Arteriovenous fistulas of the Vein of Galen region in adults: Endovascular treatment.

PURPOSE: Arteriovenous fistulas of the Vein of Galen region in adults (Ad-VGAVF) are an uncommon entity with specific anatomic features. The aim of this article is to present our experience in the endovascular treatment of this pathology and to propose a therapeutic strategy based precisely on the angioarchitecture of these lesions. MATERIALS AND METHODS: During a 20-year period, 10 patients underwent endovascular treatment of Ad-VGAVF. They were nine men and one woman with a mean age of 50 years (23-66 years) treated with the same embolization strategy. Clinical presentation, angiographic characteristics, therapeutic strategy, and clinical outcomes were recorded. RESULTS: All patients were treated exclusively by endovascular approach. Transarterial access was performed in eight patients and combined transvenous and transarterial access in two. Complete obliteration of the fistula was obtained in all patients. There were no intraprocedural complications. Post-embolization neurological symptoms occurred in 5 of 10 with complete resolution at six months in all of them. CONCLUSION: Arteriovenous fistulas of the Vein of Galen region in adults present uniform angioarchitecture despite their low prevalence. Based on this constant angioarchitecture and especially on the features of its venous drainage, judicious embolization strategy is feasible and effective. Ten cases treated entirely by endovascular approach with excellent clinical and angiographic outcomes show this treatment like a curative alternative for this entity of deep topography and severe prognosis.

Potentially serious incidental findings on brain and body magnetic resonance imaging of apparently asymptomatic adults: systematic review and meta-analysis.

OBJECTIVES: To determine prevalence and types of potentially serious incidental findings on magnetic resonance imaging (MRI) in apparently asymptomatic adults, describe factors associated with potentially serious incidental findings, and summarise information on follow-up and final diagnoses. DESIGN: Systematic review and meta-analyses. DATA SOURCES: Citation searches of relevant articles and authors' files in Medline and Embase (from inception to 25 April 2017). REVIEW METHODS: Eligible studies included prevalence and types of incidental findings detected among apparently asymptomatic adults undergoing MRI of the brain, thorax, abdomen, or brain and body. Data on study population and methods, prevalence and types of incidental findings, and final diagnoses were extracted. Pooled prevalence was estimated by random effects meta-analysis, and heterogeneity by τ2 statistics. MAIN OUTCOME MEASURES: Prevalence of potentially serious incidental findings on MRI of the brain, thorax, abdomen, and brain and body. RESULTS: Of 5905 retrieved studies, 32 (0.5%) met the inclusion criteria (n=27 643 participants). Pooled prevalence of potentially serious incidental findings was 3.9% (95% confidence interval 0.4% to 27.1%) on brain and body MRI, 1.4% (1.0% to 2.1%) on brain MRI, 1.3% (0.2% to 8.1%) on thoracic MRI, and 1.9% (0.3% to 12.0%) on abdominal MRI. Pooled prevalence rose after including incidental findings of uncertain potential seriousness (12.8% (3.9% to 34.3%), 1.7% (1.1% to 2.6%), 3.0% (0.8% to 11.3%), and 4.5% (1.5% to 12.9%), respectively). There was generally substantial heterogeneity among included studies. About half the potentially serious incidental findings were suspected malignancies (brain, 0.6% (95% confidence interval 0.4% to 0.9%); thorax, 0.6% (0.1% to 3.1%); abdomen, 1.3% (0.2% to 9.3%); brain and body, 2.3% (0.3% to 15.4%)). There were few informative data on potential sources of between-study variation or factors associated with potentially serious incidental findings. Limited data suggested that relatively few potentially serious incidental findings had serious final diagnoses (48/234, 20.5%). CONCLUSIONS: A substantial proportion of apparently asymptomatic adults will have potentially serious incidental findings on MRI, but little is known of their health consequences. Systematic, long term follow-up studies are needed to better inform on these consequences and the implications for policies on feedback of potentially serious incidental findings. SYSTEMATIC REVIEW REGISTRATION: Prospero CRD42016029472.

Cystic degeneration of hepatic adenoma: a rare complication of hepatic adenoma.

This case report describes a rare complication of hepatic adenomata in a 33-year-old female. The patient initially presented with abdominal pain, and baseline imaging demonstrated several hepatic adenomas, the largest of which (approximately 8 cm) was adjacent to the inferior vena cava. Owing to the location of this adenoma, surgical/vascular intervention was deemed inappropriate. The patient was actively observed for approximately 4 years, and managed supportively during any recurrent episodes. With follow-up CT/MRI scans, the "natural history" of this particular lesion, including haemorrhage, thrombosis and infarction, was observed. However, as intervention was unsuitable, further MRI was performed in view of these complications, allowing observation of the end-stage features of the adenoma. Appearances were consistent with a rare complication of hepatic adenoma, i.e. cystic degeneration, a process well documented in uterine leiomyoma.

Elective and Emergency Renal Angiomyolipoma Embolization with Ethylene Vinyl Alcohol Copolymer: Feasibility and Initial Experience.

PURPOSE: To report preliminary experience with angiomyolipoma (AML) transcatheter arterial embolization using ethylene vinyl alcohol (EVOH) copolymer liquid embolic agent. MATERIALS AND METHODS: Embolization was performed in 22 consecutive patients (mean age, 53.5 y; 16 women and 6 men) for symptomatic AMLs or AMLs > 4 cm. Mean AML size before treatment was 7 cm (range, 3.5-13 cm). Superselective embolization of all lesions using microcatheters was performed; EVOH copolymer was the only embolic agent used. Data collected included volume of EVOH copolymer used, AML size before and after treatment, bleeding control, rebleeding, renal function, and complications. RESULTS: Twenty-seven embolizations were performed for 25 AMLs. In 3 patients, embolization of 2 different AMLs was performed. A mean volume of 2.5 mL (range, 1-8 mL) of 6% EVOH copolymer was administered per lesion. Of embolizations, 17 (63%) were elective, and 10 (37%) were urgent. For urgent cases, primary and secondary bleeding control rates were 80% and 100%, respectively. Two urgent embolizations had early rebleeding from different previously treated vessels and a successful second embolization was performed. Mean follow-up time was 37.7 months (range, 5-124 months). Rate of postembolization syndrome was 18.5%. Mean size reduction of 45.7% ± 21.5 over the maximum length of the AML before treatment was achieved. No AML regrowth occurred during follow-up. Minor and major complication rates were 7.4% and 0%, respectively. No rebleeding and no renal function impairment occurred during follow-up. CONCLUSIONS: AML embolization with EVOH copolymer is feasible, safe, and effective. EVOH copolymer could be another embolic option for AML treatment.

Metabolism gene signatures and surgical site infections in abdominal surgery.

INTRODUCTION: Surgical site infections (SSI) represent a significant cause of morbidity in abdominal surgery. The objective of this study was to determine the gene expression signature in subcutaneous tissues in relation to SSI. METHODS: To determine differences in gene expression, microarray analysis were performed from bulk tissue mRNA of subcutaneous tissues prospectively collected in 92 patients during open abdominal surgery. 10 patients (11%) developed incisional (superficial and deep) SSI. RESULTS: Preoperative risk factors in patients with SSI were not significantly different from those in patients without wound infections. 1025 genes were differentially expressed between the groups, of which the AZGP1 and ALDH1A3 genes were the highest down- and upregulated ones. Hierarchical clustering demonstrated strong similarity within the respective groups (SSI vs. no-SSI) indicating inter-group distinctness. In a functional classification, genes controlling cell metabolism were mostly down-regulated in subcutaneous tissues of patients that subsequently developed SSI. CONCLUSION: Altered expression of metabolism genes in subcutaneous tissues might constitute a risk factor for postoperative abdominal SSI.

Results for a series of 697 arteriovenous malformations treated by gamma knife: influence of angiographic features on the obliteration rate.

BACKGROUND: Stereotactic radiosurgery (RS) is an effective tool in treating brain arteriovenous malformations (AVMs). Careful study of AVM angiographic characteristics may improve results. OBJECTIVE: To report the long-term outcomes of Gamma Knife RS (GKRS) in brain AVMs, focusing on how the angioarchitectural and hemodynamic parameters of AVMs affect the post-RS results. METHODS: This was a retrospective, longitudinal study of 697 consecutive GKRS treatments of brain AVMs in 662 patients performed at a single center between 1993 and 2005. The mean age of the patients was 37 years; the median AVM volume was 3.6 cm(3); and the mean follow-up was 11 years. Forty-five percent of patients presented with intracranial hemorrhage; 44% underwent embolization; and 7% had multiple RSs. AVM characteristics in the RS-planning angiograms were analyzed, and their relationship to the post-RS obliteration rate was determined by univariate and multivariate analyses. RESULTS: The obliteration rate after a single RS was 69.3%; after multiple RS, it was 75%. Positive predictors of obliteration included compact nidus (odds ratio = 3.16; 95% confidence interval, 1.92-5.22), undilated feeders (odds ratio = 0.36; 95% confidence interval, 0.23-0.57), smaller AVM volume (odds ratio = 0.95; 95% confidence interval, 0.92-0.99), and higher marginal dose (odds ratio = 1.16; 95% confidence interval, 1.06-1.27). Improvement or clinical stability was observed in 89.3% of patients; postprocedural bleeding was noted in 6.1%; and clinical worsening attributable to RS was seen in 3.8%. The annual risk of hemorrhage in the 4 years after RS was 1.2%. CONCLUSION: GKRS yielded a good long-term clinical outcome in most patients. Certain angiographic features of brain AVMs such as a well-defined nidus and undilated feeder arteries contribute to AVM occlusion by RS. GKRS can be regarded as the treatment of choice for AVMs <6 cm(3), even after bleeding.

Hematocrit predicts long-term mortality in a nonlinear and sex-specific manner in hypertensive adults.

Hematocrit has been inconsistently reported to be a risk marker of cardiovascular morbidity and mortality. The Glasgow Blood Pressure Clinic Study cohort included 10951 hypertensive patients, who had hematocrit measured at their initial clinic visit and followed for ≤35 years. Cox proportional hazards models were used to estimate hazard ratios for all-cause, cardiovascular, ischemic heart disease, stroke, and noncardiovascular mortality. There were 3484 deaths over a follow-up period of 173245 person-years. Hematocrit was higher in men (median, 0.44; interquartile range, 0.42-0.47) than in women (median, 0.41; interquartile range, 0.38-0.43). The lowest risk for all-cause mortality was seen in quartile 2 for men (range, 0.421-0.440) and women (range, 0.381-0.400). Compared with quartile 2, the adjusted hazard ratios for quartiles 1, 3, and 4 were, respectively, 1.11 (range, 0.97-1.28), 1.19 (range, 1.04-1.37), and 1.22 (range, 1.06-1.39) in men and 1.17 (range, 1.01-1.36), 0.97 (range, 0.83-1.13), and 1.19 (range, 1.04-1.37) in women. Men showed a J-shaped pattern for cardiovascular mortality and a linear pattern for noncardiovascular mortality in cause-specific analysis, whereas in women a U-shaped pattern was observed for noncardiovascular mortality only. Higher baseline hematocrit was associated with higher on-treatment blood pressure during follow-up. Baseline hematocrit did not affect the time to reach target blood pressure. The increased risk of death attributed to higher hematocrit was seen in men and women irrespective of their achievement of target blood pressure, indicating that the risk is independent of the effect of hematocrit on blood pressure. Hypertensive patients with hematocrit levels outside of the sex-specific reference ranges identified in this study should be targeted for more aggressive blood pressure and cardiovascular risk reduction treatment.

Eyelash trichomegaly: review of congenital, acquired, and drug-associated etiologies for elongation of the eyelashes.

Eyelash trichomegaly is defined as eyelashes which are found to be of increased length, thickness, and pigmentation. This unique finding can be present at birth as part of a variety of congenital syndromes or as a benign familial trait. There are also acquired conditions and drugs that are known to cause these changes. Case reports and clinical studies in the medical literature concerning eyelash trichomegaly were investigated and summarized to compile a comprehensive review of the etiology of eyelash trichomegaly. Previously published reviews and studies that report on the finding of increased generalized hair growth and which do not specifically mention eyelashes were not included. Trichomegaly of the eyelashes may occur as a key feature among rare congenital syndromes, develop in association with certain acquired diseases, or present as an intended or treatment-related adverse drug effect. Eyelash trichomegaly may be present from birth or manifest later in life in association with acquired diseases or drug therapy. The relevance of this finding may be benign, however eyelash trichomegaly in some individuals can be a symptom for immune dysfunction or a clinical measure of response to drug therapy.

Paclitaxel-associated subungual pyogenic granuloma: report in a patient with breast cancer receiving paclitaxel and review of drug-induced pyogenic granulomas adjacent to and beneath the nail.

Subungual and periungual pyogenic granuloma occur in association with certain systemic medications. Paclitaxel is an antitumor drug of the taxane family used in the management of breast cancer. Taxanes have many associated nail changes that may occur in patients receiving either docetaxel or paclitaxel for systemic chemotherapy. The nail changes in a 68-year-old woman with metastatic breast cancer who presented for nail changes after receiving 12 cycles of weekly paclitaxel are described herein: nail plate red-brown discoloration, onycholysis with leukonychia, proximal subungual hemorrhage, and subungual pyogenic granuloma. The literature on systemic medications associated with the development of subungual and periungual pyogenic granulomas is reviewed; drugs associated with the development of pyogenic granuloma at the locations include antineoplastics, antiretrovirals, epidermal growth factor receptor inhibitors, immunosuppressants and retinoids. In conclusion, subungual pyogenic granuloma can occur not only in patients receiving docetaxel, but also in patients treated with paclitaxel. And, paclitaxel should be included in the list of drugs associated with the occurrence of subungual pyogenic granuloma.

The Pharmacogenomics of Anti-Hypertensive Therapy.

Hypertension is a major public health problem, but measures to reduce blood pressure and thus cardiovascular risk are complicated by the high prevalence of treatment resistance, despite the availability of multiple drugs. Drug side-effects contribute considerably to suboptimal blood pressure control. Clinicians must often rely on empirical methods to match patients with effective drug treatment. Hypertension pharmacogenomics seeks to find genetic predictors of response to drugs that lower blood pressure and to translate this knowledge into clinical practice. In this review we summarise the current status of hypertension pharmacogenetics from monogenic hypertension to essential hypertension and discuss the issues that need to be considered in a hypertension pharmacogenomic study.

Resting heart rate pattern during follow-up and mortality in hypertensive patients.

There is a linear relationship between resting heart rate (HR) and mortality in normotensive and untreated hypertensive individuals. However, it is not clear whether HR is a marker of increased risk in hypertensive patients on treatment. We investigated the relationship between HR and mortality in patients with hypertension. We analyzed baseline HR, final HR, and HR change during follow-up in patients attending the Glasgow Blood Pressure Clinic. Using a threshold of 80 bpm, we classified patients into those who had a consistently high (high-high) or low (low-low) HR or patients whose HR increased (low-high) or decreased (high-low) over time. Survival analysis was carried out using Cox proportional hazards models adjusted for age, sex, body mass index, smoking, rate-limiting therapy, systolic blood pressure, and serum cholesterol. For each beat of HR change there was a 1% change in mortality risk. The highest risk of an all-cause event was associated with patients who had increased their HR by >or=5 bpm at the end of follow-up (1.51 [95% CI: 1.03 to 2.20]; P=0.035). Compared with low-low patients, high-high patients had a 78% increase in the risk of all-cause mortality (HR: 1.78 [95% CI: 1.31 to 2.41]; P<0.001). Cardiovascular mortality showed a similar pattern of results. Rate-limiting therapy did not have an independent effect on outcomes in this analysis. Change in HR achieved during follow-up of hypertensive patients is a better predictor of risk than baseline or final HR. After correction for rate-limiting therapy, HR remained a significant independent risk factor.

Complete necrosis of a spinal giant cell tumor after vertebroplasty.

In this case report, histologic evidence of complete tumor necrosis subsequent to injection of polymethylmethacrylate in a vertebral giant cell tumor is described. Radiologic and histologic findings are discussed, and literature pertaining to vertebroplasty-induced cell damaged is reviewed.

Uterine fibroids: uterine artery embolization versus abdominal hysterectomy for treatment--a prospective, randomized, and controlled clinical trial.

PURPOSE: To evaluate the effectiveness of uterine artery embolization (UAE) in the management of bleeding in patients with uterine fibroids and to compare UAE with hysterectomy, particularly with regard to length of hospital stay and associated complications (ie, safety). MATERIALS AND METHODS: A prospective clinical trial was performed with patients who were randomly assigned to one of two groups: patients who were offered the option of undergoing either UAE or hysterectomy (group 1) and patients who were not informed of the alternative treatment-that is, UAE (group 2). The primary variables that were considered for evaluation of the effectiveness, efficiency, and safety of the two procedures were, respectively, bleeding cessation, total length of hospital stay, and resulting complications. The lengths of hospital stay in the two study arms were compared on an intent-to-treat basis. Owing to crossover between the treatment arms, however, effectiveness and safety were evaluated on the basis of the actual treatment received. RESULTS: The clinical success rate for the patients who underwent UAE, which was based on the cessation of bleeding, was 86% (31 of 36 patients). The mean hospital stay for group 1 was 4.14 days shorter than that for group 2 (P <.001). Ten (25%) of the 40 patients who underwent UAE experienced minor complications, in contrast to four (20%) of the 20 who underwent hysterectomy and experienced major complications. CONCLUSION: Compared with hysterectomy, UAE is safe and effective for treatment of bleeding fibroids, necessitates a shorter hospital stay, and results in fewer major complications.

Embolización de arterias uterinas como tratamiento de miomas sintomáticos / Embolization of uterine arteries to treat symptomatic myomas

Objetivos: 1. Medir la eficacia de la embolización de las arterias uterinas en el control del sangrado vaginal a corto y medio plazo, causado por miomas uterinos. 2. Evaluar la seguridad de este procedimiento, analizando las complicaciones del mismo. Material y métodos: La población de estudio consiste en 40 mujeres sometidas a embolización de las arterias uterinas, consecutivamente enviadas desde las consultas de ginecología. Todas tenían miomas uterinos sangrantes, y eran candidatas a histerectomía. Se excluyeron pacientes con deseos de mantener la fertilidad, con miomas mayores de 10 cm de diámetro, con contraindicaciones quirúrgicas o con alergias a contrastes yodados. Las variables principales medidas en relación con los objetivos, han sido, el control del sangrado vaginal postembolización, y la frecuencia y tipo de complicaciones relacionadas con dicha intervención. Resultados: El éxito técnico en cuanto a la embolización de ambas arterias uterinas fue de un 87,5 por ciento (35/40). El éxito clínico, o el cese del sangrado, valorado en 36 pacientes a los seis meses de seguimiento, fue de un 86,1 por ciento (31/36). La complicación más frecuente, durante el procedimiento fue el espasmo de las arterias uterinas 17,5 por ciento (10/40) y el síndrome postembolización 25 por ciento (10/40) en el seguimiento postintervención. Conclusiones: La embolización de las arterias uterinas es un tratamiento seguro, y puede ser una terapia alternativa a la histerectomía, en pacientes con miomas uterinos con sangrado vaginal. (AU)

Metallic stents in the treatment of benign diseases of the colon: preliminary experience in 10 cases.

PURPOSE: To assess the effectiveness of and complications associated with metallic stent placement for treatment of benign diseases of the colon. MATERIALS AND METHODS: With radiologic guidance, the authors placed metallic stents in 10 patients with benign diseases of the colon: Nine stents were placed in the rectosigmoid colon, and one was placed in the descending colon. The stents were placed in two cases of diverticulitis complicated by pelvic abscess, four cases of colonic fistula following surgery, and four cases of postsurgical anastomotic stricture. Coated stents were placed in the cases involving fistulas and diverticulitis. RESULTS: In the two cases of diverticulitis complicated by pelvic abscess, the coated stents helped to resolve the abscesses, but both patients subsequently developed complications: fistula and perforation. Of the four cases of colonic fistula, two were resolved with stent placement. In the four cases of postsurgical stenosis, the stents temporarily relieved the symptoms of obstruction, but additional treatments were required before the patients became entirely asymptomatic. CONCLUSION: Metallic stents may represent an effective temporary treatment for certain benign colonic conditions in the absence of other therapeutic alternatives.

Nasolacrimal stents in the treatment of epiphora: long-term results.

PURPOSE: Assessment of the long-term results achieved with use of nasolacrimal stents in the treatment of epiphora caused by obstruction of the lacrimal apparatus. The role of stents in treating this condition is evaluated. MATERIALS AND METHODS: From February 1997 to April 1999, a total of 89 procedures to insert nasolacrimal stents were performed in 77 patients (20 men, 57 women; mean age, 53 years). A total of 79 stents were successfully implanted, with 10 failures (11.2%). Postprocedural course was followed for 16-38 months (mean, 27 mo) by means of clinical examinations and/or periodic dacryocystography, with removal of occluded stents. On conclusion of the study in September 2000, dacryocystography was performed in all patients in whom stents were still in place. RESULTS: Of the 79 stents deployed, two were lost, two had to be excluded from the study, 45 (60%) ceased to function, and 30 (40%) remained patent. Median duration of stent patency of these 79 stents was 20 months. Mean time to occlusion was 9.2 months for all obstructed stents; 4.4 months for improperly placed stents (via a trajectory outside the normal lacrimal drainage apparatus) and 12.2 months for stents that appeared to have been inserted properly. Of the 45 occluded stents, 40 were removed and five were left in place. Upon removal, adherence of the stents to the lacrimal apparatus was frequently observed. CONCLUSIONS: The low patency rate and the difficulties encountered in removing nasolacrimal stents during the course of long-term placement calls into question the efficacy of this method as a definitive treatment for epiphora caused by obstruction of the lacrimal drainage system, although studies comparing this and other treatment modalities are needed. Assessment of temporary stent placement may be in order.