Site Of Stenosis Research Articles

Extracranial carotid doppler correlation to multidetector CT angiography in ischemic stroke patients

The purpose of this study was to compare the diagnostic value of Color Doppler Ultrasound (CDUS), Computed Tomographic Angiography (CTA), and advantage of their combined use in defining the degree of stenosis and morphological character of atheromatous plaque in ischemic stroke patients. This was a cross-sectional study with a total of 60 patients having 120 carotid arteries were observed. The percentage of stenosis was measured at the narrowest point by modified NASCET criteria for both CDUS & CTA. Incidence of stroke was highest in the age group 50-70years with male population commonly affected. Frequency of carotid stenosis was more in male patients aged above 60 years. Hemiparesis was most common symptoms in stroke patients. The various risk factors of carotid atherosclerosis and stenosis included hypertension, diabetes mellitus, hyperlipidemia and cardiovascular disease. Atheromatous plaques with stenosis were most commonly found on right side. Carotid bifurcation was the common site for atheromatous plaque .There was significant correlation between Color Doppler Ultrasound and Computed Tomographic Angiography for detecting 70-100% stenosis. However CTA is more accurate in comparison to duplex ultrasonography in detecting 70-99% stenosis and total occlusion. There was no significant correlation between CDUS and CTA in detecting 20-49% stenosis. Duplex ultrasonography is more sensitive in detecting these lesions. Out of 49 plaques, in this study 11 were soft plaques, 26 were non-homogenous and 13 were ulcerative plaques. Color doppler has better role in plaque characterization. Besides degree of extracranial stenosis, length of the stenosis, site of intracranial stenosis and total number of stenotic sites are better assessed by CTA. Area of effected brain parenchyma and extent of collateral circulation are better assessed by CTA which aids in prognostic value. In conclusion, the advantage of the combined use of CDUS and the CTA in the identification and quantification of ICA stenosis is higher. However ultrasound had a better role in plaque characterization.

The Prevalence of Cervical Foraminal Stenosis on Computed Tomography of a Selected Community-Based Korean Population.

BackgroundCervical foraminal stenosis (CFS) is one of the degenerative changes of the cervical spine; however, correlations between the severity of stenosis and that of symptoms are not consistent in the literature. Studies to date on the prevalence of stenosis are based on images obtained from the departments treating cervical lesions, and thus patient selection bias may have occurred. The purpose of this study was to investigate the prevalence of CFS according to the site, extent, and morphology of stenosis using cervical computed tomography (CT) images obtained from patients who were visiting not because of symptoms related to the cervical spine, cervical pain, or upper limb pain.MethodsAmong patients who underwent CT from January 2016 to March 2016 for reasons other than cervical spine symptoms, a total of 438 subjects were enrolled, and 2,628 cervical disc images (C4–5, C5–6, and C6–7; left and right sides) were examined. Three orthopedic surgeons performed two measurements each at 4-week intervals. Values were used for analysis if matched by more than two surgeons; if no match was found, the median values were used for analysis. The left and right sides on the same axial image were independently classified.ResultsLeft C5–6 stenosis was most common (24.66%) among patients. At the left C6–7, there were 20 focal types and 33 diffuse types. At bilateral C4–5 and right C6–7, the focal type was more common, whereas at bilateral C5–6 and left C6–7, the diffuse type was more common. Age and the severity of stenosis showed statistically significant correlation at all cervical levels.ConclusionsThe prevalence of CFS was highest at the C5–6 level (19.06%). Compared to other levels, focal stenosis was more frequent at C4–5 and diffuse stenosis was more common at C5–6. At C6–7, the incidence of focal stenosis was higher on the right side and that of diffuse stenosis was higher on the left side.

Mitomycin C in the endoscopic treatment of tracheal stenosis: a prospective cohort study.

ABSTRACTObjective:To evaluate the efficacy of mitomycin C (MMC) in the endoscopic treatment of tracheal stenosis. Methods:Patients with laryngotracheal, tracheal, or tracheobronchial stenosis were treated with dilation and topical MMC. The inclusion criteria were as follows: being ineligible for surgery (for medical reasons) at the time of evaluation; membranous stenosis responding well to dilation; and postoperative stenosis at the anastomosis site. Etiology of stenosis and indication for treatment with MMC, as well as site, length, and percentage of stenosis, together with presence of tracheostomy and duration of follow-up, were analyzed. The outcomes evaluated were symptom-free interval ≥ 12 months, number of dilations with topical application of MMC, and complications. Results:Twenty-two patients (15 men and 7 women) were treated between 2003 and 2010. Stenosis was due to endotracheal intubation in 15 patients and surgery in 8. Pure tracheal stenosis was encountered in 13 patients, subglottic stenosis was encountered in 4, tracheobronchial stenosis was encountered in 3, and complex stenosis was encountered in 2. The length of stenosis ranged from 0.5 cm to 2.5 cm, and the percentage of stenosis ranged from 40% to 100%. Nine patients had undergone tracheostomy and had a Montgomery T-tube in situ. Treatment was successful in 14 patients, who remained free of symptoms for at least 12 months. The number of topical applications of MMC ranged from 1 to 5, and complications included fungal infection, keloid scarring, granuloma, and mediastinal emphysema. Conclusions:MMC appears to be effective in the endoscopic treatment of tracheal stenosis.

Caustic Gastric Stenosis in Adults

Introduction: Caustic gastric stenosis is relatively rare complications after voluntary or accidental ingestion of caustic substances.Methods: They analyzed all the medical recordings of the patients operated in First Surgical Clinic, “St Spiridon” Emergency Hospital Iasi during 2004-2017 (6 cases - lot A) for caustic gastric stenosis presented comparatively with a lot of 46 patients with caustic gastric stenosis (lot B) operated in the same clinic between 1990 and 2003.Results: The most frequently used substance was the caustic soda in group B and detartrant (surface cleaning product – a descaling agent) in group A. The most common site of stenosis was antral, prepyloric; this is explained by the prolonged contact of the caustic with this declivity area and by the spasm of the ankle muscles secondary to caustic action. In the period of establishment of esophageal and/or gastric stenosis, in all cases of group A, esophageal dilation with endoscopic pneumatic balloon probe was started early for both esophageal and gastric stenosis and in group B only in 19 cases. Surgical treatment depended on the extent of the corrosive lesions. In most cases, with limited antral stenosis, we performed distal gastrectomy with gastroduodenal anastomosis. In the combined lesions (esophageal and gastric stenosis) we preferred surgical interventions in two or three steps.Conclusion: Associated gastric and esophageal lesions form a distinct subgroup that often requires complex surgical resolution through laborious procedures. It is advisable to perform endoscopic dilation procedures, both esophageal and pyloric lesions, before attempting surgical treatment. Postoperative morbidity and mortality decreased over the time, through a personalized, differentiated approach to each case, into a multidisciplinary team.

Cephalic Arch Stenosis: Location of Stenosis in Indian Hemodialysis Patients.

The cephalic vein is formed over the “anatomical snuff box” and joins the axillary vein just below the clavicular level. The definition of cephalic arch is varied. In the radiology literature, it is defined as the central perpendicular portion of the cephalic vein as it traverses the deltopectoral groove and joins the axillary vein. The possible etiologies of cephalic arch stenosis are numerous. This study aimed to identify patients with cephalic arch stenosis and to discern the domain site of stenosis. This is a retrospective case series of patients who had an arteriovenous fistula with dysfunction of access and ipsilateral upper-limb edema. The clinical features of the access dysfunction were strong pulse due to increased pressure, weak thrill due to poor proximal flow, high static pressure, or decreased dialysis efficiency. All these 25 patients underwent computed tomography (CT) angiogram. The CT angiographic findings revealed cephalic arch stenosis and stenosis in 13 patients (52%). domain IV was slightly more affected than other domains of cephalic arch.

Balloon Angioplasty as a Modality to Treat Children with Pulmonary Stenosis Secondary to Complex Congenital Heart Diseases.

Background:Pulmonary stenosis is common in children with complex congenital heart diseases. Proper management of this problem, especially postoperatively, is still controversial. This study was designed to assess the rate and determinants of success or failure of balloon angioplasty for such lesions.Methods:Clinical and hemodynamic data from 40 pediatric patients (24 boys and 16 girls) with complex congenital heart diseases who underwent balloon angioplasty were reviewed retrospectively from January 2012 to December 2016. Patients were divided into four groups according to the site of stenosis, which included pulmonary valve stenosis (PVS), valved conduit stenosis, pulmonary artery stenosis (PAS), and supravalvular pulmonary stenosis (SVPS). Success rates were calculated according to defined criteria for initial success and favorable clinical impacts, and comparison between the successful subgroup and the unsuccessful subgroups was analyzed.Results:Grouped by the site of stenosis, initial success rates varied from 40.0% to 52.4% with the greatest success being seen in the PVS group, followed by the PAS group and SVPS group. In the PVS group and the PAS group, there was no statistical difference among age at dilation, postoperative interval, balloon/stenosis ratio, or pressure gradient predilation between the successful and the unsuccessful subgroups. Favorable clinical impacts included success rates of balloon angioplasty in the SVPS group, which was best (100%), followed by the PVS group (90.9%) and the PAS group (85.7%). There were a total of two transient complications (5.0%).Conclusions:Balloon angioplasty was proven to be a safe and useful modality in children with complex congenital heart diseases and postoperative pulmonary stenosis, which should be the initial therapeutic modality in selected patients.

Dynamic CT angiography for the diagnosis of patients with thoracic outlet syndrome: Correlation with patient symptoms

IntroductionVasculo-nervous structures serving the upper limbs may be compressed as they pass through three areas: the inter-scalene triangle (IST), the costo-clavicular space (CCS) and the retropectoralis minor space (RMS). The diagnosis of thoracic outlet syndrome (TOS) is essentially clinical, but requires imaging to specify the site of compression, its grade and the existence of predisposing anatomical factors, in order to guide the treatment and eliminate the main differential diagnoses. Material and methodsImages from 141 patients who underwent dynamic CT angiography of the thoracic outlets from June 2008 to January 2015 were analyzed retrospectively. Patients had unilateral or bilateral vascular, neurological, mixed or atypical symptoms. We studied the degree of stenosis of the subclavian artery with the following grading system: 1 (0-<25%), 2 (25-<50%), 3 (50-<75%), 4 (75-100%). The site of stenosis and the presence of underlying anatomical predisposing factors were also taken in account. ResultsA total of 221 thoracic outlets were analyzed. Symptoms were neurological, mixed, vascular and atypical in 30%, 28%, 13% and 12%, respectively. Among patients with bilateral acquisitions, 38 outlets were asymptomatic; 40% of symptomatic outlets and only 5% of asymptomatic ones had grade 3 or 4 stenosis. 63% of the stenosis were in the CCS and 37% in the IST; 21% had a predisposing anatomical factor most often a costo-clavicular anomaly, associated with significant stenosis in 50% of cases. ConclusionVascular stenosis of more than 50% on dynamic CT angiography is strongly associated with TOS. Predisposing factors were present in 21% of cases, causing significant vascular stenosis in half, underscoring the need for functional evaluation.

Clinical implications of differentiating between types of post-tracheostomy tracheal stenosis.

Post-tracheostomy tracheal stenosis (PTTS) can be divided into four types according to stenosis mechanism and site: subglottic, stoma, cuff, and tip granuloma. However, there is little information available regarding clinical differences among types of PTTS; therefore, we evaluated the clinical differences between these types. We retrospectively evaluated 99 PTTS patients who underwent interventional bronchoscopy between 2004 and 2014. Patients were divided into two groups according to pathophysiological similarities as follows: subglottic or stoma type (n=59) and cuff or tip type (n=40). There were no differences in baseline characteristics between groups. However, silicone stents were more frequently needed in patients with subglottic or stoma type stenosis (76%) than those with cuff or tip type stenosis (55%, P=0.031) to maintain airway patency. On the contrary, permanent tracheostomy was more frequently performed in patients with cuff or tip type stenosis (50%) than those with subglottic or stoma type stenosis (19%, P=0.002). Finally, successful removal of the tracheostomy tube without surgery and procedure- or disease-related mortality were more frequently achieved in patients with subglottic or stoma type stenosis (71%) than those with cuff or tip type stenosis (45%, P=0.012). Although there were no significant differences in baseline characteristics between PTTS types, patients with subglottic or stoma type stenosis had more favorable outcomes than those with cuff or tip type stenosis. Therefore, it could be important to distinguish between types of PTTS when assessing prognosis.

Does Anastomosis Configuration Influence Long-term Outcomes in Patients With Crohn Disease?

PurposeIn this study, we evaluated the role of various anastomoses in surgical recurrence for patients with Crohn disease (CD).MethodsWe analyzed data retrospectively from consecutive laparotomy cases involving complicated CD between 1991 and 2008. Clinical data were compared in terms of reoperation-free survival (RFS) according to the types of anastomoses, the materials used for the anastomoses, and the operating surgeon.ResultsOf 233 patients with entero-enteric or entero-colic anastomoses, 199 (85%), 11 (5%), and 23 (10%) experienced side-to-side (SS), side-to-end (SE), and end-to-end (EE) anastomoses, respectively. The SS group had the following characteristics: more extensive bowel involvement, frequent obstruction, and greater stapler use; the SS anastomoses were also frequently made by specialized surgeons (P < 0.001–0.004). EE anastomoses were frequently made by general surgeons using a hand-sewing technique (P < 0.001). No differences in RFS were noted among the 3 groups according to the type of anastomosis and the operating surgeon. However, the hand-sewn group showed better RFS than the stapler group (P = 0.04).ConclusionThe roles of the anastomotic configuration, the material used, and the operating surgeon were not significantly correlated with reoperations or complications in our retrospective CD cohort, irrespective of the higher risk of anastomosis site stricture for EE anastomoses.

An Unusual and Rare Case of Esophageal Stricture as a Result of Systemic Chemotherapy for Solid Malignancy

Esophageal stricture secondary to isolated chemotherapy is exceptionally rare. We present the case of a patient receiving adjuvant chemotherapy who subsequently developed acute, severe esophageal stricture. A 34 year old male with a diagnosis of metastatic testicular seminoma presented to the hospital following a left orchiectomy for initiation of chemotherapy. He was started on Etoposide and Cisplatin chemotherapy and received an initial five days of therapy. Two weeks following the first cycle of chemotherapy, the patient developed symptoms of dysphagia and odynophagia, and all other review of systems was negative. He had no prior history of caustic ingestions or radiation therapy. The primary team noted oral thrush which was empirically treated with antifungal therapy. As symptoms persisted throughout the second and third cycles of therapy, a gastroenterology consult was called. On exam, patients vitals were stable, physical exam was unremarkable with resolution of thrush, and initial labs were consistent with primary malignancy. Gastrograffin esophogram revealed a narrowing in the distal third of the esophagus. CT scan revealed esophageal distension to the level of the GE junction. On EGD, a site of moderate stenosis measuring 1cm x 9mm was found 29 cm from the incisors which was traversed with mild resistance. An additional site of stenosis was found 30 cm from the incisors. A severe stenosis with a luminal diameter of 3 mm was found 6 cm further. A pediatric endoscope was used due to severity of stenosis. Histopathologic examination revealed nonspecific esophagitis. Cytology was negative for malignancy. No fungal elements were noted. Patient was offered but refused treatment with endoscopic dilation. The patient opted for a laproscopic PEG tube placement to optimize nutrition. The acute onset of esophageal stricture, without any prior radiation treatment or secondary causes of dysphagia led to the diagnosis of esophageal stricture secondary to use of systemic chemotherapy. We suspect esophageal stricture as complication of systemic chemotherapy as the patient had no history of long standing acid reflux or known exposure to established nonpeptic causes of stricture. This unexpected adverse outcome is likely caused by an interplay of mucosal damage associated with chemotherapy and the rapidly proliferating cells that line the gastrointestinal tract. These findings should prompt further investigation into the pathways of such a rare isolated injury.Figure: Gastrograffin esophogram showing generalized distal narrowing of the distal esophagus.Figure: Endoscopic view of severe stenotic stricture at 36 cm from incisors measure 3 mm in inner diameter.Figure: Endoscopic view of esophagus with visualization of stricture and friable mucosa.

COMPARISON STUDY OF THE QUANTITATIVE AND SEMI-QUANTITATIVE ANALYSIS OF PATHOLOGICAL FEATURES OF CAROTID ATHEROSCLEROTIC PLAQUE INSTABILITY

Comparison study of the quantitative and semi-quantitative analysis of pathological features of carotid atherosclerotic plaque instability Huaien Zheng1, Karina Gasbarrino1, Chi Lai2, John Veinot2, Stella S. Daskalopoulou1; 1) Research Institute of the McGill University Health Centre, Montréal, Québec; 2) Department of Pathology and Laboratory Medicine, University of Ottawa, Ontario, Canada Atherosclerosis and its thrombotic complications are a major cause of morbidity and mortality worldwide. Plaque instability and rupture is an important causative factor of these complications. To estimate plaque instability level, Lovett et al has proposed a histological classification that ranges from definitely stable to definitely unstable plaques based on semi-quantitative assessment of 10 plaque pathological features. However, semi-quantitative analysis can be subject to variability. Thus, herein, we aimed to develop a method to quantitatively measure plaque pathological features and validate it with established semi-quantitative results. Carotid surgical specimens were obtained from patients who underwent carotid endarterectomy (CEA). The atherosclerotic specimen sections were taken from the site of maximum stenosis, and stained with hematoxylin & eosin, smooth muscle cell actin, CD68 (for macrophages), and CD3 (for lymphocytes). Plaque features and stability were assessed by two vascular pathologists following Lovett’s semi-quantitative classification. Whole plaque specimen sections were scanned digitally. Pathological characteristics listed in the semi-quantitative classification were quantitatively measured using ImagePro Primer software. The quantitative image analysis results were analyzed and compared with the semi-quantitative pathological scores. The quantitative results of major pathologic features are significantly different between stable and unstable plaques and they are in accordance with the semi-quantitative analysis, performed by the pathologists. The quantitative results show that fibrous tissue occupies a major part of stable plaques (35-45%), while the lipid core occupies a large part of unstable plaques (40-47%). Furthermore, inflammatory cell infiltration is much greater in unstable plaques (P < 0.01). On the other hand, plaque calcification, neovascularization, and hemorrhage have no obvious differences between stable and unstable plaques. Our results demonstrate that quantitative image analysis can provide new insight into plaque morphology and composition: 1) the amount of fibrosis, necrotic core, fibrous cap, and inflammatory cell infiltration are major decisive factors of plaque instability; 2) Calcification and neovascularization are not closely related with plaque instability. Furthermore, quantitative image analysis of plaque features is a promising method for accurate classification of plaque instability. This new quantitative method needs to be externally validated in a larger subset of CEA plaques for future clinical practice.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Influence of esophagectomy on the gastroesophageal reflux in patients with esophageal cancer.

This study aims to assess the influence of esophagectomy with gastric transposition on the gastroesophageal reflux (GER) and gastric acidity in patients with esophageal cancer. Data on 53 esophageal cancer patients who underwent 24-hour impedance-pH monitoring after esophagectomy were retrospectively analyzed. We used a solid-state esophageal pH probe in which the esophageal pH sensor is placed 1.5 cm distal to the upper esophageal sphincter and the gastric pH sensor is located 15 cm distal to the esophageal pH channel. 24-hour impedance-pH monitoring data and other clinical data including anastomosis site stricture and incidence of pneumonia were collected. We defined pathologic reflux with reference to known normative data. Stricture was defined when an intervention such as bougienage or balloon dilatation was required to relieve dysphagia. The esophageal and gastric mean pH were 5.47±1.51 and 3.33±1.64, respectively. The percent time of acidic pH (<4) was 6.66±12.49% in the esophagus and 70.53±32.19% in the stomach. Esophageal pathologic acid reflux was noticed in 32.1%, 20.8%, and 35.8% during total, upright, and recumbent time, respectively. Esophageal pathologic bolus reflux was noted in 83.0%, 77.4%, and 64.2% during total, upright, and recumbent time, respectively. Gastric acidity increased with time after esophagectomy. Esophageal acid exposure time correlated with intragastric pH. However, esophageal pathologic acid reflux was not associated with anastomosis site stricture or pneumonia. In conclusion, GER frequently occurs after esophagectomy. Thus, strict lifestyle modifications and acid suppression would be necessary in patients following esophagectomy.

Stenting for symptomatic vertebral artery stenosis: The Vertebral Artery Ischaemia Stenting Trial.

Objective:To compare in the Vertebral Artery Ischaemia Stenting Trial (VIST) the risks and benefits of vertebral angioplasty and stenting with best medical treatment (BMT) alone for symptomatic vertebral artery stenosis.Methods:VIST was a prospective, randomized, open-blinded endpoint clinical trial performed in 14 hospitals in the United Kingdom. Participants with symptomatic vertebral stenosis ≥50% were randomly assigned (1:1) to vertebral angioplasty/stenting plus BMT or to BMT alone with randomization stratified by site of stenosis (extracranial vs intracranial). Because of slow recruitment and cessation of funding, recruitment was stopped after 182 participants. Follow-up was a minimum of ≥1 year for each participant.Results:Three patients did not contribute any follow-up data and were excluded, leaving 91 patients in the stent group and 88 in the medical group. Mean follow-up was 3.5 (interquartile range 2.1–4.7) years. Of 61 patients who were stented, stenosis was extracranial in 48 (78.7%) and intracranial in 13 (21.3%). No periprocedural complications occurred with extracranial stenting; 2 strokes occurred during intracranial stenting. The primary endpoint of fatal or nonfatal stroke occurred in 5 patients in the stent group vs 12 in the medical group (hazard ratio 0.40, 95% confidence interval 0.14–1.13, p = 0.08), with an absolute risk reduction of 25 strokes per 1,000 person-years. The hazard ratio for stroke or TIA was 0.50 (p = 0.05).Conclusions:Stenting in extracranial stenosis appears safe with low complication rates. Large phase 3 trials are required to determine whether stenting reduces stroke risk.ISRCTN.com identifier:ISRCTN95212240.Classification of evidence:This study provides Class I evidence that for patients with symptomatic vertebral stenosis, angioplasty with stenting does not reduce the risk of stroke. However, the study lacked the precision to exclude a benefit from stenting.

Kilkupoziomowa niedrożność przewodu pokarmowego u młodej pacjentki powstała wkrótce po porodzie – opis przypadku

W pracy opisano przypadek 31-letniej kobiety, u której niedroż- ność jelit rozpoczęła się 2 dni po porodzie drogą naturalną. Pacjentka w II trymestrze ciąży miała wykonaną laparotomię z powodu niedrożności mechanicznej dwunastnicy i jelita cienkiego wywołanej połkniętymi ciałami obcymi. Przebieg ciąży od operacji do porodu był niepowikłany. Przedoperacyjna diagnostyka radiologiczna (pasaż) wykazała niedrożność mechaniczną dwunastnicy i jelita cienkiego. Pacjentka była operowana. Śródoperacyjnie stwierdzono bardzo powiększoną, wypełnioną gęstą treścią pokarmową dwunastnicę, poszerzone jelito cienkie w masywnych zrostach międzyjelitowych i znacznie poszerzoną początkową część okrężnicy. W żadnym miejscu nie znaleziono jednak krytycznego zwężenia jelita ani innej przyczyny zaburzenia pasażu treści jelitowej. Jelito cienkie w czasie operacji nie wykazywało perystaltyki, jednak przed operacją osłuchiwanie wykazało jej obecność. Ponieważ uwolnienie jelita ze zrostów nie rozwiązało problemu, zdecydowano się na odbarczenie jelita cienkiego i okrężnicy przez nacięcie kątnicy i następnie na wyłonienie cekostomii. Przebieg pooperacyjny był powikłany epizodem krwawienia z górnej części przewodu pokarmowego i biegunką, które jednak szybko ustąpiły po leczeniu zachowawczym. Pacjentka powróciła do zdrowia, a późniejsza diagnostyka gastroenterologiczna nie wykazała jednoznacznej patologii w przewodzie pokarmowym.

Stereoscopic particle image velocimetry of the impinging venous needle jet during hemodialysis

Stereoscopic particle image velocimetry (S-PIV) was used to quantify the dynamic flow field caused by the venous needle jet (VNJ) in an idealised model of hemodialysis cannulation. Scaling based on Reynolds number ensured dynamic similarity with physiological conditions. Measurements taken along the center plane indicate the presence of a steady secondary flow region, which develops downstream of the impingement region. Upon impingement, a wall jet forms on the floor of the vein and spreads along the curvature of the vessel. Circulating flow forms due to the interaction between the jet spreading and the wall jet. This secondary flow region represents a potential site of stenosis on the roof of the vein where flow is reversed. The effects of the circulating flows can be minimized by using shallow needle angles, low needle flow rates and placement of the needle away from the walls of the vein.

Headache, TIA and subarachnoid haemorrhage: dissecting an unusual cause for stroke-like symptoms

We present a case of supraclinoid internal carotid artery dissection. Eleven months prior, the patient developed isolated periorbital pain and was diagnosed with giant-cell arteritis with iritis. The patient experienced...

Bacterial profile in human atherosclerotic plaques

Background and aimsSeveral studies have confirmed the presence of bacterial DNA in atherosclerotic plaques, but its contribution to plaque stability and vulnerability is unclear. In this study, we investigated whether the bacterial plaque-profile differed between patients that were asymptomatic or symptomatic and whether there were local differences in the microbial composition within the plaque. MethodsPlaques were removed by endarterectomy from asymptomatic and symptomatic patients and divided into three different regions known to show different histological vulnerability: A, upstream of the maximum stenosis; B, site for maximum stenosis; C, downstream of the maximum stenosis. Bacterial DNA composition in the plaques was determined by performing 454 pyrosequencing of the 16S rRNA genes, and total bacterial load was determined by qPCR. ResultsWe confirmed the presence of bacterial DNA in the atherosclerotic plaque by qPCR analysis of the 16S rRNA gene but observed no difference (n.s.) in the amount between either asymptomatic and symptomatic patients or different plaque regions A, B and C. Unweighted UniFrac distance metric analysis revealed no distinct clustering of samples by patient group or plaque region. Operational taxonomic units (OTUs) from 5 different phyla were identified, with the majority of the OTUs belonging to Proteobacteria (48.3%) and Actinobacteria (40.2%). There was no difference between asymptomatic and symptomatic patients, or plaque regions, when analyzing the origin of DNA at phylum, family or OTU level (n.s.). ConclusionsThere were no major differences in bacterial DNA amount or microbial composition between plaques from asymptomatic and symptomatic patients or between different plaque regions, suggesting that other factors are more important in determining plaque vulnerability.

Influence of Transcutaneous Electrical Nerve Stimulation on Clinical Measures and Functional Capacity in Patients with Peripheral Artery Disease

Peripheral Arterial Disease (PAD), which is characterized by occlusive plaques in the arteries perfusing the legs, often manifests in intermittent claudication. Home‐based exercise is commonly suggested for individuals with PAD, but adherence to such programs is often poor, resulting in limited clinical benefits. Therefore, this patient population would benefit from low‐risk, inexpensive, and simple to use therapeutic interventions that can improve exercise tolerance and capacity. One such potentially beneficial intervention is transcutaneous electrical nerve stimulation (TENS), which may induce transient increases in leg blood flow sufficient to improve the matching of oxygen supply and demand distal to the site of stenosis in patients with peripheral artery disease (PAD). Thus, the purpose of this study was to test the hypothesis that a single bout of TENS applied to the lower leg (for 15 or 45 minutes) will increase resting popliteal artery blood flow and 6‐minute walk distance (6MWD) in patients with PAD. Five subjects with PAD (67–81 yrs.; Intermittent Claudication, Fontaine stage II) participated in the protocol. Four subjects attended the laboratory for three randomized visits during which bilateral lower leg TENS (burst mode; 3Hz burst rate; 100Hz freq.; 250 μs pulse duration) sufficient to evoke skeletal muscle contraction was carried out for either 15 or 45 minutes or subjects participated in a control visit. One subject completed only the control and 15 minute TENS trials. Clinical and cardiovascular measures including resting single leg popliteal artery blood flow (Doppler ultrasound), ankle‐brachial index (ABI), and toe oxygen saturation (pulse oximetry) were carried out prior to and beginning 10 minutes following TENS. Popliteal vascular conductance (PVC) was calculated as flow/mean arterial pressure. 6MWD and time/distance to claudication onset were measured on the control day and each experimental day 35 minutes post‐TENS. The 15‐minute TENS trial increased popliteal artery blood flow from 63.5 ± 10.9 to 89.8 ± 21.8 mL min−1 (42.2%; P &lt; 0.05; n=5), PVC from 0.70 ± 0.12 to 0.92 ± 0.21 mL min−1 mmHg−1 (31.5%; P &lt; 0.05; n=5), and 6MWD from 1018.0 ± 133.8 to 1141.6 ± 149.2 feet (12.1%; P &lt; 0.05; n=5). The 45‐minute TENS trial increased popliteal artery blood flow from 56.4 ± 9.3 to 74.4 ± 15.9 mL min−1 (32.1%; P = 0.056; n=4), PVC from 0.66 ± 0.15 to 0.81 ± 0.20 mL min−1 mmHg−1 (23.2%; P &lt; 0.05; n=4), and 6MWD from 943.8 ± 128.5 to 1096.3 ± 146.9 feet (14.9%; P &lt; 0.05; n=4). Furthermore, the subjects reported onset of claudication at 573.8 ± 84.4 feet of the control visit 6MW, which was compared to 810.0 ± 199.2 feet after the 15 minute TENS trial and 690.0 ± 60.1 feet after the 45 minute TENS trial (both P &gt; 0.05). Neither of the TENS trials evoked changes in ABI or toe oxygen saturation. These preliminary findings suggest that acute lower leg TENS in patients with PAD may increase leg perfusion and exercise tolerance which, if undertaken routinely, could increase either patient adherence to or efficacy of exercise prescription in this population.Support or Funding InformationSupported by the Salisbury University Faculty Mini‐Grant

Demographic And Technical Risk Factors Of 30-Day Stroke, Myocardial Infarction, And/Or Death In Standard And High Risk Patients Who Underwent Carotid Angioplasty And Stenting

Background: Carotid angioplasty and stenting (CAS) is an accepted treatment to prevent stroke in patients with carotid artery stenosis. The purpose of this study is to identify risk factors for major complications after carotid angioplasty and stenting.Methods and Material: This is a prospective study conducted at Shiraz University of Medical Sciences in southern Iran from March 2011 to June 2014. Consecutive patients undergoing carotid angioplasty and stenting were enrolled. Both standard risk and high risk patients for endarterectomy were enrolled. Demographic data, atherosclerotic risk factors, site of stenosis, degree of stenosis, and data regarding technical factors were recorded. 30-day stroke, myocardial infarction, and/or death were considered as the composite primary outcome of the study.Results: two hundred and fifty one patients were recruited (mean age: 71.1+ 9.6 years, male: 65.3%). One hundred and seventy eight (70.9%) patients were symptomatic; 73 (29.1%), 129 (51.4%), 165 (65.7%) and 62 (24.7%) patients were diabetic, hyperlipidemic, hypertensive and smoker respectively. CAS performed for left ICA in 113 (45.4%) patients. 14 (5.6%) patients had Sequential bilateral stenting. Mean stenosis of operated ICA was 80.2 +13.8 %. Embolic protection device was used in 203 (96.2%) patients. Predilation and post-dilation were performed in 39 (18.5%) and 182 (86.3%) patients respectively. Composite outcome was observed in 3.6% (3.2% stroke, 0% myocardial infarction and 1.2% death). Left sided lesions and presence of DM was significantly associated with poor short term outcome. (P value: 0.025 and 0.020, respectively)Conclusion: There was a higher risk of short term major complications in diabetic patients and left carotid artery intervention.

Tertiary center experience with primary endoscopic laryngoplasty in pediatric acquired subglottic stenosis and literature review.

Background and objectivesTo share our experience with primary endoscopic laryngoplasty in pediatric acquired subglottic stenosis and critically review the previously published studies.SettingTertiary Referral Centers, King Abdulaziz Medical City, Riyadh, Saudi Arabia.Patients and methodsA retrospective case series study was conducted, where the case notes of all pediatric patients who underwent endoscopic management as a primary surgical intervention for acquired subglottic stenosis (SGS) from 2004 to 2014 were reviewed. All patients who underwent surgical correction with primary open laryngoplasty for congenital subglottic stenosis had been excluded.ResultsA total of 60 patients with a workable diagnosis of subglottic stenosis were reviewed. Forty-five patients were included in the study and 15 patients were excluded because they underwent open laryngoplasty as a primary treatment modality for congenital subglottic stenosis. The majority of the patients were males 29 (64%), with 16 (36%) females. The main presentation was stridor and intercostal recession. Thirty-nine (86%) patients had subglottic stenosis due to prolonged intubation; 5 (11%) patients were idiopathic and one patient (3%) had inflammatory reasons. The site of stenosis was isolated SGS in 41 while 4 patients had glottic-subglottic stenosis (GSGS). In terms of the grade of stenosis: 13 patients had grade I; 23 had grade II and 9 had grade III. The character of stenosis was soft except in 5 patients with hard (mature) scar. The number of dilatation procedures ranged from 1 to 6 with a mean of 2. The endoscopic management was considered to be successful when the patient is completely asymptomatic after the follow up period of one year. No major complications were recorded among the patients. Thirty-seven (82.3%) patients had a benign course post endoscopic intervention without complications and 8 (17.7%) underwent a secondary open surgical management due to re-stenosis (P value < 0.01).ConclusionOur study showed that primary endoscopic management was successful in 82.3% of cases of acquired subglottic stenosis including those with high grade stenosis and long segment of more than 12 mm in terms of the craniocaudal length. CO2 laser was an important tool to convert mature hard stenotic segment into a soft one. The latter yielded to the lateral pressure created by balloon dilatation better.