Impact of Internal Carotid Stenosis Treatment on Cerebral Blood Flow Volume: A Comparative Study between Preoperative and Postoperative Values.

BACKGROUND Among patients with ICA stenosis, there are some cases with elevated, undisrupted, and diminished cerebral blood flow (CBF). The aim of this study was to assess the influence of ICA stenosis treatment on postoperative CBF changes in relation to preoperative CBF values. MATERIAL AND METHODS We qualified 58 patients ≥65 years old (28 males, 30 females, mean age 71.02±6.34 years) for surgical intervention due to symptomatic ≥70% ICA stenosis. In all patients, a flow volume in all extracranial arteries (internal carotid [ICA], external carotid [ECA], and vertebral arteries [VA]) was measured preoperatively and 2-3 days following the surgery. The CBF values were compared with the ones established for a healthy population of the same age. RESULTS Preoperatively, there were 3 subgroups of patients, comparing to healthy population: with elevated CBF - "significant compensation," with undisrupted CBF - "mild compensation," and with diminished CBF - "no compensation." Postoperatively, a significant CBF increase was observed in patients with preoperative "no" and "mild compensation" - 277.18±154.26 ml/min (P=0.0000001) and 221.56±98.8 ml/min (P=0.0000001). In a "significant compensation" group, there was no flow increase observed (CBF change of 2.57±58.5 ml/min, P=0.954) - a redistribution of flow was observed. CONCLUSIONS In patients with lower preoperative CBF values, surgical treatment caused a significant increase in global cerebral inflow, which was more prominent in patients with the lowest preoperative CBF. In patients with high preoperative CBF, surgical treatment resulted in a flow redistribution, but did not cause a CBF increase. Volumetric flow assessment in DUS can predict hemodynamic benefit from surgery in terms of CBF increase.

Comparison of Fine-Needle Aspiration Cytopathology with Histopathological Examination of the Thyroid Gland in Patients Undergoing Elective Thyroid Surgery: Do We Still Need Fine-Needle Aspiration Cytopathology?

BACKGROUND: The thyroid gland is responsible for various functions, but it is susceptible to pathologies. The gold standard for preliminarily diagnosing thyroid abnormalities is fine-needle aspiration cytology (FNAC), although it has some limitations; thus, postoperative histopathological examination confirms the diagnosis. The aim of the present study was to compare preoperative FNAC results with postoperative histopathological examination. METHODS: This study is a retrospective study based on FNAC and postoperative histopathology examination, which were compared and analyzed. RESULTS: This study included 344 patients between 18 and 86 years old (mean age: 53.06 ± 13.89), comprising 274 females and 70 males (mean ages 52.72 ± 13.86 and 54.39 ± 14.05, respectively) with a 3.9:1 female-to-male ratio. Statistical significance between the FNAC and histopathology results was observed (p = 0.0000), and 86 (25.00%) patients were found to have been diagnosed incorrectly based on FNAC. The sensitivity of FNAC was 92.31%, and its specificity was 82.08%, with positive and negative predictive values of 68.57% and 96.08%, respectively. CONCLUSIONS: Due to many factors, FNAC may lead to over- or under-diagnosis, increasing the chances of complications associated with the selected treatment. However, we do not have any other more accurate tools; therefore, FNAC should still remain as the gold standard of preliminary examination.

Do large parathyroid adenomas increase the risk of severe hypercalcemia?

<b><br>Introduction:</b> Primary hyperparathyroidism (PHPT) is mainly caused by parathyroid adenoma (PA). Rare variants of PA, weighing >2.0-3.5 g are called "large" or "giant" adenomas and account for about 1.5% of all PA.</br> <b><br>Aim:</b> The aim of this study was to compare normal-sized and large parathyroid lesions identifying risk factors for severe hypercalcemia.</br> <b><br>Materials and methods:</b> 27 patients with PHPT and parathyroid lesion ≥2.0 cm3 (study group) were compared with 73 patients with PHPT and lesion < 2.0 cm³ (control group). In both groups, the majority were women (81.5% - study group, 90.5% - control group, gender ratios 4.4:9.1, respectively). The patients were examined preoperatively and postoperatively: PTH, creatine, calcium, and phosphate serum and urine concentrations, and calcidiol serum levels were assessed. Preoperative ultrasonography (US) was performed.</br> <b><br>Results:</b> Patients with larger parathyroid lesions had signifficantly higher PTH and calcium serum concentrations and lower serum phosphate and calcidiol concentrations. There were no statistically significant differences in the concentration of creatine in serum and urine, calciuria, or tubular reabsorption of phosphorus (TRP). US relatively underestimated the parathyroid volume by about 0.3-0.4 mL (10% in larger lesions and 43% in smaller ones).</br> <b><br>Conclusions:</b> Due to higher PTH and calcium levels, larger parathyroid adenomas may constitute a higher risk of severe hypercalcemia. In general, US underestimated the parathyroid volume.</br>.

Intracranial Flow Volume Estimation in Patients with Internal Carotid Artery Occlusion.

(1) Background: Carotid artery occlusion (CAO) in population studies has a reported prevalence of about 6 per 100,000 people; however, the data may be underestimated. CAO carries a significant risk of stroke. Up to 15% of large artery infractions may be secondary to the CAO, and in 27−38% of patients, ischaemic stroke is a first presentation of the disease. The presence of sufficient and well-developed collateral circulation has a protective influence, being a good prognostic factor in patients with carotid artery disease, both chronic and acute. Understanding the mechanisms and role of collateral circulation may be very important in the risk stratification of such patients. (2) Materials and Methods: This study included 46 patients (mean age: 70.5 ± 6 years old; 15 female, mean age 68.5 ± 3.8 years old and 31 male, mean age 71.5 ± 6.7 years old) with unilateral or bilateral ICA occlusion. In all patients, a Doppler ultrasound (DUS) examination, measuring blood flow volume in the internal carotid artery (ICA), external carotid artery (ECA), and vertebral artery (VA), was performed. The cerebral blood flow (CBF) was compared to the previously reported CBF values in the healthy population >65 years old. (3) Results: In comparison with CBF values in the healthy population, three subgroups with CBF changes were identified among patients with ICA occlusion: patients with significant volumetric flow compensation (CBF higher than average + standard deviation for healthy population of the same age), patients with flow similar to the healthy population (average ± standard deviation), and patients without compensation (CBF lower than the average-standard deviation for healthy population). The percentage of patients with significant volumetric flow compensation tend to rise with increasing age, while a simultaneous decline was observed in the group without compensation. The percentage of patients with flow similar to the healthy population remained relatively unchanged. ICA played the most important role in volumetric flow compensation in patients with CAO; however, the relative increase in flow in the ICA was smaller than that in the ECA and VA. Compensatory increased flow was observed in about 50% of all patent extracranial arteries and was more frequently observed in ipsilateral vessels than in contralateral ones, in both the ECA and the VA. In patients with CAO, there was no decrease in CBF, ICA, ECA, and VA flow volume with increasing age. (4) Conclusions: Volumetric flow compensation may play an important predictive role in patients with CAO.

Volumetric Flow Assessment in Extracranial Arteries in Patients with 70-99% Internal Carotid Artery Stenosis.

Background: Cerebral blood flow (CBF) can be related to the risk of occurrence of neurological symptoms. Well-developed collateral circulation is a good prognostic factor in patients with cerebrovascular disease. Understanding the mechanisms of collateral circulation may be important in the diagnosis, treatment, and monitoring in this group of patients. The aim of this study covered the assessment of CBF in patients with 70−99% Internal carotid artery (ICA) stenosis, focusing on the circulation pathways and flow volume in extracranial arteries. Materials and methods: 53 patients with 70−99% ICA stenosis (mean age 73.4 ± 7 years old; 17 female, mean age 73.9 ± 7.5 years old; 36 male, mean age 73.2 ± 6.8 years old) were included in the study. In all patients a Doppler ultrasound (DUS) examination, measuring blood flow volume in the internal carotid artery (ICA), external carotid artery (ECA), and vertebral artery (VA), was performed. The cerebral blood flow (CBF) was compared to the previously reported CBF values in the healthy population > 65 years old. Results: Among the study groups three subgroups with flow differences were identified: patients with elevated CBF (significant volumetric flow compensation­26/53, 49%), patients with CBF similar to (mild compensation­17/53, 32%), and patients with CBF lower than (no compensation­10/53, 19%) the healthy, equally aged population. The percentage of patients with significant volumetric flow compensation was the highest in age groups 65−69 years old (62.5%) and >80 years old (60%). In the oldest age group (>80 years old) no patients without flow compensation (0%) were observed. The level of compensation depends on the number of the arteries with compensatory increased flow. In patients with significant volumetric flow compensation, the compensatory increased flow was observed, on average, in 3.31 arteries, in the mild compensation group­in 2.18 arteries, and in the no compensation group only in 1 artery. ICA plays the most important role in the volumetric flow compensation­the increase in the flow volume, in comparison to the reference values, was between 116.7 mL/min and 251.9 mL/min (in the ECA 57.6 mL/min−110.4 mL/min; in the VA 73.9 mL/min−104.9 mL/min). The relative flow increase was highest in the VA: 215−246%, then in the ECA: 163−206%, and finally in the ICA: 148.6−192%. The increased flow was most commonly observed in the VA­57 arteries, in second place in the ECA­42 arteries, and ICA­31 arteries. In patients with unilateral ICA stenosis, the volumetric flow increase was stated more frequently in the ipsilateral ECAs then in the contralateral ones (23 vs. 14). In the VA the opposite tendency was observed (29 contralateral vs. 23 ipsilateral). The ability of volumetric flow compensation decreased significantly with increasing age. Conclusions: Understanding the mechanisms of collateral circulation and their assessment in Doppler ultrasonography may provide a novel and easily accessible tool of identifying and monitoring patients with cerebrovascular disease.

A Woman with a 27-Year History of Hyperparathyroidism and Hypercalcemia Who Was Diagnosed with Low-Grade Parathyroid Carcinoma.

BACKGROUND Parathyroid carcinoma (PC), accounting for 0.005% of all cancers, is responsible for less than 1% of all cases of primary hyperparathyroidism, and equally affects males and females, usually in 4th or 5th decades of life. PC can occur sporadically and can be associated with congenital genetic syndromes such as hyperparathyroidism-jaw tumor syndrome (HPT-JT), isolated familial hyperparathyroidism, or multiple endocrine neoplasia 1 and 2 syndromes. Surgery is the main treatment, with a limited role of radio- and chemotherapy, which allows 49-77% of patients to survive 10 years. In this work we report the case of a patient with parathyroid carcinoma, whose treatment required 13 surgeries over a period of 27 years, together with radiotherapy and pharmacological treatment. CASE REPORT A 51-year-old woman was first diagnosed with primary hyperparathyroidism in 1993 at the age of 23. From 1993 to present, she underwent 13 surgeries and 33 courses of radiotherapy due to recurrent lesions, which initially had a character of parathyroid adenomas, then parathyromatosis, and finally were diagnosed as parathyroid carcinoma. The patient also required and currently requires complex pharmacological treatment to control the calcemia and manage the complications of the primary disease. Supervision by the multidisciplinary professional medical team allows the patient to lead a normal life with good control of the disease. CONCLUSIONS Parathyroid carcinoma is a rare disease with a number of complications; however, obtaining satisfactory long-term survival with acceptable quality of life is achievable.