High-flow carotid cavernous fistula and 'white eye': A rare and easily misdiagnosed presentation - A case report and literature review.

The three classic symptoms of carotid cavernous fistula (CCF) are pulsating exophthalmos, bruit and conjunctival chemosis. Here, we present a clinical case of isolated abducens nerve palsy due to a high-flow CCF in an 84-year-old woman, without the typical congestive orbito-ocular features. It was a diagnostic challenge because, for patients older than 50 years with cardiovascular risk factors, ischaemic mononeuropathy is the most frequent aetiology. This case illustrates the least common type of CCF that can be easily misdiagnosed. Physicians should consider fistula as a possible diagnosis in a patient with isolated abducens nerve palsy even without the classic triad.

Bilateral carotid body tumor case: A novel preoperative management.

Paragangliomas are rare neuroendocrine neoplasms. The most common form of these tumors in head and neck are non-functional carotid body tumors. These neoplasms may present an extensive growth and compromise vital neurovascular structures in the neck, such as carotid vessels. Carotid body tumors usually present clinically as painless neck masses and occur most frequently in adults averaging 45 to 50 years, being the majority of these tumors unilateral and only 5% of all cases bilateral. The main treatment for carotid body paragangliomas is surgical resection, which can be extremely challenging due to tumor hypervascularity and significant blood loss. We present a bilateral carotid body tumor case in a 61-year-old woman who presented due to a pulsatile and painless mass in the right carotid region of the neck of 1-year of evolution. The tumor was found encasing the external carotid artery and classified as Shamblin II. A novel approach for preoperative management was performed, placing a covered graft-stent in the right common and proximal (C1) internal carotid arteries in order to splint and provide structural protection for carotid vessels during surgical resection and temporarily reduce blood flow of the carotid body tumor.

High-output heart failure due to arteriovenous malformation treated by endovascular embolisation.

High-output heart failure (HF) is an uncommon condition. This occurs when HF syndrome patients have a cardiac output higher than eight litres per minute. Shunts, such as fistulas and arteriovenous malformations are an important reversible cause. We present the case of a 30-year-old man who presented to the emergency department due to decompensated HF. Echocardiogram showed dilated myocardiopathy with high cardiac output (19.5 L/min calculated on long-axis view). He was diagnosed with arteriovenous malformation by computed tomography (CT) and subsequent angiography, and a multi-disciplinary team decided to perform endovascular embolisation with ethylene vinyl alcohol/dimethyl sulfoxide at different times. The transthoracic echocardiogram showed a significant decrease in cardiac output (9.8 L/min) and his general condition improved significantly.

Quiste óseo aneurismático localizado en el techo acetabular en un varón de 11 años / Aneurysmal bone cyst located on the acetabular roof in an 11-year-old male

Resumen: El quiste óseo aneurismático es una tumoración benigna poco común, de aparición en la infancia generalmente y a nivel de extremidades. El tratamiento más habitual consiste en el curetaje y relleno con injerto. No obstante, localizaciones poco accesibles a la cirugía suponen un reto terapéutico. Se presenta el caso de un paciente de 11 años con cojera y dolor en cadera derecha sin antecedente traumático ni infeccioso. En los estudios de imagen con TAC y RM se evidencia una lesión lítica expansiva que ocupa todo el techo del acetábulo y pala ilíaca derecha, sugestiva de un quiste óseo aneurismático presentando fractura acetabular asociada. Se realizó una biopsia que confirmó el diagnóstico. Se trató mediante embolización guiada por angiografía debido al gran volumen y alto riesgo de fractura, después del curetaje y relleno con aloinjerto evolucionó satisfactoriamente y el paciente se encuentra asintomático al año de la intervención.

Abstract: The aneurysmal bone cyst is a benign rare tumor, which usually develops during childhood and it's more often found in limbs. The most accepted treatment consists in curetagge and filling with graft. However, certain locations may be inaccesible for surgery and represent therapeutical challenges. We present the case of an 11 year-old male patient with limping and right hip pain without any traumatic nor infectious record. In the image studies with CT and MRI a lytic and expansive lession was found in the upper part of the right acetabulum and right iliac wing, all of which suggested an aneurysmal bone cyst with an associated acetabular fracture. A biopsy was performed which confirmed the diagnosis. He was treated with a CT-guided embolization and, due to its size, curetagge and allograft filling afterwards. He was asymptomatic after1 year of follow-up.

Comparación de las características y curso clínico de la endocarditis infecciosa por Staphylococcus aureus meticilino sensible versus meticilino resistente / Characteristics and clinical course of endocarditis due to Methicillin-sensitive versus methicillin-resistant Staphylococcus aureus

Resumen Introducción: Staphylococcus aureus es uno de los agentes causales más comunes de la endocarditis infecciosa. Se reportan pocos estudios en Latinoamérica acerca de las diferencias entre los perfiles de resistencia a la meticilina. Objetivo: Describir las características y el curso clínico de los pacientes con S. aureus sensible a meticilina frente al resistente. Métodos: Estudio observacional retrospectivo, cohorte histórica de pacientes adultos con diagnóstico confirmado de endocarditis entre los años 2011 y 2015. Se seleccionaron pacientes positivos para S. aureus comparando las características y el curso clínico entre los casos S. aureus sensible a meticilina frente al resistente. Resultados: Se estudiaron 86 pacientes con endocarditis. 28 (33%) tenían infección por S. aureus. 21 (75%) tenían endocarditis por S. aureus sensible a meticilina y 7 (25%) por S. aureus resistente a meticilina. En el grupo S. aureus sensible a meticilina, 11 (52,3%) fueron infecciones asociadas a atención en salud. La mayoría de casos de S. aureus resistente a meticilina fueron (85,7%) adquiridos en comunidad. La mortalidad de endocarditis por S. aureus sensible a meticilina fue superior a la causada por el resistente (33,3% vs. 14%). Conclusiones: S. aureus sigue siendo el agente más frecuente en endocarditis, más comúnmente el sensible a la meticilina. Los eventos embólicos y la gravedad fueron mayores en S. aureus sensible a meticilina. La mayor proporción de endocarditis debido a S. aureus resistente a meticilina se adquirió en la comunidad, por lo que se sugiere iniciar cobertura empírica contra S. aureus resistente a meticilina en todo caso de endocarditis adquirida en la comunidad.

Abstract Introduction: Staphylococcus aureus is one of the most common sources of infectious endocarditis. There are few studies in Latin America that report on the differences between the methicillin resistance profiles. Objective: To describe the characteristics and clinical course of patients with methicillin-sensitive S. aureus (MSSA) compared to methicillin-resistance S. aureus (MRSA) Methods: An observational, retrospective study was conducted on a historical cohort of adult patients with a confirmed diagnosis of endocarditis between the years 2011 and 2015. Patients positive for S. aureus were selected and the characteristics and clinical course and the cases of MSSA were compared with those of MRSA. Results: A total of 86 patients with endocarditis were included, of whom 28 (33%) had an infection due to S. aureus, and 21 (75%) had endocarditis due to methicillin-sensitive S. aureus, and 7 (25%) due to MRSA. In the MSSA group, 11 (52.3%) were infections associated with health care. The majority (85.7%) of cases of MRSA were community acquired. The endocarditis mortality due to MSSA was higher than that caused by MRSA (33.3% vs. 14%). Conclusions: S. aureus continues to be the most common agent in endocarditis, with MSSA being more common. The embolic events and the severity were greater in MSSA. The majority of endocarditis due to MRSA is acquired in the community, and for this reason it is suggested starting empirical cover against MRSA in all cases of community acquired endocarditis.

[Aneurysmal bone cyst located on the acetabular roof in an 11-year-old male]. / Quiste óseo aneurismático localizado en el techo acetabular en un varón de 11 años.

The aneurysmal bone cyst is a benign rare tumor, which usually develops during childhood and its more often found in limbs. The most accepted treatment consists in curetagge and filling with graft. However, certain locations may be inaccesible for surgery and represent therapeutical challenges. We present the case of an 11 year-old male patient with limping and right hip pain without any traumatic nor infectious record. In the image studies with CT and MRI a lytic and expansive lession was found in the upper part of the right acetabulum and right iliac wing, all of which suggested an aneurysmal bone cyst with an associated acetabular fracture. A biopsy was performed which confirmed the diagnosis. He was treated with a CT-guided embolization and, due to its size, curetagge and allograft filling afterwards. He was asymptomatic after1 year of follow-up.

El quiste óseo aneurismático es una tumoración benigna poco común, de aparición en la infancia generalmente y a nivel de extremidades. El tratamiento más habitual consiste en el curetaje y relleno con injerto. No obstante, localizaciones poco accesibles a la cirugía suponen un reto terapéutico. Se presenta el caso de un paciente de 11 años con cojera y dolor en cadera derecha sin antecedente traumático ni infeccioso. En los estudios de imagen con TAC y RM se evidencia una lesión lítica expansiva que ocupa todo el techo del acetábulo y pala ilíaca derecha, sugestiva de un quiste óseo aneurismático presentando fractura acetabular asociada. Se realizó una biopsia que confirmó el diagnóstico. Se trató mediante embolización guiada por angiografía debido al gran volumen y alto riesgo de fractura, después del curetaje y relleno con aloinjerto evolucionó satisfactoriamente y el paciente se encuentra asintomático al año de la intervención.

Embolización de metástasis hepáticas en insulinoma maligno: de la hipoglicemia a la hiperglicemia / Embolisation of liver metastasis in malignant insulinoma: from hyperglycaemia to hypoglycaemia

Resumen Se describe el caso de un paciente de 75 años sin antecedentes de relevancia, que fue diagnosticado con insulinoma maligno en estado avanzado, con metástasis hepáticas, con síntomas por hipoglucemia hiperinsulinémica refractaria al tratamiento, y con diazóxido y octreotide de acción corta. El paciente presentó una respuesta clínica poco esperada a la embolización transarterial de metástasis hepáticas, pues a pesar de que persisten las lesiones tumorales, desarrolló hiperglucemia persistente y requirió manejo con insulina. Adicionalmente, se hace una breve revisión de la literatura sobre las opciones terapéuticas disponibles para el tratamiento sintomático de la hipoglucemia hiperinsulinémica.

Abstract The case is presented of a 75 year-old man who was diagnosed with malignant insulinoma in an advanced stage with diffuse liver metastases and symptoms due to hyperinsulinaemic hypoglycaemia refractory to treatment with diazoxide and short-acting octreotide. The patient had an unexpected clinical response to trans-arterial embolisation of liver metastases, since, despite still having the tumour, he developed persistent hyperglycaemia that required insulin treatment. A brief review of the literature is also presented on the treatment options for hyperinsulinaemic hypoglycaemia.

[Placenta percreta with bladder and rectum invasion]. / Percretismo placentario con invasión de vejiga y recto.

BACKGROUND: Placenta percreta may lead to massive obstetric haemorrhage, haemodynamic decompensation, and ultimately death. Total obstetric hysterectomy is universally accepted as treatment; however, the emergence of new techniques such as the uterine artery angioembolisation approach, and the use of chemotherapy agents such as methotrexate, are alternatives also described in the literature. CLINICAL CASE: A 28 year-old patient, in her fourth gestation, with a previous history of 2 vaginal and 1 caesarean birth 4, in her 28.4 week of pregnancy, by second trimester ultrasound, was diagnosed with placenta percreta with bladder and rectal invasion using magnetic resonance imaging. Multidisciplinary and sequential treatment included: Caesarean with placenta in situ, uterine artery embolisation immediately after caesarean, chemotherapy with methotrexate weekly for 4 doses, and finally obstetric hysterectomy after bilateral hypogastric artery ligation. The outcome was favourable and the patient was discharged in good general condition. CONCLUSIONS: The protocoled and sequential management including selective embolization immediately after caesarean section with placenta in situ, weekly chemotherapy with methotrexate and obstetric hysterectomy, preceded by bilateral ligation of the hypogastric arteries, is a therapeutic alternative to be considered in cases of placenta percreta.

Prolapso de uretra y retención urinaria postembolización prostática. A propósito de un caso / Urethral prolapse and urinary retention post- prostatic embolization. About a case

Introducción y Objetivos: Entre las complicaciones de la embolización prostática figuran el ardor miccional, la infección urinaria, la hematuria, la rectorragia, la retención urinaria, la balanitis y la hemospermia, pero hasta la fecha no se había comunicado el prolapso uretral, una patología exclusiva del sexo femenino en la especie humana, a diferencia de otras especies vertebradas donde sólo afecta a los machos.El objetivo de esta comunicación es presentar el primer caso de prolapso uretral en un varóntras haberle practicado una embolización de las arterias prostáticas como tratamiento de su hiperplasia prostática benigna.(AU)

Background and Objectives: Complications of prostatic embolization include voiding pain, urinary tract infection, hematuria, rectal bleeding, urinary retention, balanitis and hemospermia, but to date no urethral prolapse in man has been reported , being an exclusive pathology of the female sex in the human species, unlike other vertebrate species where it only affects males. The aim of this report is to present the first case of urethral prolapse in a male after having performed an embolization of the prostatic arteries to treat his benign prostatic hyperplasia.(AU)

Embolización portal hepática preoperatoria con lipiodol y gelatina absorbible / Preoperative hepatic portal vein embolisation with lipiodol and absorbable gelatin

Objetivo: Describir los resultados de la embolización portal hepática (EPH) preoperatoria con lipiodol y gelatina absorbible para generar hipertrofia hepática y permitir la hepatectomía derecha en pacientes con tumores hepáticos e hígado remanente futuro insuficiente. Materiales y métodos: Entre marzo de 2002 y abril de 2014, en 18 pacientes candidatos a hepatectomía derecha se realizó EPH con lipiodol y esponja de gelatina absorbible mezclada con contraste yodado. La estimación de los volúmenes hepáticos preembolización se hizo por tomografía computada con contraste endovenoso. Los pacientes fueron abordados mediante punción percutánea bajo guía ecográfica, seguida de angiografía. El control de la hipertrofia con estimación del volumen se realizó a la cuarta semana posembolización y el seguimiento se llevó a cabo ambulatoriamente o mediante historia clínica. Resultados: La mediana de edad fue de 58 años (relación hombre/mujer de 1:0,8) y el volumen hepático total estimado (mediana) de 1587,75 cm³. La estimación previa del volumen hepático y su relación con la porción futura remanente pre-EPH fue de 19,9%, mientras que el promedio absoluto de crecimiento del parénquima hepático remanente futuro pos-EPH se encontró entre los 306,2 y 475,2 cm³, con un 43,5% de aumento. La mediana de incremento de la relación volumen hepático total y la porción remanente pos-EPH fue de 8,5% (p< 0,001). Como complicaciones, se registró un hematoma y una necrosis aséptica. Conclusión: La EPH con lipiodol y esponja de gelatina absorbible es un procedimiento seguro y efectivo, que surge como alternativa a otros materiales de embolización.

Objective: To evaluate outcomes of preoperative hepatic portal vein embolisation with lipiodol and absorbable gelatin in order to generate liver hypertrophy and enable right hepatectomy in selected patients with liver tumours and future insufficient residual liver. Materials and methods: Portal vein embolisation (PVE) with lipiodol and absorbable gelatin sponge mixed with iodine based contrast was performed in 18 patient candidates for right hepatectomy between March 2002 and April 2014. The preembolisation liver volume evaluations were performed by computed tomography with intravenous contrast. Patients underwent an ultrasound-guided percutaneous puncture, followed by angiography. The controls of hypertrophy and volume estimation were performed in the 4 th week after portal embolisation. The patients were followed-up on an outpatient basis or by using their medical records. Results: The median age was 58 years, with a 1:0.8 male: female ratio. The total estimated liver volume, excluding the tumour, of all patients evaluated prior to surgery was 1587.75 cm³ (median). The previous estimated liver volume and its relation to the future remaining portion before PVE was 19.9%. The absolute median growth of future residual liver parenchyma post-PVE was 306.2 to 475.2 cm³, being an increase of 43.5%, and the mean growth of liver volume and remaining portion ratio post-PVE was 8.5% (P<.001). Complications were one haematoma and one aseptic necrosis. Conclusión: The selection of patients is of paramount importance, and PVE with lipiodol and absorbable gelatin in our environment is a safe and effective procedure.

Transurethral Resection of the Prostate (TURP) Versus Original and PErFecTED Prostate Artery Embolization (PAE) Due to Benign Prostatic Hyperplasia (BPH): Preliminary Results of a Single Center, Prospective, Urodynamic-Controlled Analysis.

PURPOSE: To compare clinical and urodynamic results of transurethral resection of the prostate (TURP) to original and PErFecTED prostate artery embolization (PAE) methods for benign prostatic hyperplasia. METHODS: We prospectively randomized 30 patients to receive TURP or original PAE (oPAE) and compared them to a cohort of patients treated by PErFecTED PAE, with a minimum of 1-year follow-up. Patients were assessed for urodynamic parameters, prostate volume, international prostate symptom score (IPSS), and quality of life (QoL). RESULTS: All groups were comparable for all pre-treatment parameters except bladder contractility and peak urine flow rate (Q max), both of which were significantly better in the TURP group, and IIEF score, which was significantly higher among PErFecTED PAE patients than TURP patients. All groups experienced significant improvement in IPSS, QoL, prostate volume, and Q max. TURP and PErFecTED PAE both resulted in significantly lower IPSS than oPAE but were not significantly different from one another. TURP resulted in significantly higher Q max and significantly smaller prostate volume than either original or PErFecTED PAE but required spinal anesthesia and hospitalization. Two patients in the oPAE group with hypocontractile bladders experienced recurrence of symptoms and were treated with TURP. In the TURP group, urinary incontinence occurred in 4/15 patients (26.7 %), rupture of the prostatic capsule in 1/15 (6.7 %), retrograde ejaculation in all patients (100 %), and one patient was readmitted for temporary bladder irrigation due to hematuria. CONCLUSIONS: TURP and PAE are both safe and effective treatments. TURP and PErFecTED PAE yield similar symptom improvement, but TURP is associated with both better urodynamic results and more adverse events.

MGuard Embolic Protection Stent - The Importance of Thrombus Management in ST-elevation Myocardial Infarction Primary Percutaneous Coronary Intervention: Proceedings of STEMI symposium at EuroPCR on 20-23rd May 2014 in Paris.

Distal embolisation of atherothrombotic material is a frequent consequence of percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI). This causes microvascular occlusions, leading to a further reduction in myocardial reperfusion. The MGuard™ embolic protection stent (EPS) features a unique polymer micronet mesh coating. When used in acute STEMI, the MGuard EPS shows significant improvement in myocardial flow and ST resolution, even in complicated clinical cases vs the standard approach with conventional bare metal or drug-eluting stents. Data from the andomised Safety and Efficacy Study of MGuard Stent After a Heart Attack (MASTER II) trial and from a real-life registry have shown the efficacy and safety of the MGuard in primary PCI. This report of the proceedings of a symposium at EuroPCR, 20-23 May 2014, Paris, France, discussed clinical trial data, as well as a number of clinical cases, illustrating the utility of the MGuard EPS in difficult situations.

Cierre percutáneo del ductus arterioso con coils: diagnóstico y seguimiento ecocardiográfico a largo plazo / Percutaneous closure of arterious ductus with coils: echocardiographic diagnosis and follow up

Objectives: We report about the percutaneous closure with coils of small and medium sized ductus arteriosus, and their long term follow up in a single center. Patients and Method: This is a retrospective study, including 291 patients in an intention to treat basis, between 1998 and 2006. Results: The median age and weight at time of procedure was 45 months and 16,7 Kg respectively. The immediate rate of occlusion was 82 percent and 91,3 percent at 1 year follow up. Up to 98 percent of cases needed just 1 coil to close the defect. The result was considered sub optimal in 33 cases (11,6 percent) almost half of this group was evaluated as having mild residual shunt at one year, all of them closed with additional coils percutaneously. Only the size of ductus was related to this type of result (>3 mm). Conclusions: The percutaneous closure with coils, is a highly eficacious alternative, for treatment of ductus arteriosus up to 2,5-3 mm, as minor diameter, with a very convenient cost/benefit rate. Beyond these limits the advantages disappear, and alternative devices become the treatment of choice.

Objetivos: Se reporta sobre el cierre percutáneo de ductus pequeños y medianos con coils en un solo centro, su diagnóstico y seguimiento ecocardiográfico a largo plazo. Pacientes y método: Se realizó un estudio retrospectivo sobre 291 pacientes portadores de ductus arterioso diagnosticado ecocardiográficamente en quienes se intentó el cierre percutáneo entre 1998y 2006. Resultados: La mediana de edad y peso de los pacientes al momento del procedimiento fue de 45 meses y 16,7 kg. La tasa de oclusión inmediata fue de 82 por ciento y de 91,3 por ciento a un año. En el 98 por ciento de los casos se utilizó un solo coil para cerrar el defecto. El resultado fue sub óptimo en 33 casos (11,6 por ciento) siendo casi la mitad de estos casos correspondientes a shunt residual leve a un año, todos cerrados con coil en procedimiento percutáneo adicional. Sólo el tamaño del ductus estuvo relacionado con este resultado (>3mm). Conclusiones: El cierre con coils sigue siendo un tratamiento altamente eficaz para ductus de hasta 2,5-3 mm de diámetro menor, con una relación costo/beneficio muy favorable al compararse con dispositivos alternativos. Más allá de estos límites las ventajas mencionadas tienden a disminuir en forma considerable y se hace discutible su uso.