Carotid Artery Involvement Research Articles

Carotid Atherosclerosis in Diabetic Patients and Associated Risk Factors

Objective: To determine the frequency of carotid atherosclerosis in diabetic patients and find out its association with various risk factors. Study Design: Cross-sectional analytical study. Place and Duration of Study: Department of Medicine, Combined Military Hospital, Nowshera Pakistan, from May to Jul 2022. Methodology: Patients, from both genders, were included in this study. Demographic information was obtained from all patients. Patients fulfilling the inclusion and exclusion criteria underwent carotid Doppler ultrasound after giving informed consent. High-resolution 7.5 MHz probe B mode ultrasonography and atherosclerosis was classified on the basis of grey-scale imaging. Results: A total of 100 patients were included in the study, out of which 74 were males and 26 were females. Among diabetics, 54% occurrence of atherosclerosis was seen, with a major share of 24% involvement of the left carotid artery, followed by 18% bilaterally, and 12% right carotid artery involvement. Carotid intimal media thickness increased with advancing age, with variable severity of mild in 32%, moderate in 14%, and severe stenosis in 3% of positive cases. Conclusion: There was a high association of carotid atherosclerosis with diabetes mellitus, having significant association with older age, hypertension, hyperlipidemia, and smoking.

Determining Factors Which Limit Resectability in Advanced Hypopharyngeal Malignancy.

Preoperative radiological findings of hypopharyngeal cancers are used to determine suitability for surgical resection. We sought to examine preoperative imaging characteristics to determine how well imaging findings predicted surgical resectability. A retrospective case-control study of patients undergoing a pharyngolaryngectomy in a tertiary referral center over a 2-year period was completed. Demographic details, previous treatment, subsite, TNM staging, imaging characteristics, and operative characteristics were collected. A total of 78 patients met initial inclusion criteria, of which 71 patients ultimately underwent successful surgical resection (91.1%). Preoperative images identified suspicion of prevertebral fascia invasion in 24 (30.7%) cases and carotid artery involvement in 14 (17.9%) cases. In cases of suspicion of prevertebral fascia invasion (24), 19 cases (79.2%) were resectable, and in those with carotid artery involvement (14), 11 (78.6%) were resectable. Concern for prevertebral fascia invasion on radiology led to a higher likelihood of a close margin (42% vs. 17%) in those without concerning features (p = 0.088). The present study demonstrated a high rate of resectability of hypopharyngeal and upper esophageal cancers despite imaging findings suspicious for factors that could limit resectability. In patients with advanced hypopharyngeal, especially in the salvage setting, surgery should be considered.

Clinical Characteristics of Patients with Takayasu Arteritis Undergoing Open or Endovascular Operations in China.

The operation rate for different involved arteries and the manifestation of vessel involvement of patients with Takayasu arteritis undergoing open or endovascular operations remain unclear. We aimed to investigate the clinical characteristics, vessel involvement, angiographic classification and operations information in a large cohort of patients with Takayasu arteritis undergoing open or endovascular operations at a single centre in China. From January 2017 to October 2022, a total of 153 consecutive patients undergoing open or endovascular operations were recruited from the Department of Vascular Surgery of Beijing Hospital. The demographic characteristics, clinical presentations, pattern of vascular involvement and operation information were collected and analysed. The majority of patients were female (128/153, 83.7%). The most common vascular finding was hypertension (66.7%). The subclavian (74.2%), carotid (70.1%) and renal (68.9%) arteries were the most commonly involved arteries. Type V (40.5%) was the most common angiographic classification pattern. A total of 296 open or endovascular operations were performed, including 73 percutaneous transluminal angioplasties (PTAs), 50 stent placements and 173 bypass graft operations. Patients with renal (83.3%) or carotid (65.2%) artery involvement had markedly higher rates of undergoing operations. The subclavian and carotid arteries, as well as the type V (40.5%) pattern, exhibited the highest frequency of involvement among patients with Takayasu arteritis who underwent open or endovascular operations. Variations in angiographic features can result in differences in clinical manifestations and significantly impact the possibility and modality of operations.

Spontaneous asymptomatic common carotid artery dissection resembling a carotid web: illustrative case.

Carotid artery dissection is a common cause of ischemic stroke, predominantly affecting the internal carotid artery, with rare involvement of the common carotid artery (CCA). The limited literature makes diagnosis and management challenging, particularly in asymptomatic patients. In this report, the authors present a unique case of spontaneous, asymptomatic CCA dissection that resembled a carotid web, shedding light on its clinical spectrum and management. A 70-year-old man was diagnosed with an intimal flap in the left CCA. Although the findings resembled those of a carotid web, cerebral angiography confirmed the presence of an intimal flap and arterial wall irregularities indicative of vascular dissection. Endarterectomy successfully prevented the stroke, and the postoperative recovery was uneventful. Pathological examination confirmed the diagnosis of CCA dissection. Spontaneous CCA dissection, though rare, presents significant diagnostic and therapeutic challenges. Because of morphological similarities, differentiating the diagnosis from a carotid web can be difficult. Available treatment strategies include antiplatelet therapy and surgical intervention. In this case, endarterectomy was chosen to avoid antithrombic treatment in anticipation of further invasive treatments for other conditions. The successful outcome highlights the potential as a treatment option, emphasizing the need for an individualized approach to each patient. https://thejns.org/doi/10.3171/CASE24344.

Exploration of technique for preservation of external-middle ear structure in surgery of jugular foramen paraganglioma （appended 2 case reports）

Objective:To investigate the feasibility and effect of the modified surgery of the classic infratemporal fossa type A approach for the surgical treatment of jugular foramen paraganglioma with preservation of the external and middle ear structures. Methods:The medical data of 2 patients with jugular foraminal paraganglioma treated by sublabyrinthic-transmastoid approach were retrospectively analyzed. The clinical feature, degree of tumor resection, postoperative facial nerve function and hearing retention, and the incidence of postoperative complications were evaluated. Results:Two patients were both female, and were pathologically confirmed as paraganglioma. The tumor of case 1 was staged as C2De1, and case 2 as C1De1. Tumors were completely resected in both patients. Case 1 suffered infection after surgery, with residual tympanic membrane perforation and mixed deafness. Case 2 developed mild facial paralysis（grade Ⅱ） after surgery, and recovered after symptomatic treatment. There was no tumor residue or recurrence during half a year of follow-up. Conclusion:Surgical treatment of certain paragangliomas in the jugular foramen with a combined sublabyrinthic-transmastoid and upper neck approach might achieve both complete resection of the tumor and preserving the structure and function of the outer-middle ear. This procedure is suitable for paragangliomas restricted in the jugular foramen area, with no or limited involvement of the internal carotid artery（C1 or C2）, and with no or mild hearing loss.

Clinical classification, staging and treatment strategy of radionecrosis of the nasopharynx and skull base

Objective:To establish a staging system for guiding clinical treatment and prognostic risk assessment by retrospectively analyzing the cases with radionecrosis of the nasopharynx and skull base （RNSB） after radiotherapy for nasopharyngeal carcinoma. Methods:A total of 86 cases of RNSB from January 2019 to December 2022 visited Department of Otorhinolaryngology Head and Neck, the People's Hospital of Guangxi Zhuang Autonomous Region. Seventeen patients gave up the treatment, and 69 patients who underwent treatment were included for analysis. By analyzing the results of electronic nasopharyngolaryngoscopy combined with magnetic resonance （MR）, CT, and other imaging examinations, a staging system for RNSB was proposed. The relationship between the staging system and the surgical effectiveness and clinical prognosis was further analyzed. Results:According to the severity and extent of destruction of soft tissue, bone, and the adjacent neurovascular structures, the RNSB was categorized into closed type （n=5） and open type （n=64）, of which the open type was subdivided into five types: type Ⅰ（n=4）, type Ⅱ（n=6）, type Ⅲ（n=39, of which 21 cases were type Ⅲa and 18 cases were type Ⅲb）, type Ⅳ（n=12）, and type Ⅴ（n=8）. The clinical stage of RNSB were classified based on nasopharyngolaryngoscopy and imaging examinations, receiving the second course of radiotherapy or not, the involvement of the infection site, the extent of bone destruction, the degree of internal carotid artery involvement, and the degree of brain tissue necrosis: stageⅠ（1-2 scores）, 11 cases at stageⅡ（3-4 scores）, 24 cases at stage Ⅲ（5-6 scores）, and 30 cases at stage Ⅳ（ ≥ 7 scores or more）. Twenty-two patients chose conservative treatment （2 patients at stage Ⅰ, 3 patients at stage Ⅱ, 7 patients at stage Ⅲ, and 10 patients at stage Ⅳ）. Forty-seven patients chose nasal endoscopic surgical treatment （2 patients at stage Ⅰ, 8 patients at stage Ⅱ, 17 patients at stage Ⅲ, and 20 patients at stage Ⅳ）, of which 16 cases had received free mucosal flap and/or stented septum mucosal flap repair. Patients at stages Ⅰ, Ⅱ, and Ⅲ achieved satisfactory efficacy after surgical treatment. In addition, higher clinical stage was found to correlate with the worse prognosis and higher incidence of perioperative complications, which included failure of healing because of surgical site infection, cerebrospinal fluid nasal leakage, progressive osteonecrosis, nasopharyngeal hemorrhage, and death. Conclusion:The staging system proposed in our study can be used for early detection of RNSB during regular follow-up, and is also valuable for clinical treatment guidance and prognosis assessment.

Transorbital ultrasound in the diagnosis of giant cell arteritis.

The objective of this study was to prospectively evaluate the diagnostic efficacy of transorbital ultrasound (TOS) in patients newly diagnosed with giant cell arteritis (GCA), presenting with visual symptoms. Patients with newly diagnosed, untreated GCA were examined using TOS, assessing central retinal artery flow velocity [peak systolic velocity (PSV), end-diastolic velocity (EDV), resistance index (RI)], and optic nerve diameter (OND). Vascular ultrasound was conducted to evaluate the superficial temporal arteries, their branches, facial, axillary, carotid, and vertebral arteries. We enrolled 54 GCA patients, 27 with visual symptoms, and 27 healthy controls. Eyes of GCA patients with visual symptoms demonstrated significantly lower PSV and EDV (PSV: β = -1.91; P = 0.029; EDV: β = -0.57; P = 0.032) and significantly elevated OND (β = 0.79; P = 0.003) compared with controls. RI did not significantly differ from controls (β = -0.06, P = 0.129). Vascular ultrasound identified an average of 8.7 (SD ± 2.8) pathological vessels per GCA patient. A significant negative association was observed between the number of affected vessels and both PSV (P = 0.048) and EDV (P = 0.040). No association was found with RI (P = 0.249), while a positive significant association was noted with OND (P < 0.001). This study pioneers the application of TOS to assess structural eye changes in newly diagnosed, untreated GCA patients with visual symptoms. Our findings suggest reduced central retinal artery flow and increased optic nerve diameter as potential biomarkers for serious ocular involvement in GCA. The detected association between internal and external carotid artery involvement indicates a common pathophysiological mechanism underlying systemic and ocular manifestations of GCA.

A novel ultrasound-based score for assessing carotid artery activity in Takayasu's arteritis.

The role of ultrasonography for evaluating vessel wall inflammation in Takayasu's arteritis (TAK) is well-recognised; however, an effective approach for the quantitative assessment of disease activity remains lacking. This study aimed to develop a novel ultrasound-based score for determining TAK activity. TAK patients with carotid artery involvement were prospectively followed-up for 6 months. Our proposed ultrasonographic activity score (ULTRAS, range between 0-12) consisted of wall thickness (TS, range between 0-8) and semi-quantitative echogenicity scores (ES, range between 0-4). The diagnostic performance of ULTRAS for disease activity was evaluated in terms of area under the receiver operating characteristic curve (AUC). Internal validation was subsequently performed. The patients were divided into training and validation groups (n=136 and 30. respectively). In the training group, 83 (61.0%) had active disease. At an optimal cut-off of 7, ULTRAS showed good diagnostic accuracy for active TAK (AUC, 0.88; 95% CI, 82-94). Improved diagnostic performance was achieved when combined with ESR (AUC, 0.91; 95% CI, 86-96) or CRP (AUC, 0.90; 95%CI, 86-95). In the verification group, the AUCs were 0.88, 0.95, and 0.92 for ULTRAS, ESR plus ULTRAS, and CRP plus ULTRAS, respectively. At post-treatment follow-up, the TS, ES, and ULTRAS paralleled the patients' disease remission and symptom recovery. At 3-month follow-up, an improvement in wall thickness of ≥0.3 mm correlated with symptom recovery in 50% of the patients. Our proposed ultrasound-based score carries the potential in the detection of active disease among TAK patients.

Long-Term Surgical Outcome of Class A and B Tympanomastoid Paragangliomas.

To analyze the long-term facial function as well as overall postoperative condition in surgically treated tympanomastoid PGL patients. Retrospective study. The medical records of patients with surgically managed class A and B tympanomastoid PGLs between 1983 and 2023 were thoroughly evaluated. Our center has treated a total of 213 cases of tympanomastoid PGL surgically. The mean age of patients was 54, and the male-to-female ratio was 1:6. The most common symptoms at presentation were hearing loss (80%), pulsatile tinnitus (77%), and vertigo (15%). According to the modified Fisch classification, 45% of the cases were classified as class A (A1 and A2), while 55% were classified as class B (B1, B2, and B3). All class A and most class B1 and B2 tumors were removed either with transcanal or retroauricular-transcanal approaches. However, more advanced class B3 lesions were removed with subtotal petrosectomy (SP) along with middle ear obliteration. Facial nerve outcome was excellent in all class A and B cases, while chances of postoperative paresis slightly increased with the size and extent of the tumor (p < 0.05). The hearing outcome is excellent for class A1, A2, B1, and B2 tumors, whereas more advanced class B3 cases have a loss of air conduction (AC) and increased bone conduction (BC) threshold (p < 0.05). Complete surgical removal was achieved in 97% of our cases. The most common late complication was permanent TM perforation (7%), and the recurrence rate was 3%. Tympanomastoid PGL represents the most common neoplasm of the middle ear space. The most frequent presenting symptoms include pulsatile tinnitus and hearing loss, whereas the presence of retrotympanic mass was evident in all cases at the time of initial otoscopic evaluation. Proper documentation of facial function and audiometric evaluation are crucial elements of preoperative workup. The most preferred preoperative radiologic examination is high-resolution computer tomography (HRCT), whereas magnetic resonance imaging (MRI) with or without gadolinium enhancement is reserved for cases with a dilemma of carotid artery or jugular bulb involvement. The main goal of tympanomastoid PGL treatment is complete disease removal with preservation of hearing and facial functions. Surgical treatment remains the preferred treatment modality with the benefits of complete disease removal, lower rate of recurrence and complication, and acceptable postoperative hearing level. Here, we present our 40 years of experience, which, to the very best of our knowledge, is the largest series of tympanomastoid PGL in the English literature.

Giant Meningiomas Invading the Cavernous Sinus: The “Inevitable Ones”

Abstract Introduction Giant meningiomas invading the cavernous sinus (GMICSs) are a subgroup of challenging tumors due to their volume and the extent of neurological impairment. Preserving quality of life is one of the most relevant aspects of treating patients with GMICS. Methods A retrospective study was conducted for surgeries performed between 2012 and 2022, including 33 patients presenting meningiomas with the largest diameter of at least 5 cm invading the cavernous sinus. The data from surgical intervention, Simpson grade of resection, tumor location, and morbimortality related to the surgeries were reviewed. Results The group comprised 25 women and 8 men with a median age of 56 years. The mean follow-up period was 52 months. The tumors were in the sphenoid wing, anterior clinoid, spheno-orbital, spheno-petroclival, petroclival, and Meckel's cave. Simpson grade I, II, and III were obtained in 70% of cases. The meningiomas were classified as WHO grade 1 in 94%, grade 2 in 3%, and grade 3 in 3%. The overall mortality was 3%. Permanent cranial nerve deficits occurred in 21%, transient cranial nerve deficits in 42%, cerebrospinal fistula in 15%, and hemiparesis in 18%. The recurrence/regrowth rate was 6%. The Karnofsky Performance Status score of 100 and 90 was 82%. Conclusions The surgical treatment of GMICS is an effective treatment modality with acceptable morbimortality and good long-term control. Involvement of the internal carotid artery is essential to determine the extent of resection inside the cavernous sinus, and training in the microsurgical laboratory is mandatory for safe surgical treatment.

Adult Moyamoya Disease and Moyamoya Syndrome: What Is New?

Recent advances are in the genetics, diagnosis, pathophysiology, and management of moyamoya disease (MMD), and moyamoya syndrome (MMS), a term used to describe moyamoya-like vasculopathy associated with various systemic diseases or conditions. Ring finger protein (RNF213) has been reported to be a susceptibility gene not only for MMD but also for atherosclerotic intracranial arterial stenosis and ischemic stroke attributable to large artery atherosclerosis. The latest guidelines by the Research Committee on MMD of the Japanese Ministry of Health, Labor, and Welfare, removed limitations of the previous definition that required bilateral involvement of the intracranial carotid artery to make the diagnosis, given the increasing evidence of progression to bilateral involvement in unilateral MMD. 3-dimensional constructive interference in steady-state MRI is useful for the differential diagnosis of MMD from atherosclerosis. Recent advances in the pathophysiology of MMD suggest that genetic and environmental factors play important roles in vascular angiogenesis and remodeling via complex mechanisms. The latest Japanese Guidelines and American Scientific Statement described that antiplatelet therapy can be considered reasonable. Endovascular interventional stent placement fails to prevent ischemic events and does not halt MMD progression. In the Japan Adult Moyamoya trial, a randomized controlled trial for bilateral extracranial-intracranial direct bypass versus conservative therapy in patients with MMD, who had intracranial hemorrhage, recurrent bleeding, completed stroke, or crescendo transient ischemic attack was significantly fewer with direct bypass than with conservative care. This review presents updated information on genetics, diagnosis, pathophysiology, and treatment of adult MMD and MMS. Despite recent advances, many mysteries still exist in the etiologies of moyamoya vasculopathy. The diagnostic criteria and treatment guidelines have been updated but not yet been globally established. Ongoing and future studies investigating underlying pathophysiological mechanisms of MMD and MMS may clarify potentially effective medical, surgical, or endovascular treatments.

Risk of Diabetes Mellitus in Carotid Artery Involvement Among Coronary Artery Disease Patients Including History of Infection and Antibiotics Uses

Background: Diabetes mellitus causes involvement of coronary artery diseases. Objective: The purpose of the present study was to determine the risk of diabetes mellitus in the involvement of carotid artery among coronary artery disease patients. Methodology: This case-control study was conducted in the Department of Cardiology at Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from July 2013 to June 2015 for a period of two years. Patients who had coronary artery diseases or ischemic heart diseases and diabetes mellitus undergoing coronary angiography were selected as case of this study. In control group, age, sex match patients of IHD undergoing CAG not having DM were included. Every patient was clinically examined by detailed history and physical examination during entry into study. ECG, chest X-ray, echocardiogram, blood sugar (fasting), blood 2 hrs. after 75 gm of glucose and or breakfast were analyzed. Coronary angiography was done in all patients through femoral approach by modified Seldinger technique. Carotid arteriography was performed selective and non­selective method by Hunter head or right Judkin's catheter in standard AP, lateral and oblique views. Results: A total number of 100 patients were included in this study. Of them 50 patients were coronary artery disease with diabetes mellitus and another 50 patients were coronary artery disease without diabetes mellitus. The mean height of the DM was 163.4±8.5 cm and in NDM was 160.6±7.1 cm, mean weight of DM 63.5±7.2 kg, in NDM was 62.0±15.4 kg and mean BMI in DM was 26.24±2.36 kg/m2 and in NDM was 26.38±2.05 kg/m2. The mean total cholesterol in DM was 236.9±34.1 mg/dL and in NDM was 208.0±36.4 mg/dL, mean serum TG in DM 240.5±76.3 mg/dl and in NDM was 207.6±57.8 mg/dl and mean serum IDL in DM was 166.1±130.6 mg/dL and in NDM was 142.8±30.4 mg/dL, no significant mean difference was observed between DM and NDM in height, weight and BMI (P&gt;0.05). Concussion: In conclusion, significant mean difference is observed between DM and NDM in total cholesterol, serum triglycerides. Bangladesh Journal of Medical Microbiology, July 2023;17 (2):82-87

Operative Strategies for Aplastic Circle of Willis Arteries on CTA in Meningioma Surgery: A Case Report

BACKGROUND AND IMPORTANCE: Meningiomas frequently involve critical neurovascular structures. Preoperative imaging with computed tomography angiography (CTA) can help understand the relationship of tumor with neurovascular structures. Although CTA was useful in preoperative planning and less invasive, we present a unique case in which it mistakenly represents a hypoplastic anterior cerebral artery as aplastic and thus displays poor sensitivity in the Circle of Willis. CLINICAL PRESENTATION: A 66-year-old woman presented with new onset seizures and MRI demonstrated a sphenoid wing meningioma with tumor involvement of the internal carotid artery and right M1 artery. On preoperative CTA, a right A1 artery was not appreciated. However, a hypoplastic right A1 artery was identified during careful dissection guided by micro-Doppler and found to be encased within the tumor. All arteries were preserved, and a near-total resection was achieved with a small remnant of tumor at the supraclinoid internal carotid artery. CONCLUSION: Although CTAs can be useful in understanding vascular anatomy and its association with tumors, they are not ideal for providing information about hypoplastic arterial segments. Seemingly aplastic arteries on CTA may very well be present, albeit hypoplastic. While we recognize the usefulness of a less invasive modality of CTA to help guide surgical strategy, we underscore recognizing this potential pitfall and recommend the use of the microvascular Doppler during careful dissection when working within tumor in the location of a seemingly aplastic artery.

Pre-Pulseless Takayasu Arteritis is Associated with Distinct Clinical and Angiographic Features but Similar Outcomes - A Cohort Study.

To compare the presentation, angiographic features, evolution, and prognosis of prepulseless Takayasu arteritis (TAK) with TAK with pulse loss. Pre-pulseless TAK (defined as without pulse loss in the upper limbs, lower limb, carotid, or subclavian arteries) were identified from a cohort of TAK. Demographic characteristics, clinical features, angiographic involvement, baseline and longitudinal patterns of disease activity, medication use, and mortality rates were compared between pre-pulseless TAK and TAK with pulse loss. Adjusted odds ratios (aOR, with 95%CI) for categorical variables between pre-pulseless TAK and TAK with pulse loss were computed using multivariable-adjusted logistic regression models. Time-to-event data was compared using hazard ratios (HR) with 95%CI. Compared with TAK with pulse loss, pre-pulseless TAK (91/238, 38.24%) more frequently had deranged renal function (aOR 4.43, 95%CI 1.58-12.37) and Hata's type IV disease (aOR 8.02, 95%CI 2.61-24.65), and less often had pulse or blood pressure asymmetry (aOR 0.34, 95%CI 0.18-0.63), limb claudication (aOR for upper limb 0.38, 95%CI 0.18-0.82, for lower limb 0.28, 95%CI 0.12-0.68), right subclavian (aOR 0.45, 95%CI 0.23-0.90) or left carotid artery involvement (aOR 0.42, 95%CI 0.21-0.84). Only two patients with pre-pulseless TAK developed pulse loss on follow-up. Despite fewer pre-pulseless TAK having active disease at presentation, similar proportions of patients in both groups had active disease on follow-up. Survival was similar in both groups (HR for mortality 0.41, 95%CI 0.09-1.90). Pulse loss on follow-up is uncommon in those with prepulseless TAK. Pre-pulseless TAK is associated with similar long-term outcomes to TAK with pulse loss.

Ischémie subaiguë bilatérale des membres supérieurs révélant une Maladie de Horton, une présentation assez rare : à propos d'un cas et revue de la littérature

Study's goalOur goal is to enrich the medical literature by sharing our experience in managing a case of sub-acute upper limb ischemia that revealed Horton's disease. This is particularly relevant given the current lack of well-established guidelines. IntroductionAcute upper limb ischemia is rarely seen in Horton's disease. Case ReportWe present a case of a 63-year-old female patient with sub-acute ischemia in both upper limbs, accompanied by jaw claudication and absence of bilateral temporal pulses. The CT Angiography scan revealed bilateral occlusions and stenosis of the axillary and sub-clavier arteries, as well as involvement of the external carotid arteries and its branches. The Arteriography confirmed abnormalities in the medium-sized arteries of the supra-aortic trunks. The histopathology examination of the temporal artery biopsy was negative. The patient received emergency corticosteroid therapy followed by an immunosuppressant. Due to the improved clinical condition of the upper limbs, surgical intervention was not performed.

Carotid Artery Involvement in Patients Undergoing Coronary Angiography with Diabetes Mellitus

Background: Carotid artery disease would be high in patients having coronary artery disease with diabetes mellitus. Objective: The purpose of the present study was to see frequency, pattern and severity of carotid artery disease among patients with IHD and diabetes mellitus. Methodology: This case-control study was conducted in Department of Cardiology, UCC, BSMMU from July, 2007 to June 2009. Total 100 patients were included in this study. Of them 50 patients were coronary artery disease with diabetes mellitus and another 50 patients were coronary artery disease without diabetes mellitus. Both group were underwent coronary and carotid angiography. Coronary artery stenosis is assessed by different scoring system and carotid artery stenosis are categorized as mild (&lt; 50% stenosis) moderate (50-69% stenosis) and critical (&gt;_ 70% stenosis). Moderate and critical stenosis was considered as significant carotid artery disease. Morphological character of the lesion was also assessed. Results: The mean age was found 57.48 years with 6.04 standard deviation (SD) in DM and 55.64 years with 6.34 standard deviation in NDM group and also 56.56 years with 6.49 standard deviation in the whole study population. the indications of CAG were Post MI evaluation, unstable angina, stable angina, chest pain evaluation and positive ETT were 42.0%, 20.0%, 18.0%, 10.0% and 10.0% in DM group and 32.0%, 28.0%, 20.0%, 8.0% and 12.0 in NDM group respectively. LAD was the commonest artery involved (86.0%), followed by RCA (82.0%), LCX (68.0%) and LM (6.0%) in DM study subjects. Among the NDM LAD artery involved (76.0%), followed by RCA (72.0%), LCX (64.0%) and LM (4.0%) in NDM study subjects. Conclusion: In conclusion, patients of coronary artery disease with diabetic mellitus are having higher frequency and severity of Carotid artery disease than non-diabetic coronary artery disease patients. Journal of National Institute of Neurosciences Bangladesh, January 2023;9(1):30-34

Prospective Evaluation of Locoregional Control in Oral Cavity Squamous Cell Carcinoma with Infratemporal Fossa Involvement Treated with Surgery and Adjuvant Concurrent Chemoradiotherapy

Oral cavity squamous cell carcinoma (OCSCC) is the most common head and neck cancer in India. Definitive surgery with or without post-op radiotherapy (PORT) with or without chemotherapy (CT) provides better outcomes in locally advanced OCSCC as compared to definitive chemoradiotherapy. T4b OCSCC with infra temporal fossa (ITF) involvement has varied outcome depending on the extent of ITF involvement, with low and mid ITF having relatively favorable prognosis. We aimed to prospectively evaluate outcomes in patients of OCSCC with low or mid ITF involvement treated with curative surgery followed by adjuvant concurrent chemoradiotherapy (CCRT). A total of 20 patients of T4b OCSCC (as per AJCC 8th edition) with low or mid ITF involvement were included in this single arm prospective interventional study from January 2021 to October 2022. Patients with involvement of skull base, carotid artery, prevertebral fascia and/or pterygomaxillary fissure were excluded. All patients were treated with definitive surgery with ITF clearance followed by adjuvant CCRT as indicated. Loco-regional control (LRC), Disease free survival (DFS), Overall survival (OS) were assessed using Kaplan-Meier survival analysis. Acute toxicities were assessed according to the CTCAE v5.0. Patient characteristics are summarized in table 1. Median follow-up was 11.5 months (4-21months). All patients received adjuvant CCRT with weekly cisplatin 40mg/m2 to a median number of 6 cycles (5-7 cycles). Median RT dose was 64Gy (60-64Gy). All patients tolerated treatment well. Grade 3 oral mucositis, odynophagia were seen in 8 (40%) patients each and skin toxicity, oral pain in 6 (30%) and 5 (25%) patients respectively. No grade 4 toxicities were observed LRC at three month was 73.68% with 4 local and 1 locoregional failure only. LRC at one year was 36.8% with 8 local, 1 locoregional, 2 locodistant and 1 distant failure only. Median DFS was 10.4 months. Median OS was not reached; four patients died. LRC at three months was better for patients with low ITF disease as compared to mid ITF disease (85.7% vs. 40% (p = 0.04) and at one year was 42.8% vs. 40% (p = 0.50). Selected patient of locally advanced OCSCC with low ITF involvement may benefit from trimodality therapy of surgery with ITF clearance followed by adjuvant CCRT. Acute toxicity profile was acceptable in our study.

Magnetic resonance imaging in COVID-19-associated acute invasive fungal rhinosinusitis - Diagnosis and beyond.

The aim of the study was to evaluate the magnetic resonance imaging (MRI) features of acute invasive fungal rhinosinusitis (AIFRS) at presentation and on follow-up imaging when patients receive treatment with systemic antifungal therapy and surgical debridement. This is a retrospective analysis of imaging data from a cohort of patients diagnosed with AIFRS during the second wave of COVID-19 in single tertiary referral hospital in South India between March 2021 and May 2021 (n = 68). Final diagnosis was made using a composite reference standard which included a combination of MRI findings, clinical presentation, nasal endoscopy and intraoperative findings, and laboratory proof of invasive fungal infection. Analysis included 62 patients with "Definite AIFRS" findings on MRI and another six patients with "Possible AIFRS" findings on MRI and laboratory proof of invasive fungal infection. Follow-up imaging was available in 41 patients. The most frequent MRI finding was T2 hypointensity in the sinonasal mucosa (94%) followed by mucosal necrosis/loss of contrast-enhancement (92.6%). Extrasinosal inflammation with or without necrosis in the pre-antral fat, retroantral fat, pterygopalatine fossa, and masticator space was seen in 91.1% of the cases. Extrasinosal spread was identified on MRI even when the computed tomography (CT) showed intact bone with normal extrasinosal density. Orbital involvement (72%) was in the form of contiguous spread from either the ethmoid or maxillary sinuses; the most frequent presentation being orbital cellulitis and necrosis, with some cases showing extension to the orbital apex (41%) and inflammation of the optic nerve (32%). A total of 22 patients showed involvement of the cavernous sinuses out of which 10 had sinus thrombosis and five patients had cavernous internal carotid artery involvement. Intracranial extension was seen both in the form of contiguous spread to the pachymeninges over the frontal and temporal lobes (25%) and intra-axial involvement in the form of cerebritis, abscesses, and infarcts (8.8%). Areas of blooming on SWI were noted within the areas of cerebritis and infarcts. Perineural spread of inflammation was seen along the mandibular nerves across foramen ovale in five patients and from the cisternal segment of trigeminal nerve to the root exit zone in pons in three patients. During follow-up, patients with disease progression showed involvement of the bones of skull base, osteomyelitis of the palate, alveolar process of maxilla, and zygoma. Persistent hyperenhancement in the post-operative bed after surgical debridement and resection was noted even in patients with stable disease. Contrast-enhanced MRI must be performed in all patients with suspected AIFRS as non-contrast MRI fails to demonstrate tissue necrosis and CT fails to demonstrate extrasinosal disease across intact bony walls. Orbital apex, pterygopalatine fossa, and the cavernous sinuses form important pathways for disease spread to the skull base and intracranial compartment. While cerebritis, intracranial abscesses, and infarcts can be seen early in the disease due to the angioinvasive nature, perineural spread and skull base infiltration are seen 3-4 weeks after disease onset. Exaggerated soft-tissue enhancement in the post-operative bed after debridement can be a normal finding and must not be interpreted as disease progression.

Association of carotid atherosclerosis and peripheral artery disease in patients with type 2 diabetes: risk factors and biomarkers

BACKGROUND: Carotid atherosclerosis (CA) and lower extremity peripheral artery disease (PAD) is a common and potentially life-threatening comorbidity in diabetes.AIM: to determine risk factors and biomarkers of the association of CA and PAD in patients with type 2 diabetes.MATERIALS AND METHODS: A single-center cross-sectional comparative study was carried out. Three hundred ninety one patients with type 2 diabetes were included. Duplex ultrasound of carotid and low limb arteries, screening/monitoring of diabetic complications and associated diseases, and assessment of glycemic control, biochemical and coagulation parameters were performed. Factors involved in vascular wall remodeling, including calponin-1, relaxin, L-citrulline, matrix metalloproteinase-2 and -3, were measured in blood serum by ELISA.RESULTS: The signs of CA and PAD were observed in 330 and 187 patients respectively. In 178 patients, both CA and PAD were revealed. The risk of combined involvement of carotid and lower extremity arteries was higher in patients with diabetic retinopathy (OR=2.57, p&lt;0.001), chronic kidney disease (OR=4.48, p&lt;0.001), history of myocardial infarction (OR=5.09, p&lt;0.001), coronary revascularization (OR=4.31, p&lt;0.001) or cerebrovascular accident (OR=3.07, p&lt;0.001). In ROC-analysis, age ≥65.5 years (OR=3.43, p&lt;0.001), waist-to-hip ratio ≥0.967 (OR=3.01, p=0.001), diabetes duration ≥12.5 years (OR=3.7, p&lt;0.001), duration of insulin therapy ≥4.5 years (OR=3.05, p&lt;0.001), duration of arterial hypertension ≥16.5 years (OR=1.98, p=0.002), serum L-citrulline ≥68 µmol/l (OR=3.82, p=0.003), and mean amplitude of glucose excursions ≥3.72 mmol/l (OR=1.79, p=0.006) were the risk factors for atherosclerosis of two vascular beds. In multivariate logistic regression analysis, age, diabetes duration and waist-to-hip ratio were independent risk factors for association of CA and PAD (p=0.005, p=0.0003, and p=0.004 respectively).CONCLUSION: In subjects with type 2 diabetes, carotid and lower extremity atherosclerotic disease is associated with age, diabetes duration, abdominal obesity, microvascular and macrovascular complications, glucose variability, and high serum levels of L-citrulline.

Analysis of the efficacy of endoscopic transnasal surgery for sinonasal and skull base adenoid cystic carcinoma

Objective: To evaluate the efficacy of endoscopic transnasal surgery for sinonasal and skull base adenoid cystic carcinoma (ACC), and to analyze the prognostic factors. Methods: Data of 82 patients (43 females and 39 males, at a median age of 49 years old) with sinonasal and skull base ACC who were admitted to XuanWu Hospital, Capital Medical University between June 2007 and June 2021 were analyzed retrospectively. The patients were staged according to American Joint Committee on Cancer (AJCC) 8th edition. The disease overall survival(OS) and disease-free survival(DFS) rates were calculated by Kaplan-Meier analysis. Cox regression model was used for multivariate prognostic analysis. Results: There were 4 patients with stage Ⅱ, 14 patients with stage Ⅲ, and 64 patients with stage Ⅳ. The treatment strategies included purely endoscopic surgery (n=42), endoscopic surgery plus radiotherapy (n=32) and endoscopic surgery plus radiochemotherapy (n=8). Followed up for 8 to 177 months, the 5-year OS and DFS rates was 63.0% and 51.6%, respectively. The 10-year OS and DFS rates was 51.2% and 31.8%, respectively. The multivariate Cox regression analysis showed that late T stage and internal carotid artery (ICA) involvement were the independent prognostic factors for survival in sinonasal and skull base ACC (all P<0.05). The OS of patients who received surgery or surgery plus radiotherapy was significantly higher than that of patients who received surgery plus radiochemotherapy (all P<0.05). Conclusions: Endoscopic transonasal surgery or combing with radiotherapy is an effective procedure for the treatment of sinonasal and skull base ACC. Late T stage and ICA involvement indicate poor prognosis.