Carotid and vagal body paragangliomas

Between 1972 and 2012, 25 patients presenting 32 paragangliomas of the neck were observed. Tumor locations included the carotid body (CBTs) in 21 patients and the vagus nerve in 4. Four patients had bilateral CBT and one a bilateral vagal tumor; a metachronous bilateral jugulare paraganglioma was diagnosed in one patient with bilateral CBT Shamblin type III. Five patients presented CBTs type II and three type III. Preoperative embolization was performed in 5 CBTs, with no significant difference in blood loss. Twenty-nine paragangliomas were resected (with three internal carotid artery resection): there were no cerebrovascular accident or perioperative death. Nine patients (36%) had cranial nerve palsy prior to surgery and a postoperative nerve dysfunction occurred in four other tumors (16%). Persistent nerve deficits occurred in 3 patients (12%). No evidence of malignancy was shown, intraoperatively or during a postoperative follow-up period (9 months to 18 years; mean: 8 years)

What the young physician should know about May-Thurner syndrome

May-Thurner syndrome (MTS) is an anatomically variable condition resulting in compression of the left common iliac vein between the right common iliac artery and the underlying spine with subsequent development of a left deep vein thrombosis (DVT). Although this syndrome is rare, its true prevalence is likely underestimated. Mainly, clinical symptoms and signs include, but are not limited to, pain, swelling, venous stasis ulcers, skin pigmentation changes and post-thrombotic syndrome. Correct treatment is not well established and is based on clinical presentation. Staged thrombolysis with/without prophylactic retrievable inferior vena cava filter placement followed by angioplasty/stenting of the left iliac vein appears to be the best option in MTS patients with extensive DVT. The aim of this review is to present in a simple and didactic form all variable clinical presentations of MTS and to outline possible management within the current guidelines

Pre and postoperative evaluation of transcranial Doppler pulsatility index of the middle cerebral artery in patients with severe carotid artery stenosis

In the management of severe carotid artery stenosis particular importance must be given to the evaluation of the risk of perioperative cerebral ischemic events. Our study analysed the possible relationship between the pre-operative middle cerebral artery Gosling Index, calculated after transcranial Doppler (TCD), and intra-operative stump pressure (SP), in order to identify patients with higher risk of ischemic accidents. Moreover, we studied pre- and post- operative Gosling Index values in association with possible events during follow-up. In a one-year time lapse 47 patients underwent either carotid endoarterectomy (CEA) or carotid artery stenting (CAS) with proximal embolic protection system. All patients were subject to pre- and post-operative TCD with calculation of the Gosling Index and intra-operative SP. We observed that higher pre-operative Gosling Index values are associated with lower intra-operative SP values, elements that represent a higher risk for cerebro-vascular ischemic accidents; this result is particularly evident when observing the diabetic sub-population. An increase in ischemic events did not present statistically significant differences when observing the populations treated with CEA or CAS. TCD and SP are valid and simple exams that can help identify precociously patients with a higher risk of cerebro-vascular accidents related to surgical or endovascular treatment

Treatment of de novo femoro-popliteal lesions with a new Drug Coated Balloon: early experience of a single Center in the first 50 patients

Angioplasty with drug-coated balloon (DCB) is an emerging and reliable method for the treatment of femoro-popliteal lesions. We report our experience with the Stellarex™ DCB in the first 50 patients. Methods - From July 2015 to November 2017, 50 patients (41 M, 9F), medium age (64 ± 7.4 year) were subject to 33 angioplasties (PTAs) for femoro-popliteal lesions with a paclitaxel-coated balloon (Stellarex™). Based upon clinical data sixteen patients had severe claudication (56% - Rutherford class 3); ten patients suffered from ischemic rest pain (34% - Rutherford class 4); and five presented minor tissue loss (10% - Rutherford class 5). 42% of patients showed femoro-popliteal lesion TASC-II B, and 58% presented lesions pertaining to TASC-II C. Results - Immediate technical success was 100% without perioperative complications. Primary patency rate was 94% at twelve months. In three cases restenosis (6%) was detected within a year from procedure, and a further PTA DCB was performed with primary assisted patency rates of 100% at twelve months. Two patients underwent major lower limb amputation. Three patients died during follow-up and one patient was lost at follow-up. Conclusion - DCB angioplasty with Stellarex™ is a viable alternative to traditional endovascular procedures proving satisfactory primary patency rates at twelve months. Based on our experience, treatment with DCB is a first choice technique for non-complex de novo lesions of the femoro – popliteal tract

Use of the directional atherectomy for the treatment of femoro-popliteal lesions in patients with critical lower limb ischemia

Femoro-popliteal PTA for the treatment of critical limb ischemia is frequently associated with unsatisfactory procedural success rates while directional atherectomy (DCA) has improved success rate since claudicant patients undergoing percutaneous treatment of femoro-popliteal obstructive disease. The aim of this prospective study is to evaluate the safety, efficacy and procedural success of DCA, at one year, in the percutaneous treatment of femoro-popliteal obstructive disease in patients with critical limb ischemia. Methods. From March 2012 to March 2013 18 consecutive patients with critical limb ischemia were treated with DCA (Turbohawk/Covidien-ev3 Endovascular Inc., North Plymouth, Minnesota, USA) for the treatment of femoro-popliteal obstructive disease. Patients were evaluated at 12 months. Results. Technical and procedural success was achieved in every patient. No in-hospital major adverse cardiovascular events occurred. Primary endpoint: freedom from any amputation was obtained in all patients. Secondary endpoints: clinical (Rutherford class improvement) and hemodynamic success (Ankle-brachial index improvement) was achieved in all patients. Conclusion. The use of DCA for the treatment of femoro-popliteal obstructive disease is a safe and effective therapeutic strategy for patients with critical limb ischemia. The data included in our study should be considered hypothesis-generating in order to design of a randomized trial comparison with conventional PTA

Whole-body magnetic resonance for staging and response assessment of lymphoma in a pregnant woman treated with antenatal chemotherapy

A 32-year-old pregnant female presented with bilateral supraclavicular swelling, diffuse itching and right shoulder pain. After lymph nodal biopsy, a diagnosis of nodular sclerosis Hodgkin's lymphoma was obtained. A multidisciplinary team decided to start chemotherapy before the delivery, and whole-body MRI was used to stage the disease and evaluate the response after antenatal chemotherapy. This case shows that whole-body MRI is an attractive procedure that avoids radiation exposure and contrast administration, and enables staging and follow-up of a pregnant patient without risk to the fetus

Ruolo della RM whole body nell’identificazione di reperti incidentali in pazienti con linfoma.

Scopo: Il dibattito in merito ai reperti incidentali sta divenendo emergente in molti settori radiologici, quali l’ambico cardiaco, addominale, neurologico, senologico, pediatrico, soprattutto con metodiche quali la RM e la TC. Lo scopo del nostro studio è stato di valutare l’utilità della Risonanza Magnetica Whole Body (RM-WB) nell’identificazione di reperti incidentali in pazienti con linfoma. Materiali e metodi: Sono state revisionate le RM-WB eseguite su 114 pazienti (65 maschi; età mediana 45,2 anni, range 15-86) con diagnosi istologica di linfoma (47 Hodgkin, 67 Non-Hodgkin). I reperti incidentali sono stati classificati in tre classi: non significativi (classe 1), moderatamente significativi (classe 2), significativi (classe 3). Un test Chi quadro (χ2) è stato utilizzato per valutare la significatività statistica delle differenze nella frequenza dei reperti incidentali sulla base di età (≤ 50 e > 50 anni), sesso ed istologia. Risultati: Sono stati individuati uno o più reperti incidentali nelle RM-WB eseguite in 91/114 pazienti (79,8%). I reperti incidentali più frequenti sono stati di classe 1 (43%). In 7 pazienti (6,1%) sono stati riscontrati reperti incidentali di rilevanza clinica maggiore (classe 3), che hanno richiesto approfondimento diagnostico o immediato trattamento. I reperti incidentali sono stati più frequenti nei pazienti oltre i 50 anni con una differenza statisticamente significativa rispetto a pazienti ≤ 50 anni (χ2 = 8,42, p 0,05) ed istologia (χ2 = 0,24, p > 0,05). Le figure 1, 2 e 3 mostrano alcuni casi rappresentativi del nostro studio. Conclusioni: In letteratura, parecchi studi hanno analizzato i reperti incidentali in RM-WB, effettuate sulla popolazione sana [1,2]. Il nostro lavoro è il primo che ricerca reperti incidentali in pazienti con noto linfoma e sottoposti a RM-WB. Ci sono molti vantaggi clinici, sociali ed economici associati alla diagnosi dei reperti incidentali: in primo luogo, la diagnosi precoce di una malattia porta ad un suo tempestivo trattamento con miglioramento della prognosi; in secondo luogo, la diagnosi precoce occasionale di molte malattie riduce i costi per il sistema sanitario nazionale; alcuni di questi reperti risultano essere molto utili nel caso di intervento chirurgico; infine, una valutazione approfondita delle caratteristiche cliniche dei pazienti fornisce dei dati utili ai fini della prognosi. Tuttavia, esistono conseguenze negative quali ad esempio il riscontro di un numero considerevole di lesioni accidentali, non caratterizzabili con precisione con le sole immagini RM-WB, con la conseguente possibilità si sovrastimare un reperto sospetto. E’ fondamentale pertanto trovare un equilibrio tra i benefici associati ad una diagnosi precoce ed i rischi di sottoporre il paziente ad ulteriori indagini non necessarie. Nel nostro studio la percentuale dei reperti occasionali (79.8%), simile alle percentuali precedentemente riportate in analoghi studi [3,4], cresce all’aumentare dell’età dei pazienti e non è dipendente dal sesso. La RM-WB è una tecnica promettente che evita l’esposizione a radiazioni ionizzanti e la somministrazione di mezzo di contrasto e consente di individuare reperti incidentali, offrendo la possibilità di ottenere una diagnosi precoce di patologie asintomatiche anche clinicamente rilevanti. Informazioni Personali: Dr. Domenico Albano, MD, Dipartimento di Scienze Radiologiche, Di.Bi.Med., Università di Palermo, Via del Vespro 27, 90127 Palermo, Italia Note Bibliografiche: 1. Cieszanowski A, Maj E, Kulisiewicz P et al (2014) Non-contrast-enhanced whole-body magnetic resonance imaging in the general population: the incidence of abnormal findings in patients 50 years old and younger compared to older subjects. PLoS One 26;9:e107840 2. Lo GG, Ai V, Au-Yeung KM, Chan JK, Li KW, Chien D (2008) Magnetic resonance whole body imaging at 3 Tesla: feasibility and findings in a cohort of asymptomatic medical doctors. Hong Kong Med J 14:90-96 3. Cieszanowski A, Maj E, Kulisiewicz P et al (2014) Non-contrast-enhanced whole-body magnetic resonance imaging in the general population: the incidence of abnormal findings in patients 50 years old and younger compared to older subjects. PLoS One 26;9:e107840 4. Lo GG, Ai V, Au-Yeung KM, Chan JK, Li KW, Chien D (2008) Magnetic resonance whole body imaging at 3 Tesla: feasibility and findings in a cohort of asymptomatic medical doctors. Hong Kong Med J 14:90-9

Whole-body MRI in patients with lymphoma: collateral findings

Whole body MRI (WB-MRI) is a non invasive technique increasingly used to stage (1-4) and follow-up (5-8) patients with malignancies such as lymphoproliferative disorders. It is now recognized as a promising tool that provides high quality anatomical imaging and a multiparametric approach of the en