Hyperinsulinemia, circadian variation of blood pressure and end-organ damage in hypertension.

BACKGROUND: Some patients with essential hypertension display hyperinsulinemia and/or insulin resistance. A relationship between hyperinsulinemia and blood pressure has not been conclusively established. Some evidence points to a relationship between hyperinsulinemia and evidence of cardiovascular damage. OBJECTIVES: In this study, we examined the relationship between insulin secretion in response to an oral glucose load, circadian variation of blood pressure, and evidence of vascular damage, measured by the thickness of the carotid artery and urinary albumin excretion. DESIGN: Seventy patients with essential hypertension and 35 healthy volunteers were included in the study. RESULTS: Twenty patients were hyperinsulinemic. Office blood pressure was not different between hypertensive patients with high and those with normal insulin AUC. However, night-time diastolic blood pressure was greater in hypertensive patients with high insulin AUC (93 +/- 2.9 mm Hg) than in those with normal insulin AUC (83.5 +/- 1.7 mm Hg, P < 0.005). The thickness of the carotid artery and urinary albumin excretion were greater (P < 0.05) in patients with high insulin AUC than in patients with normal insulin AUC and normotensive subjects. Insulin AUC was significantly correlated with ambulatory blood pressure, carotid artery thickness, and urine albumin excretion. Multiple regression analysis using insulin AUC as the dependent variable and UAE, triglycerides, body-mass index and office or ambulatory blood pressure as independent variables showed the strongest correlation with urine albumin excretion (P < 0.0001), triglycerides (P < 0.02) and body-mass index (P < 0.07). CONCLUSIONS: These data suggest that in patients with essential hypertension hyperinsulinemia is associated with higher levels of nocturnal blood pressure, and greater evidence of vascular damage.

Increased thickness of the carotid artery in patients with essential hypertension and microalbuminuria.

In patients with essential hypertension, the presence of microalbuminuria carries an increased risk for cardiovascular morbidity and mortality. The mechanisms responsible for this association are not clear. Microalbuminuria could signal the presence of generalised atherosclerosis. To determine the extent of atherosclerosis, we measured by B-mode ultrasound imaging the thickness of the intima and media layers of the carotid artery in 30 hypertensive patients with microalbuminuria, 30 patients without microalbuminuria and 30 normotensive healthy subjects. In hypertensive patients with microalbuminuria, urinary albumin excretion (55 +/- 4.7 mg/24 h) was greater (P < 0.01) than in patients without microalbuminuria (12 +/- 0.9 mg/24 h) and in healthy subjects (7.1 +/- 0.52 mg/24 h). In hypertensive patients with microalbuminuria, the thickness of the carotid artery (0.78 +/- 0.02 mm) was greater (P < 0.01) than in patients without microalbuminuria (0.69 +/- 0.01 mm) and in healthy subjects (0.64 +/- 0.02 mm). In hypertensive patients with microalbuminuria, the mean insulin area-under-the curve (59,703 +/- 4,874 pmol/L x 2 h) and glucose area-under-the curve (928 +/- 40.0 mmol/L x 2 h) were significantly greater (P < 0.005) than in patients without microalbuminuria (38,774 +/- 4,104 pmol/L x 2 h and 803 +/- 34.7 mmol/L x 2 h, respectively), and in normotensive healthy subjects (27,557 +/- 2563 pmol/L x 2 h and 837 +/- 31.2 mmol/L x 2 h, respectively). Serum levels of total cholesterol, triglycerides and lipoprotein(a) were higher in hypertensives with than in those without microalbuminuria. The thickness of the carotid artery was significantly correlated with microalbuminuria, blood pressure, cholesterol, serum triglycerides and insulin area-under-the curve. In conclusion, this study shows that hypertensive patients with microalbuminuria have an increased thickness of the carotid intima and media layers suggesting a greater degree of atherosclerosis. Measurements of urinary albumin excretion may be important in the evaluation of patients with essential hypertension.

Neuroma of the facial nerve masked by chronic otitis media.

The absence of facial twitching, weakness, or palsy makes the diagnosis of facial neuroma difficult. The authors report a case of neuroma of the horizontal portion of the facial nerve masked by the presence of a chronic ear. A woman with a long history of discharge and hypoacousia in her left ear presented with acute dizziness. Examination revealed grade 3 horizontal right nystagmus, left anacousia, and the appearance of an epitympanic cholesteatoma. Computed tomography (CT) was performed after the vestibular condition improved. The clinical diagnosis of chronic otitis media with cholesteatoma together with the radiologic finding of the mastoid and tympanic cavity completely occupied by soft tissue were enough to send the radiologist astray. The radiologic diagnosis confirmed that the bony destruction of the vestibule and lateral semicircular canal could be caused by a cholesteatoma. A neuroma of the horizontal portion of the facial nerve was discovered during surgery performed for the chronic ear. The postoperative study of the CT scans showed that there was no erosion of the malleus or incus, despite wide erosion of the vestibule and lateral semicircular canal. This finding would be enough to suggest the presence of pathology other than cholesteatoma. The patient refused exeresis of the neuroma. The authors recognize the difficulty in urging a patient to an operation that surely will result in worsening of the facial function. Follow-up in this case has revealed no change in tumor dimension or facial function over 3 years.

[Venous angioma associated with cavernous angioma. Presentation of three cases]. / Associazione di angioma venoso ed angioma cavernoso. Presentazione di tre casi.

Cavernous angiomas and venous angiomas may be discovered as associated lesions in the same patient. Most Authors report that Venous angiomas are not true vascular malformation; they should be considered as variant of normal venous drainage, consisting of tortuous medullary veins converging into a dilated draining one. By rule, they are quite asymptomatic, and very rarely bleed. On the other side, cavernous angiomas are true vascular malformations, usually angiographically occult. Their association is relatively rare, but it is important because of the possibility of bleeding, which should be related to the presence of the cavernous malformation. We report the cases of three patients studied by Computed Tomography, Magnetic Resonance and Digital Angiography in our Neuroradiologic Department.

Ultrasonography of the gallbladder in pregnancy.

The appearance of the gallbladder was monitored by serial ultrasound examinations in 36 women at various times during their normal pregnancy and postpartum. The gallbladder remained within normal limits in size, but there was a progressive increase in its longitudinal and transverse diameters. The contractibility of the gallbladder was also assessed and found to be satisfactory in most cases. However, the formation of sludge was demonstrated in several instances beyond the 20-25th weeks of pregnancy. Gallstones were detected in 2 patients, 1 of whom had initially normal findings on cholecystosonography during her first trimester.