Left Anterolateral Medullary Compression Due to Vertebral Artery Dolichoectasia: A Case Report and Review of Literature.

Vertebral artery dolichoectasia, characterized by the elongation, dilation, and tortuosity of the vertebral arteries, poses significant clinical challenges due to its potential to compress adjacent neural structures, particularly the medulla oblongata. This case report presents a 73-year-old hypertensive female with recurrent episodes of falls and transient loss of consciousness. Initial assessments including echocardiography and a four-vessel Doppler study were unremarkable, prompting further evaluation with MRI. High-resolution imaging sequences revealed significant dolichoectasia of the left vertebral artery, compressing the left anterolateral medulla. This compression disrupted vital autonomic and motor pathways, explaining the patient's symptoms. Management involved a multidisciplinary approach, incorporating conservative measures, potential endovascular intervention, and neurosurgical consultation. This case underscores the importance of advanced imaging techniques in diagnosing vertebral artery dolichoectasia and highlights the need for a comprehensive, multidisciplinary treatment strategy to optimize patient outcomes.

Clinical Outcomes of Iris-Supported Phakic Toric Intraocular Lenses in Corneal Ectasia.

INTRODUCTION: Our aim was to evaluate the visual and refractive outcomes of iris-fixated phakic toric intraocular lenses (IOLs) for visual rehabilitation in eyes with stable corneal ectasia. METHODS: We conducted a study looking at the clinical outcomes of iris-fixated toric IOLs (Artisan) in 33 eyes of 27 patients diagnosed with mild-to-moderate corneal ectasia at a single center (Queen Victoria Hospital, East Grinstead, UK). The main outcome measures were functional improvement [accuracy of post-operative spherical equivalent (SE), astigmatic correction, topographic parameters, uncorrected and corrected distance visual acuity (UCVA, CDVA)] and safety of the procedure: endothelial cell count and intra- and post-operative complications. RESULTS: Eighteen males and nine females of mean age 38.85 were included in the study with a mean follow-up of 18 months. All patients had ectasia due to keratoconus except one with post-refractive laser ectasia. Twelve patients had crosslinking, eight had intracorneal rings, and eight had previous keratoplasties. Mean pre-operative logMAR UCVA was 0.75 ± 0.35 improving to 0.02 ± 0.17 (p = 0.000). Mean pre-operative logMAR CDVA was 0.16 ± 0.17 improving to 0.02 ± 0.17 (p = 0.000). Mean pre-operative (SE) was - 3.5 ± 3.9 improving to - 2.75 ± 1.39 (p = 0.000) with up to 36-42 months of follow-up. The mean value of endothelial cell density in the overall sample was 2252.54 ± 473.24 cells/mm2 pre-operatively and 2126.75 ± 365.21 cells/mm2 at 24-36 months of follow-up visit. Two patients have intra-operative hyphemia secondary to iris prolapse. CONCLUSIONS: Implantation of iris-fixated phakic toric IOLs has shown high efficacy and safety in patients with mild-to-moderate astigmatism in corneal ectasia.

Coronary Artery Aneurysm or Ectasia as a Form of Coronary Artery Remodeling: Etiology, Pathogenesis, Diagnostics, Complications, and Treatment.

Coronary artery aneurysm or ectasia (CAAE) is a term that includes both coronary artery ectasia (CAE) and coronary artery aneurysm (CAA), despite distinct phenotypes and definitions. This anomaly can be found in 0.15-5.3% of coronary angiography. CAE is a diffuse dilatation of the coronary artery at least 1.5 times wider than the diameter of the normal coronary artery in a patient with a length of over 20 mm or greater than one-third of the vessel. CAE can be further subdivided into diffuse and focal dilations by the number and the length of the dilated vessels. Histologically, it presents with extensive destruction of musculoelastic elements, marked degradation of collagen and elastic fibers, and disruption of the elastic lamina. Conversely, CAA is a focal lesion manifesting as focal dilatation, which can be fusiform (if the longitudinal diameter is greater than the transverse) or saccular (if the longitudinal diameter is smaller than the transverse). Giant CAA is defined as a 4-fold enlargement of the vessel diameter and is observed in only 0.02% of patients after coronary. An aneurysmal lesion can be either single or multiple. It can be either a congenital or acquired phenomenon. The pathophysiological mechanisms responsible for the formation of CAAE are not well understood. Atherosclerosis is the most common etiology of CAAE in adults, while Kawasaki disease is the most common in children. Other etiological factors include systemic connective tissue diseases, infectious diseases, vasculitis, congenital anomalies, genetic factors, and idiopathic CAA. Invasive assessment of CAAE is based on coronary angiography. Coronary computed tomography (CT) is a noninvasive method that enables accurate evaluation of aneurysm size and location. The most common complications are coronary spasm, local thrombosis, distal embolization, coronary artery rupture, and compression of adjacent structures by giant coronary aneurysms. The approach to each patient with CAAE should depend on the severity of symptoms, anatomical structure, size, and location of the aneurysm. Treatment methods should be carefully considered to avoid possible complications of CAAE. Simultaneously, we should not unnecessarily expose the patient to the risk of intervention or surgical treatment. Patients can be offered conservative or invasive treatment. However, there are still numerous controversies and ambiguities regarding the etiology, prognosis, and treatment of patients with coronary artery aneurysms. This study summarizes the current knowledge about this disease's etiology, pathogenesis, and management.

Impact of the Grade and Jet-flow Direction of Residual Aortic Regurgitation after Valve-Sparing Root Replacement.

OBJECTIVES: The current study aimed to investigate the impact of the grade and jet direction of residual aortic regurgitation (rAR) after valve-sparing root replacement (VSRR). METHODS: The study enrolled 248 adult patients who underwent VSRR from 1995 to 2021. The patients were divided into groups based on the postoperative rAR. Patients with rAR were further categorized per the rAR grade and jet direction. The primary endpoint was the development of aortic regurgitation ≥ moderate and/or the need for valve replacement during the follow-up, analyzed by a multivariable competing risk analysis. The secondary endpoints included the occurrence of rAR and overall survival. RESULTS: The median age of the patients was 36.5 years, and 79.8% were diagnosed with connective tissue disease. After VSRR, 146 patients did not present with rAR. However, 102 had rAR (77 with minimal central, 18 with minimal eccentric, and 7 with mild). The 5- and 8-year incidence rates of the primary endpoint were 14.6% and 17.9%, respectively. The rAR was a significant risk factor (P=0.001), and eccentricity and mild rAR seemed to play an important role. The risk factors of rAR included dilated root, preoperative moderate regurgitation, and redo sternotomy. The overall survival was influenced only by age. CONCLUSION: rAR after VSRR operation could be a risk factor for AR progression. Minimal central rAR generally has a tolerable clinical course. However, patients with even minimal eccentric AR may develop AR progression, so active surveillance and timely management might be required. Further, early VSRR can help reduce the rAR.

Identification of right coronary artery ectasia with echocardiography and confirmation with multimodal imaging.

We present the case of a patient with myocardial infarction due to coronary ectasia. A transthoracic echocardiogram showed a unique image of a cystic-like mass in the right atrium corresponding to the ectatic right coronary artery (arrows), which was confirmed with computed tomography.

Tubular Ectasia of the Epididymis: A Case Report and Literature Review.

Tubular ectasia of the epididymis is a rare benign disorder that, when present, is usually seen in patients post-vasectomy. It can also be seen in patients with a prior history of trauma or local infection. Patients typically present with a palpable scrotal mass and dull-aching pain. It is important to differentiate this disease from other common disorders such as varicocele, hydrocele, spermatocele, or even testicular malignancy. We report a rare case of tubular ectasia of the epididymis in a 55-year-old patient with palpable scrotal swelling with no prior operative history of vasectomy nor any history of trauma. We share this patient's ultrasonography findings along with a literature review of this uncommon disease.

Vitamin-K antagonist versus dual antiplatelet therapy in management of isolated and non-obstructive atherosclerotic coronary artery ectasia.

BACKGROUND: Treatment of isolated and non-obstructive atherosclerotic coronary artery ectasia (CAE) is still controversial. AIM: To assess the efficacy and safety of vitamin-K antagonist (VKA) versus dual antiplatelet (DAPT) therapy in management of patients with isolated and non-obstructive atherosclerotic CAE. METHODS: We prospectively enrolled 79 patients diagnosed on elective coronary angiography to have either isolated CAE or non-obstructive atherosclerotic CAE. Patients were assigned in 1:1 pattern to receive either VKA (warfarin) or DAPT (aspirin plus clopidogrel). Patients were followed-up for nine-months. The primary endpoint was the cumulative events rate including acute coronary event, target vessel intervention, or cardiac death. Analysis of cumulative events at different time intervals, its individual components, and bleeding were considered secondary endpoints. RESULTS: Cumulative events rate was 33%, with mortality rate of 2.5%. Both treatment groups showed comparable cumulative events during the nine-months follow-up duration. Nevertheless, Kaplan-Meier analysis beyond the first 3-months of follow-up showed significantly higher event-free survival among the VKA-group. Recurrent events (≥2) were significantly higher among the DAPT-group. Both groups showed no major bleeding events. Multivariable cox-regression analysis showed that presence of significant coronary tortuosity, use of DAPT in reference to VKA, and lower percent time in therapeutic range (%TTR) among those receiving VKA were significant independent predictors of clinical adverse events beyond the first 3-months of follow-up. CONCLUSION: Cumulative adverse events were comparable among both treatment groups for isolated non-obstructive CAE. However, adverse events were significantly more frequent in the DAPT-group beyond the first three months.

Mechanical thrombectomy using neurovascular catheter from radial artery during acute myocardial infarction: A case report.

Coronary occlusion due to large thrombus is frequently encountered during ST-elevation myocardial infarction (STEMI). Despite guidelines discourage this practice, often thrombus aspiration is necessary to reduce thrombotic burden and to prevent embolization. We report a case of mechanical thrombectomy with a Neurovascular Catheter from radial artery during inferior STEMI.

Association of remnant cholesterol with coronary artery ectasia: a cross-sectional study.

OBJECTIVE: Coronary artery ectasia (CAE) is a condition characterized by the localized or widespread dilation of one or more coronary arteries. The majority of CAE patients do not present with clinical symptoms, and the exact cause of CAE remains unclear. Therefore, a retrospective analysis was conducted to explore the potential causes of CAE. METHODS: This study was a retrospective analysis of patients who underwent coronary angiography at Guangdong Provincial People's Hospital between January 2017 and July 2022, of whom 679 patients were ultimately enrolled in the study. Among them, 260 patients were diagnosed with CAE, whereas 419 patients with normal coronary results composed the control group. Remnant cholesterol (RC) was calculated as total cholesterol (TC) minus high-density lipoprotein cholesterol (HDL-C) minus low-density lipoprotein cholesterol (LDL-C). The association between RC levels and the risk of CAE was assessed via multivariable logistic models. RESULTS: Out of the 679 patients who participated in this study, with an average age of 59.9 years, 38.3% were diagnosed with CAE. Patients with CAE had higher RC levels than did those without CAE (P = 0.001). A significant positive association was observed between RC levels and the risk of CAE, with a multivariable adjusted odds ratio (OR) of 1.950 (95% confidence interval [CI]: 1.163-3.270). There was a significant positive association between RC levels and the risk of CAE in both single-vessel and multivessel dilation cases, as well as in isolated CAE and dilation secondary to coronary atherosclerosis. According to the subgroup analyses, RC levels were positively associated with the risk of CAE in participants with hypertension (OR, 1.065; 95% CI, 1.034-1.098). CONCLUSION: RC levels are positively correlated with CAE, implying that a focus on RC could be beneficial in CAE research.

Learning the Randleman Criteria in Refractive Surgery: Utilizing ChatGPT-3.5 Versus Internet Search Engine.

Introduction Large language models such as OpenAI's (San Francisco, CA) ChatGPT-3.5 hold immense potential to augment self-directed learning in medicine, but concerns have risen regarding its accuracy in specialized fields. This study compares ChatGPT-3.5 with an internet search engine in their ability to define the Randleman criteria and its five parameters within a self-directed learning environment. Methods Twenty-three medical students gathered information on the Randleman criteria. Each student was allocated 10 minutes to interact with ChatGPT-3.5, followed by 10 minutes to search the internet independently. Each ChatGPT-3.5 conversation, student summary, and internet reference were subsequently analyzed for accuracy, efficiency, and reliability. Results ChatGPT-3.5 provided the correct definition for 26.1% of students (6/23, 95% CI: 12.3% to 46.8%), while an independent internet search resulted in sources containing the correct definition for 100% of students (23/23, 95% CI: 87.5% to 100%, p = 0.0001). ChatGPT-3.5 incorrectly identified the Randleman criteria as a corneal ectasia staging system for 17.4% of students (4/23), fabricated a "Randleman syndrome" for 4.3% of students (1/23), and gave no definition for 52.2% of students (12/23). When a definition was given (47.8%, 11/23), a median of two of the five correct parameters was provided along with a median of two additional falsified parameters. Conclusion Internet search engine outperformed ChatGPT-3.5 in providing accurate and reliable information on the Randleman criteria. ChatGPT-3.5 gave false information, required excessive prompting, and propagated misunderstandings. Learners should exercise discernment when using ChatGPT-3.5. Future initiatives should evaluate the implementation of prompt engineering and updated large-language models.

Anticoagulant and antiplatelet treatment effects on the incidence of major cardiovascular events in patients with coronary artery ectasia: An updated systematic review.

INTRODUCTION: Coronary artery ectasia (CAE), widenings in sections of the arteries, is a rare condition found in up to 3-5% of angiography cases. Sometimes recurrence of major adverse cardiac events (MACE) has been reported in the CAE subjects. The present systematic review aims to collect and summarize reports on whether the use of anticoagulants in addition to single antiplatelet/dual antiplatelet therapy (SAPT/DAPT) in CAE patients with significant occlusion/heavy thrombus is efficient and safe in decreasing the incidence/recurrence of MACE. MATERIAL AND METHODS: A systematically comprehensive search was performed covering PubMed, Scopus, ISI Web of Science, and Google Scholar databases. RESULTS: Twenty-five studies were found including 20 case reports, four case series, and one randomized clinical trial. Of 20 case reports 15 were male (75 %), and five were female (25 %). Of the four the case series, all showed positive outcomes after DAPT plus anticoagulant in more than 50 % of patients; two took only DAPT and 13 took anticoagulant ± DAPT, and five compared both. Cases received DAPT only experienced recurrences of MACE. The other cases were uneventful with less MACE and better outcomes after the use of anticoagulant ± DAPT. Results of these case-series included 457 CAE patients showed that more than 80 % of subjects were male, and in all studies tailored pharmacological interventions, including antiplatelet and anticoagulant (warfarin) therapies, resulted in less MACE and mortality. CONCLUSION: It can be concluded that antiplatelet (SAPT/DAPT) must be applied in combination with anticoagulants to provide more efficient protection against MACE in CAE patients. However, further high-quality randomized clinical trials are needed to confirm the results.

A Case With Twists and Turns: A Report of Vertebrobasilar Dolichoectasia.

Vertebrobasilar dolichoectasia (VBD) is a rare anatomical abnormality of the vertebral artery system, defined as irregular expansion, elongation, and tortuosity of vertebral arteries. Anomalies of the vertebrobasilar artery can have a wide variety of clinical presentations, ranging from simple headaches to debilitating strokes. We present the case of an atypical presentation of VBD which mimicked trigeminal neuralgia by compressing the trigeminal nerve. There are currently no guidelines concerning the management of VBD, nor is there evidence of a definitive cure. This case invoked discussions among the medical team as to whether management should be medically or surgically focused, as well as long-term outcomes for patients with VBD. The superiority of medical versus surgical treatment of this issue is still a debated topic. This patient trialed medical management with dexamethasone and carbamazepine with no improvement in symptoms. He then underwent surgical gamma knife treatment but even this invasive measure was unsuccessful at relieving his symptoms. We hope that by presenting this case, we can display how the therapies available for VBD are limited and often unsuccessful in relieving the disease burden in patients with VBD.

Utility of artificial intelligence in the diagnosis and management of keratoconus: a systematic review.

Introduction: The application of artificial intelligence (AI) systems in ophthalmology is rapidly expanding. Early detection and management of keratoconus is important for preventing disease progression and the need for corneal transplant. We review studies regarding the utility of AI in the diagnosis and management of keratoconus and other corneal ectasias. Methods: We conducted a systematic search for relevant original, English-language research studies in the PubMed, Web of Science, Embase, and Cochrane databases from inception to October 31, 2023, using a combination of the following keywords: artificial intelligence, deep learning, machine learning, keratoconus, and corneal ectasia. Case reports, literature reviews, conference proceedings, and editorials were excluded. We extracted the following data from each eligible study: type of AI, input used for training, output, ground truth or reference, dataset size, availability of algorithm/model, availability of dataset, and major study findings. Results: Ninety-three original research studies were included in this review, with the date of publication ranging from 1994 to 2023. The majority of studies were regarding the use of AI in detecting keratoconus or subclinical keratoconus (n=61). Among studies regarding keratoconus diagnosis, the most common inputs were corneal topography, Scheimpflug-based corneal tomography, and anterior segment-optical coherence tomography. This review also summarized 16 original research studies regarding AI-based assessment of severity and clinical features, 7 studies regarding the prediction of disease progression, and 6 studies regarding the characterization of treatment response. There were only three studies regarding the use of AI in identifying susceptibility genes involved in the etiology and pathogenesis of keratoconus. Discussion: Algorithms trained on Scheimpflug-based tomography seem promising tools for the early diagnosis of keratoconus that can be particularly applied in low-resource communities. Future studies could investigate the application of AI models trained on multimodal patient information for staging keratoconus severity and tracking disease progression.

Enhancing ectasia screening using advanced AS-OCT: a case series of challenging refractive candidates.

Purpose: Ectasia screening in candidates for laser refractive surgery is mandatory during preoperative evaluation. Despite the availability of modern imaging techniques, refractive surgeons often face borderline decisions when patients present with suspicious tomographic findings. This case series presents refractive candidates with suspicious tomographic findings and demonstrates how to interpret them using Scheimpflug imaging and additional anterior segment optical coherence tomography (AS-OCT). Setting: Department of Ophthalmology, University Hospital, LMU Munich. Case series: This case series examines six potential candidates for refractive surgery with a mean age of 29.2 ± 3.9 years, whose corneal assessments using Scheimpflug imaging raised suspicion for ectasia. Each candidate was additionally examined with AS-OCT and reevaluated. The mean manifest subjective spherical equivalent was -3.67 ± 1.8 diopters. The total corneal thickness measured 537 µm ± 30 µm at its thinnest point. None of the candidates had any reported underlying corneal or ophthalmic diseases, and slit lamp examinations revealed no abnormal morphological findings. Conclusions: Both Scheimpflug imaging and AS-OCT are appropriate tools for screening refractive candidates for ectasia. While topographic and elevation analyses yielded comparable results regarding corneal structure, the epithelial mapping provided by AS-OCT played a critical role in decision-making for cases with borderline tomographic findings. Establishing a global consensus on the use of epithelial mapping in ectasia screening is necessary.

Combined Rotating Ultra-High-Resolution Spectral Domain OCT and Scheimpflug Imaging for In Vivo Corneal Optical Biopsy.

PURPOSE: This article introduces the Pentacam® Cornea OCT (optical coherence tomography). This advanced corneal imaging system combines rotating ultra-high-resolution spectral domain OCT with sub- 2-micron axial resolution and Scheimpflug photography. The purpose of this study is to present the first experience with the instrument and its potential for corneal diagnostics, including optical biopsy. METHODS: In this prospective study, the Pentacam® Cornea OCT was used to image the corneas of seven patients. The novel wide-angle pericentric scan system enables optimal OCT imaging performance for the corneal layer structure over the entire width of the cornea, including the limbal regions. A detailed analysis of the resulting images assessed the synergism between the OCT and Scheimpflug photography. RESULTS: The Pentacam® Cornea OCT demonstrated significantly improved image resolution and ability to individualize corneal layers with high quality. There is a synergism between the OCT high-definition signal to individualize details on the cornea and Scheimpflug photography to detect and quantify corneal scattering. The noncontact exam was proven safe, user-friendly, and effective for enabling optical biopsy. CONCLUSIONS: Pentacam® Cornea OCT is an advancement in corneal imaging technology. The ultra-high-resolution spectral domain OCT and Scheimpflug photography provide unprecedented detail and resolution, enabling optical biopsy and improving the understanding of corneal pathology. Further studies are necessary to compare and analyze the tomographic reconstructions of the cornea with the different wavelengths, which may provide helpful information for diagnosing and managing corneal diseases.

Gastric Antral Vascular Ectasia: Resolution of Bleeding and Stabilization of Hematocrit Following Orthotopic Liver Transplantation.

Gastric Antral Vascular Ectasia (GAVE) is an uncommon cause of chronic gastrointestinal bleeding and iron deficiency anemia in the geriatric population. It is often associated with cirrhosis of the liver and is hypothesized to result from synthetic liver dysfunction. Treatment options include argon plasma coagulation, endoscopic band ligation, and radiofrequency ablation. An orthotopic liver transplant may be effective for patients with advanced liver disease. In this case report, we describe a 60-year-old woman with a history of cirrhosis secondary to nonalcohol-related steatohepatitis (NASH) and GAVE syndrome who presented with abdominal pain and melena. She had multiple prior episodes of gastrointestinal bleeding, leading to long-term transfusion dependency. An urgent esophagogastroduodenoscopy revealed the presence of GAVE with active bleeding. The patient was supported with blood transfusions and transferred to a transplant center, where she underwent orthotopic liver transplantation. Following the transplantation, her hemoglobin levels improved and remained stable. She was no longer noted to require any further blood transfusions during outpatient follow-up visits. This case report substantiates the role of synthetic liver dysfunction in the development of GAVE. Also, it suggests that patients with advanced cirrhosis and refractory GAVE may benefit from liver transplantation as a potential treatment option.

Recurrent Upper Gastrointestinal Bleeding due to Radiation-Induced Hemorrhagic Gastroduodenal Ectasia: A Review of Current Treatment Options for Radiation-Induced Gastric Injury.

Introduction: Acute upper gastrointestinal bleeding is one of the most common medical emergencies that present to the hospital, and delineating the underlying etiology is essential to provide adequate definitive treatment. The purpose of this case report was to review the diagnosis and treatment of a rare complication known as radiation-induced hemorrhagic gastritis (RIHG) that can occur in patients with prior radiation exposure. The motivation for this study arose from the identification of a case within our institution. Case Presentation: The study involved a review of the diagnosis and management of a patient who presented with anemia and recurrent episodes of gastrointestinal bleeding at our institution after undergoing treatment for metastatic biliary adenocarcinoma. With the advent of new therapies, we aimed to investigate the various techniques utilized to manage these patients and highlight the importance of maintaining a high index of suspicion for RIHG as a potential etiology of gastrointestinal bleeding in patients with a relevant medical history of radiation exposure. Despite the literature review, we found that there is a lack of guidelines in the approach to the management of these patients. Conclusion: This case report underscores the rarity of radiation-induced gastritis and the complications that may arise from its diagnosis, including recurrent GI bleeding. Further investigation into identifying definitive treatment and creating guidelines for its management is desperately needed.

Atrial septal defect becoming clinically evident after cardiac surgery for annuloaortic ectasia: a case report.

Background: Right ventricular volume overload is the key finding in a patient with previously undiagnosed atrial septal defect (ASD). Case summary: A 68-year-old female was referred to our hospital due to progressive pulmonary artery dilatation observed on her chest X-ray. Echocardiography revealed a secundum ASD with right ventricular dilatation. She had undergone aortic root replacement and aortic valve replacement for annuloaortic ectasia and aortic insufficiency 12 years prior to the diagnosis. She was also diagnosed with Marfan syndrome, which was supported by family histories. Computed tomography did not show a secundum ASD before the surgery. We finally closed the secundum ASD with catheter closure device. Discussion: Ascending aneurysm might mask the presence of secundum ASD. Monitoring the change in pulmonary artery dilatation overtime is useful for the diagnosing secundum ASD.