk of hypercalcemia)in the treatment of Chronic Renal Disease (AU)

[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.

Aislamiento del herpesvirus humano tipo 6 en la sangre de pacientes receptores de trasplante renal

No disponible

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.

La enfermedad por citomegalovirus en el trasplante renal / Cytomegalovirus infection in renal transplant patients

El citomegalovirus (CMV) es el mayor patógeno viral después de un trasplante renal. Se estima que el CMV causa enfermedad sintomática en un porcentaje que varía según los trabajos desde un 8-35 por ciento y ocasiona la muerte en el 2 por ciento de los pacientes. Los factores de riesgo de la infección por CMV son el estado serológico del donante y receptor, el tratamiento inmunosupresor y la carga viral. La prevención de la infección y/o enfermedad por CMV en el trasplante renal se puede plantear mediante tres estrategias: profilaxis universal, profilaxis dirigida o tratamiento precoz.Hay tres tipos de medidas profilácticas para prevenir la infección y enfermedad por CMV en los pacientes trasplantados que deben utilizarse de forma combinada: la disminución en el riesgo de adquisición o reactivación del virus, la inducción de protección inmunológica (vacunación e inmunoprofilaxis pasiva con inmunoglobulinas inespecíficas o hiperinmunes) y ¡a utilización de fármacos antivirales; los fármacos utilizados en la profilaxis han sido: aciclovir oral, ganciclovir i.v., oral y valaciclovir. En base a la evidencia disponible se recomienda realizar profilaxis en los siguientes grupos, dependiendo del estado serológico del donante y receptor: - Donante CMV+ y receptor CMV-- (D+/R-): profilaxis recomendada.-- Donante CMV- y receptor CMV+ (D-/R+): depende.- Donante CMV+ y receptor CMV+ (D+/R+): depende de la inmunosupresión.-- Donante CMV- y receptor CMV'- (D-/R-): no hacer profilaxis (AU)

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.

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.