Focal Narrowing Research Articles

Three-Dimensional Optical Coherence Tomography Evaluation of Vascular Changes at Arteriovenous Crossings

To study the three-dimensional morphologic features of retinal arteriovenous crossings with optical coherence tomography (OCT) and elucidate the vascular changes associated with crossing phenomena as seen on fundus photographs. We examined 150 consecutive eyes with no ocular disease. In each eye, fundus photographs were taken, and one randomly selected arteriovenous crossing was examined by OCT. The OCT analysis was performed by using sequential thin sections along and perpendicular to the retinal vessels. The OCT analysis of these arteriovenous crossings showed that the veins abruptly changed their directions to pass the artery and frequently displayed focal luminal narrowing with no compression or flattening. The OCT measurements revealed that the veins narrowed by 21.0% ± 12.9% at the crossings. The degree of narrowing correlated positively with the diameter of the crossing arteries (r = 0.419, P < 0.001). On fundus photographs, crossing phenomena were observed in 103 of the 150 selected crossings. Venous narrowing measured by OCT was more severe in eyes with crossing phenomena on fundus photographs (P < 0.001). Four types of crossing phenomena were observed: concealment, tapering, deflection, and humping. Venous narrowing rates were similar among all four types. Although the subjects with deflection or humping phenomena were more likely to suffer from hypertension, the mean venous narrowing rate at such crossings was similar to that observed with the other crossing phenomena. Arteriovenous crossings exhibited focal narrowing of the venous lumen with no compression or flattening. Increased venous narrowing and larger arteries were observed at crossings with crossing phenomena.

Morphometric analysis of small arteries in the human retina using adaptive optics imaging

Objectives:The wall-to-lumen ratio (WLR) of retinal arteries is a recognized surrogate of end-organ damage due to aging and/or arterial hypertension. However, parietal morphometry remains difficult to assess in vivo. Recently, it was shown that adaptive optics retinal imaging can resolve parietal structures of retinal arterioles in humans in vivo. Here, using adaptive optics retinal imaging, we investigated the variations of parietal thickness of small retinal arteries with blood pressure and focal vascular damage.Methods:Adaptive optics imaging of the superotemporal retinal artery was done in 49 treatment-naive individuals [mean age (±SD) 44.9 years (±14); mean systolic pressure 132 mmHg (±22)]. Semi-automated segmentation allowed extracting parietal thickness and lumen diameter. In a distinct cohort, adaptive optics images of arteriovenous nicking (AVN; n = 12) and focal arteriolar narrowing (FAN; n = 10) were also analyzed qualitatively and quantitatively.Results:In the cohort of treatment-naive individuals, by multiple regression taking into account age, body mass index, mean, systolic, diastolic and pulse blood pressure, the WLR was found positively correlated to mean blood pressure and age which in combination accounted for 43% of the variability of WLR. In the cohort of patients with focal vascular damage, neither FANs or AVNs showed evidence of parietal growth; instead, at sites of FANs, decreased outer diameter suggestive of vasoconstriction was consistently found, while at sites of AVNs venous narrowing could be seen in the absence of arteriovenous contact.Conclusion:High resolution imaging of retinal vessels by adaptive optics allows quantitative microvascular phenotyping, which may contribute to a better understanding and management of hypertensive retinopathy.

Retinal microvascular structure and function in patients with risk factors of atherosclerosis and coronary artery disease

ObjectiveRetinal microvascular signs are markers of cardiovascular disease risk. There are limited data, on relationships between retinal microvascular signs and retinal microvascular endothelial function. We sought to determine the relationship of retinal vascular signs with retinal microvascular endothelial function in patients with or at high risk of coronary artery disease. MethodsParticipants with atherosclerosis risk factors and coronary disease (n = 258; mean age 57 ± 11 years) were recruited to have static and dynamic retinal vascular assessment. Retinal arteriolar dilatation in response to flicker light (FI–RAD) was measured using the Digital Vessel Analyser and expressed as percentage increase over baseline diameter. Static retinal photographs were acquired utilising a digital fundus camera for measurement of central retinal artery and vein equivalent (CRAE and CRVE), arteriovenous nicking (AVN) and focal arteriolar narrowing (FAN). ResultsIntra-class correlation coefficient was 0.82 for flicker-light induced retinal arteriolar dilatation. There were modest associations in retinal vascular measurements between eyes. For each 10 μm decrease in retinal arteriolar diameter, the absolute increase in FI–RAD was 0.28% (95% CI 0.11, 0.45; p = 0.002) independent of age, gender and atherosclerosis risk factors. AVN and FAN were associated with attenuated FI–RAD (β = −0.67%; 95% CI −1.20, −0.15; p = 0.012) and (β = −0.83%; 95% CI −1.44, −0.23; p = 0.007) respectively after adjustment for age and gender. ConclusionAssessment of retinal microvascular endothelial function is reproducible and correlated with retinal microvascular structure and signs, independent of atherosclerosis risk factors. Assessment of retinal vascular structure and function may provide insights into atherosclerotic disease.

Changing Perspectives in Classifications of Hypertensive Retinopathy.

Hypertensive retinopathy represents the ophthalmic findings of end organ damage secondary to systemic arterial hypertension. The eye is a target organ as well as an established prognostic indicator of systemichypertension. Based on ophthalmoscopically visible alterations, several classifications, the majority of them grading hypertensive fundus changes into four stages have been suggested. The recognition of hypertensive retinopathy is important in cardiovascular risk stratification of hypertensive individuals. The review evaluates the changing perspectives in classification & prognostic significance of fundal lesions. consists of retinal vascular changes that are pathologically related to both transient & persistent microvascular damage from elevated blood pressure. Ocular changes can be the initial finding in an asymptomatic patient with hypertension necessitating primary referral. In other instances, asymptomatic patient may be referred to an ophthalmologist for visual problems caused by hypertensive changes. Elevation of systemic blood pressure causes both focal and generalized constriction of retinal arterioles mediated by autoregulation. These findings are relatively common in long standing hypertension. A prolonged duration of high blood pressure can be associated with a breakdown of inner blood retinal barrier with extravasation of plasma & RBCs . Retinal haemorrhages, cotton wool spots, intraretinal lipids & in severe cases , the development of macular star configuration of intraretinal lipid can be seen. Although its name implies only retinal involvement, changes in both choroid & optic nerve are observed. When choroidal vessels are severely affected by elevated blood pressure, as in acute hypertension, fibrinoid necrosis of choroidal arterioles can cause occlusion of areas of choriocapillaris, with a subsequent breakdown of outer blood retinal barrier. Ocular findings in accelerated hypertension are divided into three distinct categories: hypertensive retinopathy, hypertensive choroidopathy & hypertensive optic neuropathy. Ophthalmic findings in acute malignant hypertensive retinopathy include focal arterial narrowing, cotton wool spots, intraretinal transudates , macular edema and retinal haemorrhages. Cystoid macular edema, lipid deposits and arteriolar changes are signs of malignant hypertensive retinopathy (2) . Cotton wool spots are fluffy, elevated, tan white areas of retinal opacity occurring within a few disc diameters of optic nerve, caused by occlusion of terminal retinal arterioles. Cotton wool spots typically resolve in 3-6 weeks and are associated with permanent nerve fiber layer loss in the vicinity of the lesion (2) . Periarteriolar intraretinal transudates are tan white retinal lesions which resolve without residual retinal damage in 2-3 weeks (3) . Macular edema and subretinal fluid are retinal findings related to hypertensive choroidal changes affecting the retinal pigment epithelium, with alterations in the blood retinal barrier. Clinical changes from hypertensive choroidopathy are directly related to the release of endogenous vasoconstrictor agents (eg.,angiotensin II, epinephrine, vasopressin) during systemic hypertension. Angiographically, there is delayed, patchy choroida lfilling

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Disturbed Coronary Hemodynamics in Vessels With Intermediate Stenoses Evaluated With Fractional Flow Reserve

Background— In chronic ischemic heart disease, focal stenosis, diffuse atherosclerotic narrowings, and microcirculatory dysfunction (MCD) contribute to limit myocardial flow. The prevalence of these ischemic heart disease levels in fractional flow reserve (FFR) interrogated vessels remains largely unknown. Methods and Results— Using intracoronary measurements, 91 coronaries (78 patients) with intermediate stenoses were classified in 4 FFR and coronary flow reserve (CFR) agreement groups, using FFR&gt;0.80 and CFR&lt;2 as cutoffs. Index of microcirculatory resistance (IMR) and atherosclerotic burden (Gensini score) were also assessed. MCD was assumed when IMR≥29.1 (75 th percentile). Fifty-four (59.3%) vessels had normal FFR, from which only 20 (37%) presented both normal CFR and IMR. Among vessels with FFR&gt;0.80, most (63%) presented disturbed hemodynamics: abnormal CFR in 28 (52%) and MCD in 18 (33%). Vessels with FFR&gt;0.80 presented higher IMR [adjusted mean 27.6 (95% confidence interval, 23.4–31.8)] than those with FFR≤0.80 [17.3 (95% confidence interval, 13.0–21.7), p=0.001]. Atherosclerotic burden was inversely correlated with CFR ( r =−0.207, P =0.055), and in vessels with FFR&gt;0.80 and CFR&lt;2 (n=28, 39%), IMR had a wide dispersion (7–72.7 U), suggesting a combination of diffuse atherosclerotic narrowings and MCD. Vessels with FFR≤0.80 and normal CFR presented the lowest IMR, suggesting a preserved microcirculation. Conclusions— A substantial number of coronary arteries with stenoses showing an FFR&gt;0.80 present disturbed hemodynamics. Integration of FFR, CFR, and IMR supports the existence of differentiated patterns of ischemic heart disease that combine focal and diffuse coronary narrowings with variable degrees of MCD.

Flow reversal promotes intimal thickening in vein grafts

After vascular interventions, unidentified mechanisms disrupt the homeostasis of a focal narrowing to initiate an intimal thickening response. We hypothesize that perturbations in the hemodynamic microenvironment are the initiating event for this disruption of homeostasis and intimal thickening in vein bypass grafts. The objective of this study was to investigate the relation between local flow perturbations and its influence on the vein graft architecture. An external ligature was used to create an 80% focal midgraft stenosis in bilateral rabbit carotid vein grafts. A unilateral distal ligation created a ninefold difference in flow rate between high-flow and low-flow grafts. Ten vein grafts were harvested at 28 days and serially sectioned for morphologic evaluation and vein graft reconstruction. Computational fluid dynamics analyses were performed to examine the hemodynamic environment within these complex flow regions. The largest intimal thickening occurred exclusively within the region immediately distal to the maximum stenosis in high-flow grafts, which was characterized by persistent flow separation and reversal for the entire cardiac cycle. In regions of low to moderate shear stress (<5 Pa), the typical inverse correlation between intimal thickness and wall shear was observed. Regions of vein bypass grafts exposed to persistent flow reversal are most at risk for intimal thickening and loss of lumen.

Bilateral popliteal artery entrapment syndrome in a young man

A 33-year-old man with no significant medical history presented with exercise-induced right calf discomfort progressing to the right foot and calf numbness. Popliteal, dorsal pedal, and posterior tibial pulses were absent on the right, with no swelling, ulceration, or tenderness. Lower extremity computed tomography angiography 1 day after presentation revealed luminal compromise of the left popliteal artery (A), occlusion of the distal right superficial femoral and popliteal arteries, and short-segment stenosis present in the left popliteal artery. Magnetic resonance imagining of the right knee (B) revealed an anomalous tendinous slip arising from the medial head of the gastrocnemius, causing focal narrowing of the artery.

Aerodynamics in Cardiac CT

It seems not long ago that invasive coronary angiography was considered as the undisputed diagnostic standard and management determining test for patients with ischemic heart disease. Registry data have shown that reliance on noninvasive testing for myocardial ischemia, positioned as a gatekeeper to restrict referral to the catheterization laboratory, is far from optimal in clinical practice.1 Coronary computed tomographic (CT) angiography (CCTA), which was developed and validated during the past decade, allows noninvasive visual confirmation of the presence or absence of coronary artery disease (CAD). Meanwhile the cardiology community has rediscovered an appreciation for functional parameters of CAD, particularly for clinical decision making. Cardiac CT is arguably the most accurate noninvasive technique to exclude CAD, with sensitivities and negative predictive values >95% as reported in meta-analyses.2 Unfortunately, CCTA has a tendency to overestimate the severity of CAD, particularly in the presence of coronary calcifications. More than ever before, we are aware of the complex and unpredictable relation between angiographic stenosis and myocardial ischemia. Compared with invasive fractional flow reserve (FFRcath), which is currently considered as the clinical standard of lesion-specific hemodynamic significance, both invasive and noninvasive coronary angiography overestimate the functional severity of CAD.3,4 Current clinical practice guidelines recommend consideration of both anatomic and functional parameters in the treatment of stable CAD. There seems to be no prognostic benefit from revascularizing hemodynamically nonsignificant stenosis, whereas on the other hand, mechanical treatment of myocardial ischemia is difficult in the absence of focal narrowing of the epicardial coronary branches. In that context, a diagnostic modality able to provide both angiographic and functional information during a single, noninvasive examination would be highly desirable. Article see p 881 For decades, (computer) simulations of air flow around objects have defined the design of aircrafts and automobiles. Based on the …

UNUSUAL COMPLICATION OF VERTEBRAL ARTERIAL DISSECTION

IntroductionVertebral artery dissection (VAD) is a common cause of ischemic stroke in patients younger than 45 yrs of age. VAD is rarely life–threatening but we here present a patient with...

Achalasia: Case Report of an Unreported Post-treatment Result

Background: Achalasia is a primary esophageal disorder affecting the esophageal body and lower esophageal sphincter (LES) whose pathophysiology involves the destruction of the myenteric plexus resulting in aperistalsis. Case: A 30-year-old Latin American woman with history of Hodgkin's lymphoma, status postchemotherapy and radiation, and GERD was referred to evaluate 4 years of progressive retrosternal pain, choking sensation, and regurgitation of food. EGD revealed normal-appearing mucosa without dilation or retained food/fluid; however, did have mild resistance with passage of the endoscope at the LES. Manometry showed esophageal aperistalsis with normal LES pressure, but incomplete relaxation. Physical exam was unremarkable. The patient's oncologist did not believe her symptoms were due to pseudo-achalasia from lymphoma given the lymphoma's aggressive nature and presence of symptoms for 3 years prior to lymphoma diagnosis. Barium swallow revealed a dilated fluid-filled esophagus with distal esophageal tapering and focal narrowing of the LES. Esophageal emptying study demonstrated abnormal emptying of the distal esophagus. Pneumatic dilation with a 30-mm achalasia balloon was performed with complete cessation of dysphagia and near resolution of her retrosternal pain. Unique to our patient is the previously unreported timed esophageal emptying study normalization with only 5% retention at 2.5 minutes and 2.6% retention at 10 minutes. The patient has become and remains symptom free at 9 months. Discussion: As in this patient, achalasia can go undiagnosed for years given its low prevalence, slow progression, and associated vague symptoms. Typical symptoms include dysphagia to solids and liquids, angina like chest pain, and regurgitation of undigested food. Diagnosis is based on symptoms and esophageal manometry demonstrating esophageal aperistalsis and poor LES relaxation. Barium esophagogram demonstrating esophageal dilation and distal tapering can assist diagnosis and may detect pre-clinical symptomatic recurrence. Upper endoscopy is typically normal, but can be utilized to rule out pseudo-achalasia. Treatment is palliative and is aimed at reducing LES pressure and facilitating esophageal emptying. Laparoscopic myotomy and pneumatic balloon dilatation offer definitive sustained benefits, as shown with our patient's esophageal emptying study. Intrasphincteric botulinum toxin injection and medications (calcium channel blockers and nitrates) can offer transient benefits in selected patients.

Role of EUS in Diagnosis of Autoimmune Pancreatitis

Context The diagnosis of autoimmune pancreatitis (AIP) is based on a combination of pancreatic histology, imaging, serology, other organ involvement, and response to steroids. In this setting, endoscopic ultrasound (EUS) is considered the procedure of choice to obtain pancreatic tissue in order to establish the diagnosis and/or to exclude malignancy. However, negative cytology or histology obtained by EUS-FNA does not exclude AIP. In order to further investigate these subgroups of patients, there are two promising imaging tools: real-time EUS elastography of the pancreas and contrast-enhanced EUS. Objective and methods To evaluate the diagnostic yield of EUS in detection of AIP by comparing EUS findings with standard radiological imaging (CT and/or MRI) in patients with suspected autoimmune disease referred to our tertiary center. Results Thirty-two patients with radiological suspicious of AIP underwent EUS. Focal enlargement of pancreatic parenchyma and focal narrowing of main pancreatic duct (MPD) were detected in the same way by MRI and EUS, being both techniques better that CT (12/21, 12/32, and 7/19, respectively). Diffuse pancreatic parenchyma enlargement and detection of multiple stricture of MPD were better identified by EUS (8/19 with CT, 3/21 with RMN, 12/32 with EUS; 1/19 with CT, 1/21 with RMN, 6/32 with EUS, respectively). Focal and diffuse AIP presented hypervascularization pattern after contrast agent injection in the majority of patients (10/13). At elastography, focal AIP presented with a pattern of small spotted mainly blue colour signals that are evenly spread, showing a different pattern from pancreatic cancer. In addition, when targeted masses were unclear on fundamental B-mode EUS imaging, elastography was useful to find the targeted area to biopsy. Conclusion We believe that EUS elastography and contrast-enhanced EUS alone or in combination are promising tools in the diagnostic approach of focal AIP. It seems that in the near future their use might be integrated in the diagnostic algorithms of AIP.

Retinal Vasculature

See related article, pp 706–711 Ong et al1 studied 2907 participants in the Atherosclerosis Risk in Communities Study, who were free of diabetes mellitus, stroke, or coronary artery disease at baseline, and were followed for 13 years. Using retinal photographs and a simplified classification of hypertensive retinopathy, they found that even among patients who were well-controlled on antihypertensive medication, moderate/severe retinopathy carried a nearly 3-fold increase in the risk of stroke. Retinal signs of vascular pathology include an increased light reflex of the retinal arterioles (copper wiring or silver wiring, thought to occur as a result of atherosclerotic vessel wall thickening) and other arteriolar changes, including focal arteriolar narrowing, arteriovenous nicking, and microaneurysms. Retinal cotton-wool spots and exudates are the visible manifestations of small retinal infarctions and retinal hemorrhages, respectively, and represent the retinal consequences of the underlying arteriolar disease. All these findings predict an increased risk of vascular disease, and in particular, the risk of stroke,2 but the kind of stroke predicted differs with the retinal …

Fundus Fluorescein Angiographic Findings in Patients Who Underwent Ventricular Assist Device Implantation

Disruption of microcirculation in various tissues as a result of deformed blood rheology due to ventricular assist device (VAD) implantation causes novel arteriovenous malformations. Capillary disturbances and related vascular leakage in the retina and choroidea may also be seen in patients supported by VADs. We aimed to evaluate retinal vasculature deteriorations after VAD implantation. The charts of 17 patients who underwent VAD implantation surgery for the treatment of end-stage heart failure were retrospectively reviewed. Eight cases (47.1%) underwent pulsatile pump implantation (Berlin Heart EXCOR, Berlin Heart Mediprodukt GmbH, Berlin, Germany); however, nine cases (52.9%) had continuous-flow pump using centrifugal design (HeartWare, HeartWare Inc., Miramar, FL, USA). Study participants were selected among the patients who had survived with a VAD for at least 6 months, and results of detailed ophthalmologic examinations including optic coherence tomography (OCT) and fundus fluorescein angiography (FA) were documented. All of the 17 patients were male, with a mean age of 48.5 ± 14.8 years (15-67 years). Detailed ophthalmologic examinations including the evaluation of retinal vascular deteriorations via FA were performed at a mean of 11.8 ± 3.7 months of follow-up (6-18 months). Mean best-corrected visual acuity and intraocular pressure were found as logMAR 0.02 ± 0.08 and 14.6 ± 1.9 mm Hg, respectively in the study population. Dilated fundoscopy revealed severe focal arteriolar narrowing in two patients (11.8%), and arteriovenous crossing changes in four patients (23.5%); however, no pathological alteration was present in macular OCT scans. In patients with continuous-flow blood pumps, mean arm-retina circulation time (ARCT) and arteriovenous transit time (AVTT) were found to be 16.8 ± 3.0 and 12.4 ± 6.2 s, respectively; whereas those with pulsatile-flow blood pumps were found to be 17.4 ± 3.6 and 14.0 ± 2.1 s in patients (P=0.526 and P=0.356, respectively). FA also revealed a tendency for increased frequency of dye leakage from the optic disc in our study population. Except for remarkable delays in both ARCT and AVTT as well as a tendency for increased frequency of dye leakage from the optic disc, ophthalmologic evaluations revealed no other significant pathology or vascular deterioration in the retina that could be attributed to artificial heart systems.

SP0026 Ultrasound Assessment of the Cartilage

Musculoskeletal ultrasound (US) is a valuable imaging modality for detecting and quantifying a range of joint pathologies occurring in rheumatic diseases (1-2). In inflammatory arthritis and in osteoarthritis (OA) it...

Structural Changes in the Retinal Microvasculature and Renal Function

To evaluate the associations between chronic kidney disease (CKD) and microalbuminuria, and a comprehensive range of retinal microvascular abnormalities including traditional and new retinal vascular measures. This was a population-based, cross-sectional study on 3280 urban Malay adults. The albumin/creatinine ratio (ACR) was calculated from spot urine samples. Estimated glomerular filtration rate (eGFR) was calculated from serum creatinine concentration. Retinal vascular caliber and geometry were quantified from retinal fundus photographs using a semiautomated computer-assisted program. Qualitative changes including focal arteriolar narrowing, arteriovenous nicking, and opacification of the arteriolar wall were assessed by trained graders. In multivariate analyses adjusting for age, sex, hypertension, diabetes, and smoking, narrower retinal arteriolar caliber (P = 0.008), smaller retinal vascular fractal dimensions (P = 0.014), and the presence of AV nicking and opacification (P = 0.005 and P < 0.001, respectively) were significantly associated with lower eGFR. In multivariate adjusted logistic regression analyses, none of the retinal markers was associated with CKD. A smaller fractal dimension (P < 0.001) and the presence of focal arteriolar narrowing, AV nicking and opacification were associated with higher ACR (P < 0.001, P = 0.01, and P = 0.002, respectively). Narrower retinal arterioles (P = 0.041); smaller fractal dimensions (P = 0.006); and focal arteriolar narrowing, AV nicking, and opacification (P = 0.007, P = 0.007, and P = 0.012, respectively) were associated with higher likelihoods of having microalbuminuria. Quantitative changes of the retinal vascular geometry and qualitative changes in the vessel architecture are associated with markers of renal dysfunction and damage.

What is the ideal biological marker in diagnosis of diabetic neuropathies?

What is the ideal biological marker in diagnosis of diabetic neuropathies?

Significant Response to Lower Acetylcholine Dose Is Associated with Worse Clinical and Angiographic Characteristics in Patients with Vasospastic Angina

Background and ObjectivesThe intracoronary injection of acetylcholine (Ach) has been shown to induce coronary spasms in patients with variant angina. Clinical significance and angiographic characteristics of patients with a significant response to lower Ach dosages are as-yet non-clarified compared with patients responding to higher Ach doses.Subjects and MethodsA total of 3034 consecutive patients underwent coronary angiography with Ach provocation tests from January 2004 to August 2010. Ach was injected in incremental doses of 20, 50, 100 µg into the left coronary artery. Significant coronary artery spasm was defined as focal or diffuse severe transient luminal narrowing (>70%) with/without chest pain or ST-T change on the electrocardiogram (ECG). We compared the clinical and angiographic characteristics of patients who responded to a lower Ach dose (20 or 50 µg, n=556) to those that responded to a higher Ach dose (100 µg, n=860).ResultsThe baseline clinical and procedural characteristics are well balanced between the two groups, except diabetes was higher in the lower Ach dose group and there were differences in medication history. After adjusting for confounding factors, the lower Ach dose group showed more frequent temporary ST elevation and atrioventricular block on the ECG. Furthermore, the group of patients who responded to the lower Ach dose was associated with a higher incidence of baseline and severe spasm than those who responded to a higher Ach dose.ConclusionPatients with a significant response to a lower Ach dose were associated with more frequent ST elevation, baseline spasm, and more severe spasm compared with those who responded to a higher Ach dose, suggesting more intensive medical therapy with close clinical follow-up is required for those patients.

Mid-aortic dysplastic syndrome as a rare cause of hypertension in young

Introduction: Mid-aortic syndrome (MAS), coarctation of abdominal aorta is a rare disease with only 200 reported cases. It is characterized by constriction of distal thoracic and/or abdominal aorta and its branches, therefore is also known as abdominal aortic coarctation. The MAS is characterized radiologically by severe narrowing of abdominal aorta and its branches and most of these patients usually die due to progressive severe hypertension before the age of 35-40 if left untreated. Case Report: A 13-year-old boy was admitted with persistent headache and vomiting for one month and repeated generalized tonic clonic seizures for two days. His past history was unremarkable. The highlight of the clinical examination blood pressure was 240/150 mmHg in both the upper limbs, and all peripheral pulses were palpable. Blood pressure was similar in upper and lower limbs and a systolic bruit heard over the epigastrium. Ultrasonography showed a localized narrowing of a suprarenal segment of the abdominal aorta with an abrupt focal dilatation of the abdominal aorta approx 1.7cm below origin of superior mesenteric artery. Magnetic resonance angiography of the aorta and its branches showed a distinct fusiform dilatation of abdominal aorta just below the origin of the superior mesenteric artery. Focal narrowing of abdominal aorta was noted just proximal to the dilatation. Conclusion: We diagnosed a case of mid-aortic coarctation with post stenotic dilatation associated with left renal artery stenosis leading to secondary hypertension in a teenage boy presenting with reversible posterior leukoencephalopathy and seizures. The boy was referred for vascular surgery but the patient refused any operative procedure.

Call-Fleming Syndrome (Reversible Cerebral Artery Vasoconstriction) and Aneurysm Associated with Multiple Recreational Drug Use

Drug abuse represents a significant health issue. Evidence suggests that recreational drug use has a direct effect on the cerebral vasculature and is of greater concern in those with undiagnosed aneurysms or vascular malformations. The authors report a case of thunderclap headache with a negative head CT and equivocal lumbar puncture after a drug-fueled weekend. The patient underwent diagnostic cerebral angiogram which demonstrated multisegmental, distal areas of focal narrowing of the middle, anterior, posterior, and posterior inferior cerebral artery and an incidental aneurysm. It is often difficult to determine the exact origin of symptoms; thus we were left with a bit of a chicken or the egg debate, trying to decipher which part came first. Either the aneurysm ruptured with associated concomitant vasospasm or it is a case of Call-Fleming syndrome (reversible cerebral artery vasoconstriction) with an incidental aneurysm. The authors proposed their management and rationale of this complex case.